There is good evidence in the literature to support the medical management of postoperative chylous ascites.7–9
Some studies have reported success rates in the order of 90% with 6 weeks of parenteral feeding and fasting.10
Surgical management includes either open or laparoscopic approach to direct suture ligation of the chyle leakage,11–13
or insertion of a peritoneovenous shunt,12
and is typically reserved for cases refractory to maximal medical management.
We recommend that patients with substantial postoperative chylous ascites should be considered for surgical intervention as opposed to conventional treatment with bowel rest and parenteral nutrition. Here we describe laparoscopic suture ligation as the principal management option in the treatment of postoperative chylous ascites. To our knowledge, only one other such report exists.13
In our experience clipping of the leak site under direct visualisation is more effective than diathermy. Attempts at coagulation therapy prove futile and difficult due to the fragility in the surrounding tissue and the risk of inadvertent heat damage to important surrounding structures. Conversely, clips or other sealing devices such as the “ligasure” and the harmonic scalpel have proven useful when dealing with these large peri-aortic lymphatics.
Prolonged parenteral nutrition and fasting cause substantial distress and morbidity for patients. With surgical management, patients are able to return to normal activities much sooner and resume work rapidly, an important factor for many living donors.
A reluctance to intervene surgically may stem from the fact that chylous leak may be difficult to visualise at the time of surgery. This was not the case, however, in our patient, where the leak was seen actively spurting, nor indeed in the case described by Gill et al
Furthermore, adoption of the laparoscopic approach allows abdominal exploration with minimal morbidity, utilising previous port sites. We acknowledge that in patients suffering from chylous ascites post-aortic aneurysm surgery or in those undergoing retroperitoneal lymph node dissection, a resultant haematoma or altered anatomy may obscure the site of chyle leak. However, this did not appear to be an issue among the two reported cases of chyle leakage following a laparoscopic nephrectomy, where the site of the chyle leakage was clearly visualised.
Although chylous ascites remains a rare complication after laparoscopic donor nephrectomy, a suggested approach might include early surgical intervention for rapid onset, high output (>100 ml over 24 h) ascites, while reserving a trial of conservative medical management for low output ascites, which presents later.
- Laparoscopic donor nephrectomy (LDN) is being performed more frequently for organ procurement from healthy individuals. It is thus important to have consensus on the best strategy for the management of any subsequent complications.
- Chylous ascites following LDN has been previously described and managed expectantly with bed rest, fasting and medical treatment. This is an unacceptable strategy in healthy living donors.
- Laparoscopic suture ligation of a chyle leak can be performed utilising pre-existing port site incisions. This precludes the need for prolonged fasting, bed rest and expectant medical treatment.
- The surgical approach is likely to be more successful in acute onset, high volume postoperative chyle leak.