Chylous ascites following laparoscopic live donor nephrectomy: A new improved treatment paradigm

Abstract

Chylous ascites is a difficult, albeit uncommon complication of laparoscopic live donor nephrectomy (LLDN). Lymphatic leak is believed to be a result of injury to the cisterna chyli, regional lymph nodes, or other peri-aortic lymphatics intraoperatively. Recommended management with dietary modifications can result in malnutritionand immunodeficiency. We present four patients who developed chylous ascites fol-

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

“…The right renal artery is usually considerably longer than the left and therefore requires a less-extensive dissection with respect to near the aorta. 5 In addition, the right renal artery is positioned latero-caudal and posterior to the inferior vena cava, thus it is farther away from the para-aortic lymph nodes that are left undisrupted. 14 During donor evaluation, both kidneys are screened, and the kidney ultimately chosen for donation should be the one with either decreased function in GFR and/or morphological abnormality (cysts, stones, lipomas, and number of vessels) with the intent of minimizing donor morbidity.…”

“…Sinha and Mamode 26 asserts that early intervention should be considered as opposed to conservative measures for severe cases, although almost all documented cases of severe chylous ascites are first managed conservatively. Conversely, Dale et al 5 believe that intra-abdominal drain placement should be considered as a first-line therapy in select patients for treatment of chylous ascites as a reasonable alternative to both conservative and surgical management. Interventional radiology is the next step if conservative management fails with surgical intervention as last resort.…”

“… 2 Disruption to the cisterna chyli and its main lymphatic tributaries around the para-aortic region intraoperatively leads to a collection of chylous fluid within the peritoneal cavity. 3 - 5 Chylous ascites after LDN, first reported by Shafizadeh et al 6 in 2002, is a rare and problematic complication that can result in significant morbidity, prolonged hospital stays and thus increased health care costs. 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%.…”

Management of intractable post‐adrenalectomy chylous ascites with microsurgical intra‐abdominal lymphaticovenous anastomosis: A case report and literature review

“…Nutritional adjustment by providing a low fat or mid‐chain diet is recommended; they are effective in 75% of cases (Weniger et al, 2016). More aggressive diet control with TPN and an element diet can lead to bowel rest to reduce the lymphatic flow and enhance healing of the injured duct (Dale et al, 2019). Conservative management, however, prolongs the hospital stay and results in malnutrition and reduced immune function owing to the loss of lymphocytes and protein; long‐term TPN supplement may also increase the risk of catheter related infection or venous thrombosis, the timing of applying TPN nutrition is still an issue for debate (Rimensberger et al, 1998).…”

“…Surgical interventions including closed drainage, pleuro‐peritoneal or peritoneo‐venous shunting, and suturing the leaking point, have been recommended when metabolic complications present, symptoms continue for more than 2 weeks, or the drainage volume is >1 L for a week (Stager et al, 2010). Early transcutaneous peritoneum drainage is the first step (Dale et al, 2019). Abdominal paracentesis can be an alternative.…”