Objectives: Chylous ascites is a rare complication that may occur after living donor nephrectomy. The continuous loss of lymphatics, which carries a high risk of morbidity, may ensue in possible immunodeficiency and protein-calorie malnutrition. Here, we presented patients who developed chylous ascites after robot-assisted living donor nephrectomy and reviewed the current literature of therapeutic strategies for chylous ascites.

Materials and Methods: We reviewed the medical records of 424 laparoscopic living donor nephrec-tomies performed at a single transplant center; among these, we studied the records of 3 patients who developed chylous ascites following robot-assisted living donor nephrectomy.

Results: Among 438 living donor nephrectomies, 359 (81.9%) were laparoscopic and 77 (18.1%) were by robotic assistance. In the 3 cases highlighted in our study, patient 1 did not respond to conservative therapy, which consisted of diet optimization, total parenteral nutrition, and octreotide (somatostatin). Patient 1 subsequently underwent robotic-assisted laparoscopy with suture ligation and clipping of leaking lymphatic vessels, allowing the chylous ascites to subside. Patient 2 similarly did not respond to conservative treatment and developed ascites. Despite initial improvement after wound interrogation and drainage, patient 2 had continued symptoms, resulting in diagnostic laparoscopy and repair of leaky channels leading to the cisterna chyli. Patient 3 developed chylous ascites 4 weeks postoperatively and received ultrasonographic-guided paracentesis by interventional radiology, with results showing an aspirate consistent with chyle. The patient's diet was optimized, allowing for initial improvement and eventual return to normal diet.

Conclusions: Our case series and literature review demonstrate the importance of early surgical intervention after failed conservative management for resolution of chylous ascites in patients after robot-assisted donor laparoscopic nephrectomy.

Key words : Chyle leak, Living-donor kidney transplant, Robotic donor nephrectomy

Introduction

Over the past decades, the use of minimally invasive (laparoscopic or robotic) living donor nephrectomy (LDN) has increased, as this procedure has shorter surgical times and length of hospital stay and less postoperative pain.^1,2 Living donor nephrectomy has been widely accepted as low risk and is associated with improved postoperative outcomes than older traditional approaches, with major complication rates reportedly ranging from 0.2% to 0.6% and minor complications rates ranging from 8% to 9.8%.³ A recent systematic review of postoperative complications of minimally invasive LDN revealed an overall rate of 7.3%.^3,4 Complications mainly included infections (2.6%) and bleeding (1%). Cardiopulmonary comp-lications, injury to other organs, gastrointestinal complications, and throm-boembolic events accounted for >1% of the cases of complications.⁴

Chylous ascites (CA) is an uncommon comp-lication caused by a disruption of the lymphatic system, leading to the expulsion of lymph into the abdominal cavity.^3,5,6 Up to two-thirds of CA cases in the Western hemisphere are due to underlying malignancy and cirrhosis.^7,8 Resection of an abdominal aortic aneurysm is a surgical procedure most frequently associated with CA, which is a rare complication of laparoscopic LDN with an incidence varying between 0.6% and 5.9%.^9-13 The initial treatment includes the optimization of nutritional status by using a high-protein, low-fat diet that is supplemented with medium-chain triglycerides. Conservative treatment along with total parenteral nutrition (TPN) has demonstrated up to 60% to 80% efficacy in resolution of symptoms.^5,9,14 In addition to dietary modifications, octreotide, a somatostatin analog, therapeutic computed tomography (CT) or ultrasonograph-guided paracentesis, and intra-abdominal drain placement have been shown to be effective.^9,12,15 Refractory cases to conservative treatment may require meticulous surgical ligation of the disrupted lymphatics.^7,16 It is not yet well understood whether the incidence of CA and its optimal treatment thereafter differ when treated with robotic-assisted LDN (RA-LDN) or laparoscopic LDN.

The purpose of the study was to report 3 cases of RA-LDN and to review the literature on CA after LDN and the therapeutic strategies.

Materials and Methods

This retrospective study was conducted by reviewing the medical records of 424 laparoscopic LDNs performed at single transplant center. The study was conducted in accordance with the latest version of the Helsinki Declaration as well as the Declaration of Istanbul on Organ Trafficking and Transplant Tourism after approval from the Institutional Review Board.

