Coeliac ascites is a rare complication of abdominal surgery, mostly characterized by slow recovery and long duration. Due to its low incidence, it is unfamiliar and unappreciated by medical staff and sometimes tricky to manage [1]. Recently, there are 4 cases of postoperative celiac disease in patients who underwent abdominal surgery in our department, all of which were treated non-operatively and achieved more satisfactory therapeutic effect, this paper makes a retrospective analysis in order to discuss the characteristics and treatment of postoperative celiac disease. Zhang Xiaoqiao, Department of General Surgery, General Hospital of Jinan Military Region, Jinan, China 1 Data and Methods 1.1 Case data From January 2002 to February 2006, a total of four patients developed celiac disease after abdominal surgery, and their surgical methods included: gastrojejunostomy in one case, retroperitoneal tumor resection in one case, and palliative total gastrectomy in two cases. The determination of celiac ascites was based on the appearance of ascites and the celiac test. Where the drainage fluid from the abdominal cavity is milky and turbid, and celiac ascites is suspected to occur, the celiac test is carried out to confirm, i.e., equal amounts of ascites and ether are mixed, and after sufficient shaking, it is static and stratified, and the intermediate layer which may be dissolved with fat is examined by microscope, and celiac particles are found, that is, the celiac test is positive. 1.2 Treatment All four patients received non-surgical treatment after the occurrence of celiac ascites, continued abdominal drainage, and were given nutritional support. Cases 1 and 2 were first treated with total parenteral nutrition (TPN), which was changed to enteral nutrition (EN) after 7-14 days, and Cases 2 and 3 were directly treated with EN. The nitrogen supply of TPN formula was about 0.18-0.22 g.kg-1.d-1, and the nonprotein calories were 108.2-146.4 kJ (26-35 kcal).kg-1.d-1, with a sugar-fat ratio of 2: 1, and routine supplementation of vitamins, trace minerals, and electrolytes.The EN formulation was a self-prepared low-fat formula using soy protein powder as the nitrogen source, with a daily supply of 70-100 g (1.0-1.7 g. kg-1.d-1) of protein, and nonprotein calories supplied from glucose, sucrose, or commercially available nutritious rice flour, 250-320 g per day, providing 70-80 kJ (16.7-19.2 kcal) of non-protein calories . kg-1.d-1, in addition to a certain amount of vitamins and electrolytes. The above nutrients were mixed proportionally under clean conditions and prepared into a liquid with a concentration of about 20% for tube feeding or oral administration.During the period of EN support, the patients were given an intravenous infusion of fat emulsion and fat-soluble vitamins once a week to replenish essential fatty acids, etc.The patients were given a fat emulsion and fat-soluble vitamins once a week to replenish essential fatty acids. 2 RESULTS 2.1 POSTOPERATIVE PROCEEDINGS The four patients had a smooth recovery in the early postoperative period, and all of them started to take oral diet after the recovery of intestinal peristalsis. Cases 1, 3, and 4 underwent EN support via jejunostomy or nasojejunal catheter since 2 days after surgery. When the oral diet or EN basically reached the full volume around 10 days after the operation, the originally clarified and gradually reduced abdominal drainage fluid was found to increase and become turbid and milky white, with a positive celiac test for ascites, which was judged to be postoperative celiac ascites, and the non-surgical treatment, mainly nutritional support, was begun. The amount of abdominal drainage then gradually decreased, and the drainage fluid returned to yellow and clarified, and the celiac test turned negative after 2-3 days, except for case 4, which turned negative after 9 days. However, this patient continued to be tube-fed with a high-fat diet even after celiac ascites was judged to be celiac, and was found to have switched to low-fat enteral nutrition only after 3 days. Among the 4 patients, except for case 3 who died of acute hepatic and renal insufficiency on the 17th postoperative day, the other 3 gradually improved and were eventually discharged from the hospital with drain removal, and were put on a low-fat diet orally for 1 month after tube removal, followed by gradual return to a normal diet. During the follow-up period of 2-6 months, no abdominal distension was observed, and no ascites was detected by abdominal ultrasound. 2.2 Ascites test indexes and other test results After the celiac test was positive in cases 1, 2 and 4, the triglyceride concentration of the abdominal drainage fluid was also high, reaching about 1.5 mmol/L (1.12-1.56 mmol/L), and then decreased to 0.2-0.5 mmol/L after the celiac test became negative. The Rivalta test was also positive in all cases of positive celiac disease. Ascites cell count (nucleated cells), all positive celiac disease test are dominated by lymphocytes, the count can be as high as 893 × 106 / L, the proportion of nucleated cells in more than 70%, the highest up to 95% (Case 2), when the celiac disease test negative after the cell count decreased significantly, the proportion of lymphocytes is mostly reduced to about 20%. After the development of celiac disease, the patient’s peripheral blood lymphocyte count also gradually decreased to <1×109/L. The lowest was in case 2, where the lymphocyte count decreased from 1.18×109/L preoperatively to only 0.4×109/L on the 17th postoperative day (9 days after the development of celiac disease), whereas case 4, where the lymphocyte count was 2.22×109/L preoperatively, (36.7%), and postoperatively had dropped to 0.9 × 109/L (13.3%) on day 7, and by day 10 postoperatively, when the diagnosis of celiac disease was clarified, the lymphocyte count was 0.5 × 109/L, which was only 7.9% of the white blood cells. In all four patients, serum albumin was above 30 g/L preoperatively, and decreased to varying degrees in the postoperative period, ranging from 25 to 27 g/L. In particular, in case 2, on postoperative day 22, when the celiac test had turned negative, the amount of ascites drainage had decreased to about 250 ml/day, and low-fat EN support had been initiated, the patient's serum albumin continued to decrease to 23 g/L, and the amount of ascites resumed to increase, but all of them had light yellow The ascites volume increased again, but it was light yellow, the Rivalta test was negative, the celiac test was negative, and the triglyceride concentration was only 0.01-0.03 mmol/L. After the nutritional status improved and the hypoproteinemia was corrected on the 40th day after the operation, the ascites volume gradually decreased, and the drain was finally removed. 