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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 14  |  Issue : 4  |  Page : 374-376

A rare complication after laparoscopic donor nephrectomy: Chyle leak - A case report


1 Department of Nephrology, Rajagiri Hospital, Kochi, Kerala, India
2 Department of Urology, Rajagiri Hospital, Kochi, Kerala, India

Date of Submission11-May-2020
Date of Acceptance05-Aug-2020
Date of Web Publication30-Dec-2020

Correspondence Address:
Dr. Sneha P Simon
Department of Nephrology, Rajagiri Hospital, Aluva, Kochi, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_43_20

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  Abstract 


Live kidney donors are healthy individuals who are willingly undergoing major surgery to alleviate the misery of another individual. It is important to minimize the risks of this procedure and at the same time maximize donor safety. Chyle leak following donor nephrectomy is extremely rare. We report a case of chylous ascites combined with chylothorax following laparoscopic donor nephrectomy. Usually, it responds to conservative measures. Our patient had failed to respond to a conservative line of management and required surgical correction with good outcomes.

Keywords: Chyle, laparoscopic, nephrectomy


How to cite this article:
Simon SP, Thomas J, Tidayath BN, Bhat SH. A rare complication after laparoscopic donor nephrectomy: Chyle leak - A case report. Indian J Transplant 2020;14:374-6

How to cite this URL:
Simon SP, Thomas J, Tidayath BN, Bhat SH. A rare complication after laparoscopic donor nephrectomy: Chyle leak - A case report. Indian J Transplant [serial online] 2020 [cited 2021 Feb 24];14:374-6. Available from: https://www.ijtonline.in/text.asp?2020/14/4/374/305426




  Introduction Top


Donor workup in renal transplantation is extensive to ensure donor safety at all costs and at the same time providing an adequately functioning kidney to the recipient. However, complications may occur. One of them, although very rare, is postoperative chyle leak.[1] Chylous ascites is the leakage of fluid from transected lymphatic vessels after the surgery. Usually, it may go unnoticed intraoperatively because of high intraabdominal pressure created by pneumoperitoneum, which masks leakage from the low-pressure lymph vessels. [2,3] We describe a case of postoperative chyle leakage following laparoscopic donor nephrectomy (LDN), which is managed successfully with surgery.


  Case Report Top


A 32-year-old female with no comorbidities, who underwent left LDN for altruistic kidney donation on September 19, 2018. Her pretransplant workup was normal. Her peri-operative course was uneventful and discharged on the third day after the removal of the Jackson-Pratt abdominal drain and Foleys catheter.

Tenth postoperative day, she developed a cough and right-sided pleuritic chest pain. A chest X-ray was taken on that day by the physician, reported it as right lower zone consolidation with mild parapneumonic effusion, and she was initiated on antibiotic. After 1 week of the antibiotic course, she reported worsening of her respiratory symptoms hence advised computed tomography of the chest and abdomen. Imaging revealed right-sided massive pleural effusion with gross ascites [Figure 1].
Figure 1: Chest X-ray showing right pleural effusion

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In view of respiratory distress and massive pleural effusion, an intercoastal drain was placed. The physical appearance of pleural fluid was milky and cloudy [Figure 2]. The pleural fluid analysis further revealed a total count of 95,000 cells/cumm, differential count L90N10 red blood cells 60,000 cells/cumm, and the presence of mesothelial cells. Triglycerides 3000 mg/dl with chylomicrons, lactate dehydrogenase 154U/L, albumin 2.7 g/dl, sugar 176 mg/dl, adenosine deaminase 16.58 U/L, protein 5.7 g/dl, cholesterol 80 mg/dl, and culture yielded no growth.
Figure 2: Right chest drain showing chylothorax

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She was started immediately on injection octreotide, orlistat, and low fat-high protein diet as conservative measures. The chyle leak persisted and the chest drain volume was around 500 ml even on the 6th day of conservative management. Hence, she was taken for diagnostic laparoscopy. Intraoperatively, there were dense adhesions of the descending colon and at the arterial stump, surgeons could identify leaking hilar lymphatics. Using the proline sutures leaking area was ligated. Subsequently, her chyle leak subsided and she was discharged without any collection in the peritoneal or pleural cavities [Figure 3], [Figure 4], [Figure 5]. Her follow-up visits were unremarkable.
Figure 3: Repeat chest X-ray showing clearance of pleural effusion

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Figure 4: Computed tomography chest showing massive right-sided pleural effusion on left with complete clearance after repair of chyle leak

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Figure 5: Computed tomography abdomen showing ascites on left with clearance after repair on right side

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  Discussion Top


Chylous ascites is caused by several pathological conditions, such as congenital defects of the lymphatic system, malignant neoplasm, liver cirrhosis, blunt or surgical trauma, surgical injury to the lymphatic channels, and peritoneal infections by nonspecific bacteria, parasite, and tuberculosis.[1]

Postoperative chylous ascites is caused by the disruption of lymphatic channels and subsequent chyle leakage. The mechanism of postoperative chylous ascites is surgical damage to the thoracic duct, cisterna chili, or other major retroperitoneal lymphatic channel that results in lympho peritoneal fistula formation and accumulation of chyle in the peritoneal cavity. It is rare to follow urological procedures. The reported incidence of chylous ascites after laparoscopic nephrectomy ranges from 0.013% to 5.9%.[2]