The technique for laparoscopic LDN has been previously described.¹⁷ For RA-LDN, briefly, the patient is placed on a lateral decubitus position with the table flexed. The procedure was performed by 2 transplant surgeons with the da Vinci Surgical System Xi. We used 4 arms with fenestrated bipolar forceps (EndoWrist bipolar cautery instrument; Intuitive Surgical). In arm 1, a monopolar cautery hook (EndoWrist monopolar cautery instrument; Intuitive Surgical) for dissection was used. In arm 2, a camera was used (3D Vision System 8 mm 30-degree endoscope; Intuitive Surgical). In arm 3, fenestrated tip-up forceps were used (EndoWrist Tip Up instrument; Intuitive Surgical). Arm 4 was used for retraction and the holding of tissue. Additionally, a 5-mm port was placed in periumbilical area as a bedside assistant for suctioning and other purposes. A Pfannenstiel incision was used for a GelPort (Applied Medical) insertion and later for kidney retrieval.

The kidney was exposed after mobilization of descending and splenic flexure of the colon anteriorly, and the gonadal vein was identified and traced up to the left renal vein. The robotic vessel sealer (EndoWrist Vesselsealer; Intuitive Surgical) was applied to divide the gonadal and the adrenal veins, in addition to the lumbar vein. The veins around the kidney were dissected. The renal artery was dissected anteriorly. The ureter was dissected all the way up to the pelvic brim circumferentially for completion. The upper pole of the kidney was mobilized and then rotated medially for a posterior dissection to free the renal vein and artery. Next, the ureter was clipped distally and cut. The remaining renal artery and vein were stapled using a 30-stapler (EndoWrist Stapler; Intuitive Surgical) with a white vascular load. The kidney was extracted through the GelPort and placed in an Endocatch bag (Medtronic). Before the trocars were removed, the kidney bed and vascular stumps were revised, and a hemostasis was performed. With the operation ?eld found to be dry, all incisions were closed intracutaneously. The patient tolerated the procedure well and was awakened from anesthesia without any issues.

Results

Of the 438 LDNs, 359 (81.9%) were purely laparoscopic LDNs and 77 (18.1%) were RA-LDNs. Among the 438 LDN, there were 3 cases of CA. They occurred after RA-LDN

Case 1

Using the Xi da Vinci robotic platform, a previously healthy 46-year-old male related living donor (recipient was his cousin) underwent elective transperitoneal left RA-LDN (Table 1). His body mass index (BMI; in kilograms divided by height in meters squared) was 30 and his preoperative CT scan showed conventional anatomy of the right and left kidney. We choose the left kidney, which had a single artery, vein, and ureter.

On postoperative day 1 after RA-LDN, the patient had increased abdominal distension and pain. A CT scan was performed to rule out intra-abdominal pathology, which showed dilated loops of bowel consistent with an ileus. After conservative treatment, his condition improved, and he was discharged by postoperative day 4. On routine clinic follow-up on postoperative day 8, he presented with severe scrotal swelling and a small amount of milky white discharge from the area of the laparoscopic incisions. His abdomen at the time was soft, nontender, and nondistended. The patient was given furosemide and advised to keep his scrotum elevated to alleviate the edema.

On postoperative day 12, he came to the emergency department with symptoms of abdominal pain, abdominal distension, and obstipation. A CT scan of the abdomen and pelvis showed a large volume of intra-abdominal fluid (Figure 1). He was subsequently admitted to the hospital. On posto-perative day 13, paracentesis was performed by the interventional radiology (IR) team, and 4.6 L of milky fluid was drained. The fluid drained was found to have a triglyceride level of 966 mg/dL, consistent with chyle (Table 2). Subsequently, he had an IR-guided drain placed to continue the drainage of chyle. He was started immediately on TPN, octreotide, and a clear liquid diet. He had a daily fluid drainage from the abdomen that ranged between 700 and1000 mL.

On postoperative day 42, the patient developed a generalized, severe abdominal pain. Peritoneal fluid analysis demonstrated methicillin-resistant staphylo-coccus aureus (MRSA) peritonitis, and the patient was subsequently started on vancomycin. On postoperative day 46, a decision was made that surgical intervention was the most appropriate next step. Thus, on postoperative day 49, high-fat food was given the night before the repair to identify the injured lymphatic duct.

