A 67-year-old woman with intense esophagitis (grade III of Savary) and a mild hiatal hernia underwent a laparoscopic Nissen fundoplication in February 2000. Her most important clinical symptoms were retrosternal pain, acid and food regurgitation, and heartburn. She was also dependent on proton-pump inhibitors for symptom relief.
No problems or difficulties occurred during the procedure. At laparoscopy, no abnormality was found. Her immediate postoperative period was unremarkable. A hook electrocautery was used for dissecting the diaphragmatic crura and opening the retroesophageal window.
Twenty days after the surgery, the patient complained of abdominal pain and distension. Physical examination revealed an increased abdominal girth, ascites, and exaggerated tympanism. Diffuse ascites was also confirmed by an ultrasound examination. A paracentesis was performed and showed a white-milky odorless fluid with a specific gravity of 1.030, sodium 135 mEq/L, potassium 3.6 mEq/L, total protein 4.4 g/L, amylase 25 U/L, triglycerides 1024 ng/dL, cholesterol 241 ng/dL, red blood cell count of 3450, and white blood cell count of 2150 (70% lymphocytes). Electrophoresis of the fluid showed that lipids were mainly in the form of chylomicrons. Gram stain and bacterial cultures were negative.
A central line was placed and parenteral nutrition started. Over the next 3 weeks, the abdominal girth improved with decreased firmness and increased bowel sounds. The central line was removed on day 20 and oral fat-free diet restarted. One-month later, abdominal ultrasound demonstrated no ascites.