Chylous ascites in laparoscopic renal surgery: Where do we stand?

Thoracic duct stent treatment for chyle leak after nephrectomy

Chyle leak is a rare and serious condition caused by damaged lymphatic vessels. It can occur after retroperitoneal surgery involving extensive lymphadenectomy for kidney cancer. Besides lymphatic channel damage, the obstruction of the thoracic duct worsens the leakage. Managing patients with thoracic duct obstruction and postsurgical chyle leakage is challenging due to limited data on how to handle this condition. In this case report, a 28-year-old female patient underwent left nephrectomy for left kidney cancer. Three days after the surgery, milky fluid drained from the left renal fossa. Conservative treatment failed, and further examination through magnetic resonance lymphangiography revealed the absence of the thoracic duct and contrast extravasation at the left renal fossa. Lymphangiography confirmed distal thoracic duct obstruction. The patient's condition was successfully managed by using thoracic duct stenting. This report contributes to the understanding that thoracic duct obstruction can lead to lymphatic collateral circulation within the abdomen, thereby increasing the risk of postoperative chylous leak.

Chylous Ascites Following Laparoscopic Donor Nephrectomy: A Case Report

Chylous ascites is a form of peritoneal fluid accumulation that can arise from trauma or lymphatic obstruction. In this report, we present the first case of chylous ascites following laparoscopic donor nephrectomy in our high-volume kidney transplant center. The patient presented to the emergency department three weeks post-procedure with complaints of abdominal distention and discomfort, accompanied by constipation and nausea. Radiological confirmation of ascites was followed by paracentesis, which yielded 20 mL of milky fluid that was analyzed and confirmed as chylous ascites. A subsequent pigtail drain was inserted, resulting in a total drainage of 4 L of fluid. Chylous ascites is a rare complication of abdominal surgeries, with higher body mass index and the American Society of Anesthesiologists physical status score system being significant risk factors. Conservative management involving diet modification is the initial therapy, with percutaneous drainage or more aggressive surgical interventions considered if conservative measures are not effective, with high success rates reported for these interventions. Here, we report a case of chylous ascites following donor nephrectomy as the first case reported from our region.

Chylous ascites after donor nephrectomy: MR lymphangiography and lymphatic embolization treatment

Chylous ascites results from the leakage of lipid-rich lymphatic fluid into the peritoneal cavity. Most postsurgical chylous ascites occurs following abdominal aortic surgeries. However, rarely, it is a complication after laparoscopic donor nephrectomy. Postsurgical chylous ascites are often managed with conservative treatment or surgery, but lymphatic embolization may be required. Here, we presented a 45-year-old male patient who was referred for abdominal distension for 1 week after left donor nephrectomy. The drain fluid was milky and fluid analysis revealed high concentrations of triglycerides and chylomicron, confirming diagnosis of chylous ascites. The patient was treated with conservative therapy including a low-fat diet and fluid drainage but continued to have high draining output (up to 1500-2000 mL/24 h). He underwent magnetic resonance lymphangiography and intranodal lymphangiography, revealing extravasation of contrast into the abdomen and the left renal fossa. We embolized the interstitial lymphatic of the left retroperitoneal and lymphatic vessels leak. The patient was discharged from hospital at the fifth day after intervention. In this article, we demonstrate lymphatic lesions, the safety, and success of this technique.

Treatment of Postoperative Lymphatic Leakage Applying Transpedal Lymphangiography - Experience in 355 Consecutive Patients

PURPOSE

 Report of experience from a single institution in treating postoperative lymphatic leakage (PLL) applying conventional transpedal lymphangiography (TL).

MATERIALS AND METHODS

 453 patients with the initial diagnosis of PLL receiving TL between 03/1993 and 09/2018 were identified in the database. Only patients with confirmed PLL were included in the study. The technical success, safety, and treatment success of TL were evaluated. Independent predictors of TL treatment failure were examined using univariate and multivariate logistic regression analysis.