The patient underwent robotic-assisted exploratory laparoscopy to repair the chyle leak. During the exploration, a small chyle leak was identified near the upper part of the renal artery lateral to the aorta (Figure 2). Several 2/0 Vicryl and 3/0 silk stitches were placed in the lymphatic tissue to control the leak. Fibrin glue was placed on the surface of the aorta and kidney bed. A drain was placed on kidney bed to prevent fluid accumulation. The procedure went without complications. Drain output was substantially reduced; by postoperative day 4, the drain output had completely ceased.

Total parenteral nutrition was discontinued, and the patient was started on a low-fat, high-protein diet, which was well tolerated with appropriate return of bowel function. He was discharged on postoperative day 7 from the chyle leak repair and monitored with close follow-up. During the subsequent visits, he was doing well and tolerated a normal diet without any symptoms.

Case 2

A previously healthy 59-year-old female and related living donor (recipient was her sister) underwent an elective left RA-LDN, performed by 2 surgeons using the da Vinci Xi platform. Her only relevant past medical and past surgical history included a caesarean section and open hysterectomy. Her perioperative BMI was 25. Preoperative CT angiography of the abdomen and pelvis demonstrated normal anatomy and vasculature of the 2 kidneys (Table 1 ). The left kidney was selected for organ donation given its single artery, vein, and ureter. A similar operative approach as previously described was undertaken for this case, in which a 3-port technique was utilized. The patient’s Pfannenstiel incision site from her prior hysterectomy was used to place the GelPort. After the kidney was completely freed, the ureter was clipped as distally as possible. The kidney was removed from the donor using an Endocatch specimen retrieval bag. The procedure was well tolerated by the patient, who awoke uneventfully from anesthesia and recovered in the postanesthesia care unit.

The patient experienced obstipation for 2 days, which resolved on a bowel regimen. The Foley catheter was removed on postoperative day 1. She was ambulating well during this time. The patient developed dependent, temporary reactive edema in the bilateral lower extremities (thigh and pelvic) and was given appropriate diuresis with interval improvement. On postoperative day 2, the pain regimen was switched from an epidural patient-controlled analgesia to oral pain medications without any issues. Other than some clear drainage appreciated from one of the incision sites, which was appropriately dressed, the patient’s immediate postoperative course was uneventful. She was discharged by postoperative day 4.

On postoperative day 6, the patient called to report increased weight gain, abdominal bloating, decreased appetite, and drainage from the wound. She came to the clinic the same day and presented with scant yellow drainage from the incision site and swelling of the lower abdomen and genitalia on physical exam. She tested positive for a urinary tract infection and underwent laboratory testing of urine and wound cultures. The patient underwent CT of the abdomen and pelvis, which revealed subcutaneous emphysema, pneumomediastinum, perisplenic fluid collection, and foci of air at the surgical bed. On postoperative day 7, a chest CT scan was performed, verifying the lung findings seen on the abdominal CT. At this time, she was started on Lasix for diuresis.

On postoperative day 8, the patient returned to the clinic; physical examination showed copious yellow-white, milky drainage from the incision site for which an ostomy was placed for drainage. Culture results returned positive for Group B Strep and Enterococcus faecalis. She was admitted to the transplant service and started on Augmentin and a low-fat, high-protein diet for presumed chylous leak. Lasix was stopped due to her elevated creatinine levels in the setting of the recent LDN. The drainage diminished overnight. Abdominal ultrasonograph demonstrated 2 fluid collections under the incision site (3.1 × 0.4 × 2.4 cm) and (1.0 × 8.6 × 1.2 cm); however, retroperitoneal ultrasonography did not demonstrate any organized fluid collections in the retroperitoneal cavity. On postoperative day 9, drainage had stopped, and the patient was tolerating her modified diet; thus, the ostomy was removed, and she was discharged.