It usually goes unnoticed intraoperatively because of high intraabdominal pressure created by pneumoperitoneum, which can mask leakage from the low-pressure lymphatics.[3]

The majority of the cases reported in the literature so far are following left LDN, which may be due to the preferred side for the surgery. The anatomical distribution of lymphatics is another reason for the difference in incidence among two sides. The ascending vertical lumbar lymphatic trunks lie between the aorta and inferior vena cava, and no periaortic lymphatic dissection is done in right laparoscopic nephrectomy. Moreover, cisterna chyli, which is the dilatation of lumbar lymphatic trunk, is located near aorta, which may get injured during left nephrectomy.[3]

Postoperative chyle leak tends to occur earlier as soon as the patient resumes oral intake, or it might take weeks or even months before becoming clinically evident in the absence of a drain. In this setting, progressive abdominal distension, dyspnea, nausea, vomiting, and eventually, malnutrition can raise the suspicion of postoperative chylous ascites.[4]

Abdominal aortic surgery is the most common cause of postoperative chylous ascites, accounting for >80% of postoperative chylous complications. This was rarely reported in the urologic field before the introduction of laparoscopic surgery. The proposed cause for this increased incidence of chylous ascites after laparoscopic nephrectomy is that lymphatics are not routinely ligated during laparoscopic surgery, even though they are usually burned with energy-based sealing devices such as monopolar or bipolar electrocautery and ultrasonic shears.[5]

Although most cases of chylous ascites after laparoscopic nephrectomy can be successfully managed conservatively with diet modifications (low-fat diet, medium-chain triglyceride diet, and total parenteral nutrition) without critical sequelae, occasionally, severe refractory cases can evolve. These severe refractory cases can cause devastating complications such as malnutrition, infection, and immunological deficiency and often require invasive and aggressive treatment because chyle is rich in fat, lymphocytes and immunoglobulins; therefore, uncurbed chyle leakage leads to loss of nutrition and immunocompetency.[5] Therefore, in patients with high volume leaks, early surgical intervention can minimize the prolonged morbidity and need for frequent therapeutic interventions in the postoperative period. Options in refractory cases include exploration with ligation/clipping of disrupted lymph vessels, application of fibrin glue, povidone-iodine installation, or placement of peritoneovenous shunt.[6]

Our patient, who underwent laparoscopic left donor nephrectomy, remained uneventful till the tenth day of the perioperative period. Then, she presented with massive ascites and pleural effusion, which failed to show any response with a combination of conservative measures for 6 days (even though in literature it says 4–8 weeks of conservative measures), she was taken for surgical procedures with a good outcome. Our case is peculiar, with the presence of massive chylothorax associated with chylous ascites. There was nothing to suspect procedure-related pleural injury as evidenced by the lack of postoperative respiratory distress.

Retrospectively, we reviewed the recordings of the surgery and could find out few dilated lymphatics with evident leak near the renal artery (hilum), which were transected while using a harmonic scalpel and left without ligation [Figure 6]. This emphasizes the need to have meticulous dissection around the hilar area during LDN and ligation of dilated or transected WElymphatics using staples or clips.[7]
Figure 6: Intra operative image of chyle leak

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  Conclusion Top


Chylous ascites is a rare complication of LDN. It causes significant morbidity and reduces the advantages of the minimally invasive approach. Chyle leak following donor nephrectomy may be prevented by meticulous surgical dissection and clipping/ligating all the lymphatic tissue around the renal vessels. Chylous ascites is usually managed with conservative measures but rarely may require surgical intervention.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Leibovitch I, Mor Y, Golomb J, Ramon J. The diagnosis and management of postoperative chylous ascites. J Urol 2002;167:449-57.  Back to cited text no. 1
    
2.
Kim BS, Yoo ES, Kim TH, Kwon TG. Chylous ascites as a complication of laparoscopic nephrectomy. J Urol 2010;184:570-4.  Back to cited text no. 2
    
3.
Seth A, Sharma A, Kenwar DB, Singh S. Chylous ascites: Complication of laparoscopic donor nephrectomy. Case report and review of literature. Transplantation 2019;103:e74-8.  Back to cited text no. 3
    
4.
Capocasale E, Iaria M, Vistoli F, Signori S, Mazzoni MP, Valle RD. et al. Incidence, diagnosis, and treatment of chylous leakage after laparoscopic live donor nephrectomy. Transplantation 2012;93:82-6.  Back to cited text no. 4
    
5.
Combe J, Buniet JM, Douge C, Bernard Y, Camelot G. Chylothorax and chylous ascites following surgery of an inflammatory aortic aneurysm. Case report with review of the literature. J Mal Vasc 1992;17:151-6.  Back to cited text no. 5
    
6.
Zomorrodi A, Buhluli A. Instillation of povidone iodine to treat lymphocele and leak of lymph after renal transplantation. Saudi J Kidney Dis Transpl 2007;18:621-4.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Guglielmo N, Melandro F, Nudo F, Mennini G, Sandri GB, Berloco PB, et al. Chylous leakage after a laparoscopic live-donor nephrectomy: Case report and literature review. Exp Clin Transplant 2016;14:338-40.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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