3 DISCUSSION Postoperative celiac ascites is rare, with only a few hundred cases reported in the literature to date [1], and usually complicates extensive retroperitoneal operations, such as a variety of vascular surgeries and retroperitoneal lymph node dissection for malignant tumors of the pelvic organs, with surgeries of the abdominal aorta being the most likely to lead to its occurrence [2, 3]. The mechanism of celiac ascites lies in the injury of the celiac pool, thoracic duct or its main genera, and is also facilitated by the massive production of celiac and the obstruction of lymphatic return. Of the four patients in this article, the surgery in case 2 involved the retroperitoneal area below the left renal artery and to the left of the abdominal aorta, and the possibility of injury to the major lymphatic channels exists. Cases 1, 3, and 4 were patients with advanced malignant tumors with extensive intra-abdominal metastases, particularly two patients with gastric cancer who had fused lymph nodes in the root of the celiac artery. Although these patients did not undergo extensive retroperitoneal surgery, surgical maneuvers can lead to injury of lymphatic vessels, and at the same time, extensive lymphatic metastases may lead to impaired lymphatic return, both of which together lead to the development of postoperative celiac ascites. The diagnosis of celiac ascites relies on laboratory tests for ascites. In the early postoperative period, because the gastrointestinal function has not been fully recovered, the amount of intestinal feeding is limited, the lymphatic drainage from the intestine is small, and the coeliac particles formed after fat absorption are also small, so it is difficult to differentiate it from the general abdominal drainage fluid, and about 10 years after the operation, the gastrointestinal function of the patient basically recovers, and the patient eats a normal diet or the enteral nutrition reaches the full amount, and a large amount of coeliac-rich lymphatic fluid from the intestinal tract leaks into the The amount and appearance of the abdominal drainage fluid changed significantly and was easily recognized by the naked eye. Therefore, the diagnosis of all four patients in this paper was clarified at this stage. This also suggests that in patients with risk factors for the development of celiac disease, monitoring the triglyceride concentration of the abdominal drainage fluid and the presence or absence of celiac particles in the postoperative period may lead to the diagnosis of celiac disease at an earlier time [4]. Celiac ascites can have several adverse effects on the body. Prolonged and large amounts of celiac disease will inevitably lead to a significant loss of protein, nutrients, and lymphocytes in the body, which can lead to some degree of malnutrition and immunocompromise. The accumulation of large amounts of celiac fluid in the abdominal cavity can also lead to complications such as respiratory distress due to mechanical factors such as increased intra-abdominal pressure and diaphragmatic elevation; coupled with the effects of the primary disease, the prognosis for patients with celiac disease, especially self-initiated celiac disease, is poor in general, with mortality rates reported in the literature to be as high as 43% to 83%. However, in the absence of severe coexisting disease, the prognosis of postoperative celiac disease is relatively good [2, 5]. In the four patients in this paper, the amount of ascites was small and was promptly drained and treated, only case 3 died of liver and renal failure due to coexisting cirrhosis, and the rest of the patients did not have serious complications. Once celiac disease is diagnosed, in most cases, non-surgical treatment is preferred to drain the ascites by laparotomy or catheterization, and at the same time try to reduce the production of celiac disease in order to facilitate the self-healing of lymphatic rupture [6,7]. The main component of celiac fluid comes from celiac particles absorbed by the intestinal lymphatic system. Reducing or eliminating the fat content of food or even fasting to rest the intestines can significantly reduce the production of lymphatic fluid, therefore, dietary treatments that are high in protein, low in fat, or contain medium-chain fatty acids have always been an important part of the non-surgical treatment of celiac ascites. TPN has become another important treatment for celiac disease and has been recommended by some scholars as the first line of treatment for celiac disease because it can keep the intestines in a state of complete disuse, minimize the lymphatic fluid from the intestines, and maintain the nutritional status of the patient [2, 8]. In recent years, other authors have used growth inhibitors in the treatment of celiac ascites with the aim of further reducing celiac production [9-11]. In this paper, two patients treated with a combination of TPN and low-fat enteral nutritional support in the early stage, and two patients treated with only low-fat enteral nutritional support in the later stage, the ascites coeliac test turned negative in a relatively short period of time, and the amount of drainage flow was also significantly reduced. However, due to the low energy density of the enteral nutritional support formula used, which failed to ensure adequate calorie and protein supply, the patients recovered more slowly and were in poorer nutritional status. This also suggests that if we supplement some nutrients via the parenteral route at the same time as EN, it may be more conducive to the patient's recovery. Through the treatment of the four patients in this paper, we appreciate that celiac ascites secondary to abdominal surgery in general and advanced malignant tumor surgery in particular is easy to control, responds better to nutritional support therapy, and can achieve better efficacy by simply applying inexpensive low-fat enteral nutrition, with the disadvantage of a long treatment cycle. References (omitted)