On postoperative day 11, the patient called the clinic because drainage had resumed. The following morning, she was examined, and an ostomy was placed again. A repeat CT of the abdomen and pelvis demonstrated interval increases in free pelvic fluid and stable perisplenic fluid. Wound aspirate revealed elevated triglyceride levels of 677 mg/dL (Table 2). The patient was taken to the operating room the same day for assessment of the wound and closure of any leakage. In the operating room, the surgeon used scissors to cut the previous sutures and went down to the level of the fascia. The leak was visualized from the most medial corner of the incision and turbid fluid poured out. The incision was opened 1 cm and a UR stitch was used to reinforce that corner with a figure 8 stitch approach multiple times. The corner of the fascial incision was sealed and no longer leaked. The skin was left open, and the incision was irrigated multiple times. The procedure was well tolerated.

On postoperative day 12 from the RA-LDN, the first day after return to the operating room for wound assessment and fascial reinforcement, the patient had slight edema over the right hip and thigh and notable swelling of the lower abdomen. An abdominal ultrasonography performed on postoperative day 13 demonstrated moderate ascites (Figure 3). On postoperative day 14, the patient’s abdomen was mildly distended with a positive fluid wave. She tolerated her low-fat, high-protein diet with no significant abdominal pain. The patient expressed the desire to seek care alternatively and was deemed suitable for discharge on postoperative day 15.

On postoperative day 19, the patient returned to the operating room at a different institution for a diagnostic laparoscopy with repair of the chylous leak from the cisterna. Over 5 L of chyle in the abdomen was removed. The leak was identified lateral and posterior to the aorta below the level of the renal hilum, at what appeared to be a staple line from the previous arterial ligation. Multiple clips, including locking and titanium clips, were utilized to seal all leaky channels leading to the cisterna chyli. Postoperatively, the patient had mild accumulation of ascites that improved over time. She was started on TPN (for a duration of 18 days), a no-fat diet, and octreotide injections (for 8 days). On postoperative day 4 following the chyle leak repair, the patient was discharged home. We kept in touch with the patient and colleagues from the outside hospital during this time and during the recovery process. Approximately 1 month after surgical repair, the patient returned to work, participated in physical therapy, tolerated her regular diet, and returned to her regular weight. Approximately 18 months after surgicalrepair, she reported doing extremely well and had run a marathon. Her latest laboratory work returned revealing her baseline postoperative renal function (creatinine 1.10 mg/dL, blood urea nitrogen 21 mg/dL, glomerular filtration rate 55 mL/min/1.73 m²) and an otherwise unremarkable basic metabolic panel and complete blood count within normal limits.

Case 3

A previously healthy 42-year-old related living female donor (recipient was her brother) with no significant past medical history underwent a left RA-LDN using the Xi da Vinci platform (Table 1). Her perioperative BMI was 24.5. Preoperative CT angiography of the abdomen and pelvis de-monstrated standard anatomy of both kidneys and a nonenhancing cyst in the lower pole of the left kidney. The left kidney was again selected for organ donation given its solitary artery, vein, and ureter. The procedure was performed by 1 transplant surgeon with the aid of a trained physician assistant who was well-versed in bedside assistance with the da Vinci surgical system. The procedure was carried out in standard fashion through a Pfannenstiel incision as previously described. The ureter was clipped distally. The kidney was removed from the donor in an Endocatch specimen retrieval bag. Surgicel was placed on the vein and artery stump areas for hemostasis. The patient tolerated the procedure well and awakened from anesthesia uneventfully.

On postoperative day 1, the patient experienced some nausea and increased abdominal pain. She was started on Reglan, naproxen, and Robaxin for presumed muscle cramps. Her symptoms improved overnight, and she was discharged by postoperative day 2. During a routine follow-up call, the patient reported reduced appetite due to mild abdominal pain, for which small frequent meals were advised. During a visit with her primary care physician on postoperative day 9, the patient reported abdominal pain and constipation, for which Colace was started. When she returned to the clinic for routine follow-up on postoperative day 13, the patient reported improvement in her abdominal pain. Her renal function was stable, and her incision sites were healing well.

