Chylous Ascites: Complication of Laparoscopic Donor Nephrectomy. Case Report and Review of Literature

Abstract

Background. Chylous ascites (CA) is an extremely rare complication after laparoscopic donor nephrectomy (LDN). It can increase the hospital stay, morbidity in postoperative period and thus negating the benefits of laparoscopic surgery. Most of the cases were managed conservatively, but surgical intervention may be occasionally required. This report describes the importance of accurate localization of the leaking chyle duct and its repair by endosuturing in a renal donor not responding to conservative treatment. Methods. A comprehensive review of literature regarding this rare complication after LDN was performed with Pubmed/Medline and Google Scholar using “chyle,” “complications,” and “laparoscopic donor nephrectomy” as keywords. The demographic profile and management of patients is discussed in detail. The various surgical modalities used to manage these patients are described. Results. Fifty-four cases of chyle leak/ascites have been reported after LDN in literature to date. Around 77% donors with CA could be successfully managed conservatively with dietary measures and total parenteral nutrition. Surgical intervention was required in nearly 23% donors ranging from clip application, use of argon coagulation, endosuturing with application of glue after 36.1 ± 19.07 days of failed conservative treatment. Donors with massive ascites or requiring frequent large-volume paracentesis on conservative treatment are likely to require surgical therapy. The present case was successfully managed with laparoscopic endosuturing and has no recurrence at 6 month follow-up. Conclusions. Chylous ascites is a rare complication after donor nephrectomy in experienced centers. Although conservative management remains the first line of treatment, early surgical treatment shall be undertaken in cases of massive ascites.

Massive Chylous Ascites After Living Donor Nephrectomy Successfully Treated With Lymphatic Embolization

“…It appears that the incidence of chylous leakage/ascites after LDN is higher than previously reported, with the most recent data from Dale et al suggesting incidence ranges from 0.6% to 5.9%. 5 , 7 , 8 This is a notable increase from a previous 2009 report by Aerts et al 9 who estimated incidence to range from 0% to 1.8%. Current literature review shows that to the best of our knowledge, only 54 cases have been documented, with most of them occurring after left, rather than right, LDN.…”

“…The shorter renal vein and liver retraction are some of the reasons that make right-sided LDN less preferable. 10 In a retrospective review by Seth et al 7 of complications from a single-center study of 253 patients undergoing LDN (51 right and 202 left) from 2003 to 2012, there were 15 noted cases of chylous ascites after left nephrectomy (7.4%) compared to 1 case after right nephrectomy (1.9%). Similar findings were noted in a large retrospective review in India by Kumar et al 11 Other anatomic factors may also contribute to decreased chylous leak after right-sided LDN compared to left.…”

“…Ingesting milk or a high-fat diet prior to imaging promotes lymphatic flow, thereby increasing the chances of identifying the source of leak. 2 , 7 Lymphoscintigraphy is a noninvasive technique with no known adverse side effects. However, facilities may not be equipped to routinely perform this test.…”

“…More than half of patients are managed conservatively with diet and paracentesis for symptomatic relief. 3 , 7 , 13 , 21 , 22 Replacing albumin after large volume paracenteses (>5 L) is recommended as it can reduce mortality. 23 Patients who either fail conservative measures or have massive ascites requiring multiple large volume paracentesis, like the patient in this case, necessitate early intervention.…”

“…Current literature review shows that to the best of our knowledge, only 54 cases have been documented, with most of them occurring after left, rather than right, LDN. 7 , 10 , 11 …”