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

Abstract

Chylous ascites may result from a variety of pathological conditions, most of them from nontraumatic causes, such as congenital defects of the lymphatic system, infections, liver cirrhosis, and malignancy. Rarely, chylous ascites occurs as an iatrogenic complication after left-sided laparoscopic donor nephrectomy (LDN). Injury to the cisterna chyli and its main lymphatic tributaries around the para-aortic region intraoperatively can cause the lymphatic fluid to accumulate. There is currently no standardized treatment for chylous ascites as there have only been 54 cases documented to date. Most patients can be managed with conservative therapy. Recommended guidelines include high-protein and low-fat diet with medium-chain triglycerides. Paracentesis is often used as a diagnostic and therapeutic first-line measure with total parenteral nutrition (TPN), bowel rest, and somatostatin analogue as adjunct therapies. We present a case of massive chylous ascites refractory to conservative therapy. The patient had progressive abdominal distention and unintentional weight gain 2 weeks postoperatively warranting multiple paracenteses of >7 L of chylous fluid. Ultimately, the patient was successfully treated with lymphatic embolization using N-butyl cyanoacrylate glue.

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

“…In the study of Hiffa et al. [1] , the patient was successfully treated with intranodal lymphangiography embolization of the left retroperitoneal chylous leak under ultrasound guidance. In this patient, we embolized the reflux of chyle from the cisterna chyli and then the afferent lymphatic vessels at the lumbar to ensure the permanent occlusion of chylous fistular.…”

“…The non-traumatic cause includes congenital defects of the lymphatic system, infections, malignancy, and increased peritoneal lymphatic pressure secondary to obstruction [ 1 , 2 ]. CA may follow abdominal aortic surgery and retroperitoneal lymph node dissection, and rarely after donor nephrectomy which damages the cisterna chyli or lymphatics tributaries [1] . The diagnosis of CA is based on the presence of a triglyceride level higher than 110 mg/dL [3] .…”

Post-operative chyle leak following nephrectomy: Inference from tertiary care center and review of literature

“…Hippa et al 24 in their case report of chyle leakage (CL) after laparoscopic hand-assisted left donor nephrectomy, noted a persistent leak. The patient underwent lymphoscintigraphy and embolization on post-surgery day (PSD) 42 at an interventional radiology lymphatic center.…”

Lipiodol Lymphangiography and Embolization of Chylous Ascites After Pancreatoduodenectomy

“…Thus, early diagnosis and intervention is essential to minimize morbidity and mortality. Chylous leaks can happen anywhere along the pathway of chyle that begins in the intestinal lymphatic ducts and continue through the cisterna chyli and into the thoracic duct 2,5,7,11,15 . In this study, the patient was a 67-year-old male with previous chronic pancreatitis who underwent pancreatoduodenectomy for ductal adenocarcinoma of the pancreatic head.…”

“…Lymphangiography and percutaneous embolization are a less invasive procedure and have been reported to have a therapeutic effect in 56-86% of patients with lymphatic leaks 1,2 . Intranodal lymphatic embolization has been previously described in the treatment of some visceral lymphatic leaks 1,5,13 . This study aimed to present a case of chylous ascites after pancreatoduodenectomy treated with lipiodol lymphangiography and embolization.…”