On postoperative day 28, the patient called the office because of decreased appetite and abdominal distension. She reported no issues passing flatus or with having bowel movements. The patient arrived at the clinic on the same day, and her physical examination demonstrated distension with positive shifting dullness. Abdominal ultrasonograph revealed significant ascites (Figure 4). The patient chose to pursue conservative management initially. Ultrasonograph-guided paracentesis was performed by IR on the same day, yielding 5350 mL of milky white fluid, later found to contain a triglyceride level >4250 mg/dL and be consistent with chyle (Table 2) (Figure 5). She was started immediately on a low-fat, high-protein diet.

On postoperative day 36, the patient returned to the clinic for follow-up. Her abdomen at this time was mildly distended in the lower quadrants, suprapubic, and right and left iliac fossa, without rebound or guarding. Repeat abdominal ultraso-nography demonstrated interval decrease of free fluid in the abdominal cavity, although some fluid now extended into the pelvis (Figure 6). The patient was counseled on her options for conservative management versus surgical treatment. She ultimately decided to continue conservative management for the time being and underwent ultrasonograph-guided paracentesis with IR. An additional 2500 mL of milky fluid was removed that same day (Figure 7).

On postoperative day 43, the patient returned to the clinic for routine follow-up. Her examination showed the abdomen to be soft, flat, nontender, and nondistended. Abdominal ultrasonograph demonst-rated trace ascites. The patient returned to clinic again on postoperative day 49 for repeat abdominal ultrasonograph imaging, which demonstrated no intra-abdominal fluid. Patient was advanced to a 40-g, low-fat diet and has been doing well at subsequent visits.

Discussion

Chylous ascites, or chyle fluid accumulation in the abdomen, is a rare complication following laparoscopic LDN or RA-LDN.18 This uncommon iatrogenic complication typically occurs from disruption of abdominal lymphatics, such as the cisterna chyli or other retroperitoneal lymphatic channels encountered intraoperatively, causing a lymph-peritoneal fistula.¹⁹ Although often seen as a complication of abdominal aortic aneurysm resection, CA is emerging as a rare complication seen in gynecologic and urologic procedures as well as laparoscopic procedures, particularly left-sided donor nephrectomies.^9,11,20,21 Although rare, this complication may be caught intraoperatively, where prompt ligation and clipping of the lymphatic vessels allows for immediate correction without pos-toperative issues.²² One suggested cause for CA in laparoscopic LDN is the dissection of fibro-fatty tissue while dissecting around the renal vessels without sequential clipping, sometimes necessitating reexploration to clip or ligate the leaky channel.²⁰ Until now, about 60 incidences of CA after a laparoscopic LDN have been reported.^{9,10,19,20,23-45} To our knowledge, the present cases are the fourth, fifth, and sixth reports of CA after a RA-LDN in the literature.^18,22

Although detailed history and physical exa-mination provide initial clues on diagnosis, CA diagnosis is established by fluid analysis of an overall milky appearance, containing a triglyceride level of >110 mg/dL, cytology (lymphocyte predominance), cell count, and chemical analysis.⁷ The most common symptoms of CA are abdominal distension and weight gain; however, some patients may have gastrointestinal symptoms and shortness of breath from the elevated intra-abdominal pressure.^7,19 Computed tomography might be of particular use for postoperative cases of CA to determine the location and extent of possible injury.⁷ For those patients who do not respond to conservative treatment, other imaging modalities such as lymphangiography, lymphoscintigraphy, or radionuclide scan may be considered.^5,19 Initial treatment of CA includes palliative paracentesis and diet optimization consisting of low-fat diet that is supplemented with medium-chain triglycerides, TPN, and somatostatin; however medical management is often prolonged and associated with significant morbidities.^11,13,46 The constant depletion of proteins and lymphocytes in CA contributes to nutritional and immunologic deficits.^5,11,13,46

Surgical ligation of the leaking lymphatic channel for surgical candidates, such as those who can tolerate LDN, as well as peritoneovenous shunting or percutaneous transabdominal embolization for poor surgical candidates, become possible treatment options once patients no longer respond to conservative treatment.^5,19,27 The exact time to intervene and operatively repair the leak remains controversial. Some authors suggest initial conservative management for at least 8 to 12 weeks.^5,20,46 Others advocate for early operative intervention.^11,19,38,46 In this report, we present 2 patients who did not respond to conservative treatment and developed prolonged, debilitating conditions due to worsening CA. They required ope-rative management within 7 and 3 weeks, respectively. We also present 1 patient who had successful conservative measures after ultrasonograph-guided paracentesis was performed (Table 3).