RESULTS

 355 consecutive patients (218 men, 137 women; median age of 62 years) who underwent TL for PLL (e. g., chylothorax) after ineffective conservative treatment were included. The median time between causal surgery and TL was 27 days. The median technical success rate of TL was 88.5 %, with a median volume of Lipiodol of 10.0 ml. No complication of TL was recorded. Three groups were defined according to the different clinical courses: group A (41/355, 11.5 %) - TL with technical failure; group B (258/355, 72.7 %) - "therapeutic" TL alone with technical success; and group C (56/355, 15.8 %) - "diagnostic" TL with simultaneously invasive treatment (incl. surgical revision and percutaneous sclerotherapy). Treatment success rate and median time to treatment success were higher in group C than in group B, but without significant differences (64.3 % vs. 61.6 %, p = 0.710; six vs. five days, p = 0.065). Univariate and multivariate logistic regression analyses for group B confirmed drainage volume (> 500 ml/d) and Lipiodol extravasation as independent predictors of TL clinical failure (odds ratios [ORs] of 2.128 and 2.372 [p = 0.005 and p = 0.003, respectively]).

CONCLUSION

 TL is technically reliable, safe, and effective in treating PLL. When conservative treatment fails, TL can be regarded as the next treatment option.

KEY POINTS

  · TL is technically reliable, safe, and effective for treating PLL.. · When conservative treatment fails, TL can be regarded as the next treatment option.. · Drainage volume > 500 ml/day is an independent predictor of clinical failure after TL.. · Lipiodol extravasation is an independent predictor of clinical failure after TL..

CITATION FORMAT

· Pan F, Richter GM, Do TD et al. Treatment of Postoperative Lymphatic Leakage Applying Transpedal Lymphangiography - Experience in 355 Consecutive Patients. Fortschr Röntgenstr 2022; DOI: 10.1055/a-1717-2467.

Chylous Ascites after Laparoscopic Donor Nephrectomy: Case Report

Chylous ascites refers to the accumulation of chyle in the abdominal cavity. Postoperative chylous ascites is most commonly associated with abdominal aortic surgeries. However, it is a rare complication following laparoscopic nephrectomy. It causes loss of fat, protein, and antibodies causing malnutrition and immunodeficiency. Thus, it is important to treat it as early as possible. We hereby report a case of chylous ascites following laparoscopic donor nephrectomy. A 55-year-old female was admitted at our center 2 weeks after undergoing left laparoscopic donor nephrectomy with abdominal distension and constipation. USG abdomen revealed free fluid in the abdomen. Paracentesis revealed chylous ascites. The patient was started on conservative treatment, including a diet rich in proteins and low in fats; conservative treatment, however, was unsuccessful. Lymphangiography and subsequent embolization of the defect were done, and she made a full recovery.

Conservative management of chylous leak after open radical nephrectomy in an adult patient: a case report and literature review

Background

Chylous ascites is rare but still a recognized complication of retroperitoneal surgeries caused mostly by inadvertent trauma to lymphatic channels. In this article, we present a case report and literature review of adult patient, with malignant tumor of upper urinary tract, who developed chylous leak after open nephrectomy.

Case presentation

We present a case of chylous leak for a 67-year-old female patient, presented to urology clinic with complaining of left loin pain and gross hematuria, found to have upper urinary tract tumor, she underwent open radical nephrectomy with lymph nodes dissection, and postoperatively she had chylous leak that is treated conservatively using octreotide and spironolactone without the need for total parenteral nutrition.

Conclusion

Conservative management should always be the first choice of management of chylous leak and chylous ascites. Careful anatomical identification and securing of the periaortic lymphatics are needed to decrease the risk of postoperative chylous leak and ascites.

Iatrogenic chylous collection post laparoscopic nephrectomy

With the increasing number of laparoscopic nephrectomies, trauma to lymphatic channels has become an increasingly recognised complication. Early diagnosis and prompt management are key to avoid highly morbid sequelae including severe malnutrition and immunodeficiency. This case reviews the important complication of a retroperitoneal chylous collection following laparoscopic radical nephrectomy.