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Laparoscopic donor nephrectomy (LDN) is an established operation for organ procurement in living donor transplantation. Living donor renal transplantation is being performed more frequently and is associated with better graft function and survival. The minimal access approach for organ procurement from healthy individuals ensures early convalescence and improved patient participation. Here we describe a rare complication of LDN. Postoperative chylous ascites frequently occurs secondary to aortic surgery. Though previously described after LDN, its treatment remains contentious. Conventional strategies have adopted an expectant approach with medical management. These include parenteral feeding, bowel rest and somatostatin analogue usage. We report laparoscopic suture ligation as the principal management of postoperative chyle leak. We advocate surgical exploration in acute onset, high output chylous ascites. Pre-existing port site incisions were used for undertaking successful laparoscopic repair. This surgical approach enabled faster convalescence and reduced hospital stay—important considerations for our healthy living donor.
Chylous ascites is a rare clinical condition that occurs as a result of disruption of the abdominal lymphatics. Several pathophysiological aetiologies have been implicated, including malignant neoplasm, spontaneous bacterial peritonitis, abdominal tuberculosis, peritoneal dialysis, pelvic irradiation, carcinoid syndrome, and congenital defects of lacteal formation.1 Other relatively more common causes include post-abdominal, particularly vascular, surgery, blunt abdominal trauma, and cirrhosis—up to 0.5% patients with ascites from cirrhosis have chylous ascites.2
Abdominal aortic surgery is the procedure most frequently implicated in chylous complications, via injury to retroperitoneal lymphatics, in particular the cisterna chyli. Although lymphatic leaks account for only 1% of all complications after aortic surgery, it is implicated in over 80% of the cases of post-surgical chylous ascites.3 Laparoscopic donor nephrectomy (LDN) is a procedure first described only 13 years ago.4 Although postoperative chylous ascites has been described in several patients, its management has proven difficult.
We are increasingly performing LDNs. In the last 2 years, at our institution we have encountered two cases of post-LDN chylous ascites. With more LDNs being performed, we envisage an increase in this previously rare postoperative complication, from the reported 1–2% incidence in the literature. In the absence of clear consensus for the management of this complication, we report an alternative to conventional medical and expectant treatment. We describe a technique for laparoscopic repair, utilising previous port site incisions, which resulted in complete resolution of the chyle leak. We advocate early surgical intervention and treatment in acute onset, high output postoperative chyle leakage. This enabled our essentially healthy living donor to return to normal activities of daily living much sooner—an important consideration for such patients.
A 38-year-old woman underwent an apparently uncomplicated left hand assisted LDN. Her son received the live related renal transplant with good graft function. Her surgical history consisted of a previous laparoscopic cholecystectomy. On the fourth postoperative day she complained of increasing abdominal distension and an ultrasound scan confirmed a 6×15 cm collection adjacent to the left renal bed. The patient’s symptoms improved spontaneously and she was discharged on the fifth postoperative day.
The patient continued to suffer from abdominal distension and re-presented to her local hospital, where a recurrent collection was identified and milky white fluid aspirated. This was identified as chyle, and a percutaneous drain was inserted under ultrasound guidance. The classical “milky white” chylous output remained consistent at 400–500 ml in 24 h. Attempts at conservative management with clamping of the drain and tamponade were unsuccessful. We than proceeded to conventional management of postoperative chylous ascites with therapeutic paracentesis, diuretics and restricting salt intake, high protein, low fat, medium chain triglyceride diet, gut resting and parenteral feeding.5 We also instituted somatostatin, which has shown to be effective in reducing chylous output.6
In the fourth postoperative week, with no resolution of lymph drainage, the patient underwent a diagnostic laparoscopy. A transperitoneal approach was performed at a pneumoperitoneum of 12 mm Hg. The patient received 200 ml of high fat milk 6 h preoperatively, to maximise lacteal secretions. At laparoscopy, the site of the cisterna chyli leakage was clearly visualised (fig 1).
We performed direct suture ligation and reinforced the suture line with titanium clips. There was immediate resolution of chylous output postoperatively. The patient made an uneventful recovery and was discharged on the third postoperative day. No ascites was detected at 1 month, 6 month or 12 month follow-up. There were no short or long term complications from the additional surgical intervention.
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.13 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.
Competing interests: None.
Patient consent: Patient/guardian consent was obtained for publication.