Symptom onset in our series ranged from day 6 to 28 postoperatively. Patient 1 continued to experience drainage and abdominal pain while being treated conservatively for several weeks on low-fat diet, TPN, and octreotide. Without any significant improvement, he eventually developed MRSA peritonitis, a life-threatening complication. He ultimately required surgical intervention on postoperative day 46 with ligation of leaking lymphatic channels for definitive treatment and resolution of symptoms. This highlights the importance of early surgical intervention in the localization and repair of leaking chyle duct after patients do not respond to conservative treatment to avoid life-threatening outcomes.

Patient 2 in this series also presented with clinical symptoms typical of CA and was started on a low-fat, high-protein diet for presumed chylous leak from the wound. Equivocal imaging postoperatively did not warrant immediate surgical exploration. However, repeat imaging, additional milky leakage from surgical wound sites, and an interval increase in abdominal/pelvic distension and free fluid necessitated further assessment in the operating room. A more aggressive exploration may have discovered the source of leak sooner. However, a diagnostic laparoscopy on postoperative day 19 was ultimately successful in identifying and repairing the source of chyle at the cisterna chyli. This case demonstrates the benefit of early surgical exploration for the localization and repair of a persistently leaky chyle duct after failed conservative management.

Patient 3 highlights the potential role of conservative tapping and fat-free diet for treatment of patients with CA following RA-LDN. Ascites in patient 3 was quickly identified on abdominal ultrasonography when she presented in the clinic with concerns for chylous leak. Ultrasonography-guided paracentesis performed by IR in conjunction with dietary optimization did not immediately resolve the CA. However, with close follow-up and monitoring of symptom progression, repeating the paracentesis when symptoms returned in 1 week resulted in successful treatment of CA without requiring return to surgery. Subsequent visits demonstrated a slow resolution in ascitic buildup when the source was not directly and surgically repaired.

A management strategy based on daily drain output and similar reports have demonstrated that patients with postoperative CA can be successfully treated nonoperatively and that patients may require surgical reexploration to definitively seal the chyle leak once conservative therapy is not successful.^9,13 Although more than half of CA secondary to LDN may resolve with conservative treatment alone, life-threatening complications from unresolved CA may emerge, including continued excessive chylous losses, nutritional deficiency, and cachexia.^9,13 Our experience also demonstrated the possibility of MRSA peritonitis. Capocasale and colleagues reported results in 8 donors who were treated conservatively after developing postoperative CA and concluded that the complication may significantly prolong hospital stay.¹¹ For this reason, some authors argue in favor of early surgical intervention to achieve definitive repair, prevent immunologic and nutritional derangements, and ultimately shorten hospital stays.^5,11,46

From our literature review of all currently reported cases of CA after laparoscopic LDN, 47 of 60 patients (78%) were successfully treated conservatively (Table 4). The remaining 13 required operative repair, with most performed laparoscopically. Although why certain patients may require operative management and others respond to conservative measures alone remains unclear, it may have to do with the extent of the lymphatic defect. It remains to be seen whether the transition to more RA-LDN procedures may contribute to a higher incidence of CA.²²

Including our present cases, 6 instances of CA after RA-LDN have been reported in the past 7 years.^18,22 Half of these patients required operative repair due to failure to respond to conservative measures alone. Therefore, we suggest an abridged period of conservative management, close monitoring, and a lower threshold for operative exploration after RA-LDN. If symptoms do not resolve within the first few weeks, surgical repair should be thoughtfully considered to identify the leak. This will avoid the complications of CA and comorbidities associated with prolonged hospitalization. The ideal candidate may have already attempted diet optimization, paracentesis, drain placement, and somatostatin with no lasting improvement.

Conclusions

Early surgical intervention after failed conservative management is important for the complete resolution of CA in patients who have had RA-LDN. We propose that prompt surgical reexploration with identification and repair of lymphatic leak once patients do not respond to initial, conservative measures could carry less morbidity and decrease hospital stays compared with conservative treatment alone.

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