Laparoscopy and Robotics

Management Protocol for ChylousAscites After Laparoscopic Nephrectomy

Ankush Jairath, Abhishek Singh, Arvind Ganpule, Shashikant Mishra, Ravindra Sabnis,and Mahesh Desai

OBJECTIVE To devise a management protocol for chylous ascites after laparoscopic nephrectomy.

Financial Disclosure: The authoFrom the Muljhibhai Patel UroAddress correspondence to: An

Department of Urology, MuljhibhE-mail: ankushjairath@gmail.comSubmitted: January 31, 2015,

ª 2015 Elsevier Inc.All Rights Reserved

PATIENTS ANDMETHODS

We retrospectively reviewed the data of the patients that underwent laparoscopic nephrectomybetween January 2010 and January 2014 in our institution for different indications and were

diagnosed with chylous ascites. We also analyzed a different management protocol that was used.

RESULTS The overall incident rate of chylous ascites was 0.77%. It was more commonly seen on left side

and with simple nephrectomy rather than radical. Three out of 9 patients were managed bysurgical intervention, rest were successfully managed on conservative treatment in the form ofdietary modification, total parenteral nutrition, or octreotide.

CONCLUSION Chylous ascites is a rare but morbid condition following laparoscopic nephrectomy. To manage

this complication, we propose preventive and treatment strategies based on symptoms andamount of chylous ascites using our experience and review of the literature. UROLOGY -: -e-,2015. � 2015 Elsevier Inc.

hylous ascites is the accumulation of chyle in theperitoneal cavity1,2 and represents one of the

Cuncommon complications after retroperitoneal

surgery. It has been reported after laparoscopic nephrec-tomy with a variable incidence ranging from 0.6% to5.9%,3-5 incidence being higher in radical as well as indonor nephrectomies.

Although most of the cases can be managed conser-vatively,6 some of them need invasive and aggressiveapproach in order to correct the chylous leakage andprevent the devastating complications related to malnu-trition and infection.1

Chylous ascites is a rare occurrence after laparoscopicnephrectomy and has diverse management option withlack of uniformity in treatment patterns. We propose amanagement protocol for this challenging complicationbased on our institutional experience.

PATIENTS AND METHODS

We retrospectively reviewed the data of the patients that un-derwent laparoscopic nephrectomy in our institution fordifferent indications, ranging from donor to simple and radicalnephrectomies.

In the patients that presented with chylous ascites followingthe procedure, clinical parameters as well as management pro-tocol were retrospectively reviewed and outcomes wereevaluated.

rs declare that they have no relevant financial interests.logical Hospital, Nadiad, Gujarat, Indiakush Jairath, MS Surgery, DNB Urology (Resident)ai Patel Urological Hospital, Nadiad, Gujarat, India.

accepted (with revisions): June 1, 2015

h

We used the following management options in our patients:

1. Dietary management:Patients were put on total restriction of long-chain fatty acids.

Medium-chain triglycerides (MCT) powder or MCT oil of 5 g or5 mL, respectively, thrice a day (TDS) was started and increasedto 15 mL or 15 g TDS if needed. MCT was mixed with limewater/Gatorade/Enerzal to make it palatable. This provided350-400 kcal energy. The target protein intake was 2 g/kg. Restof energy requirements were met with carbohydrate intake.We started the following dietary regimen for 2 weeks: 2 egg

white with 200 mL Amul toned fat-free milk (100 calories and15 g protein) TDS (300 calories), half-cup boiled potatoeswith added salt in the morning and evening (150 calories), 1bowl boiled vegetables, such as cauliflower, french beans,carrot, peas, twice a day (100 calories per serving) plus one-and-a-half bowl rice (150 calories) with 1 bowl green grams(350 calories, 63 g carbohydrates, 24 g protein) twice a day.With this diet we supplemented multivitamins, essential fattyacids, and micronutrients.

2. Injection octreotide 100 mcg subcutaneous TDS3. Total parenteral nutrition (TPN)4. Laparoscopic surgical ligation of lymphatics

RESULTSBetween January 2010 and January 2015, we performed1156 laparoscopic nephrectomies, including 649 livedonor, 330 simple, and 177 radical procedures. Nine casesof postoperative chylous ascites were diagnosed, with atotal incidence of 0.77%. Average time of presentationwas 17 days post surgery. Majority of this complicationwas seen after simple and donor nephrectomy, while 1case of radical nephrectomy also presented with chylousascites (Table 1).

ttp://dx.doi.org/10.1016/j.urology.2015.06.0010090-4295/15

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Table 1. Demographic data and management protocol used in different patients on the basis of our experience

CaseAge

(years)/sex Primary Procedure Presentation Initial Management Final Management Outcome

1 41/M B/L laparoscopic pretransplant native kidneynephrectomy

Chylous fluid on 4th PODfrom drain

Octreotide with dietaryrestriction

Continued the sameconservative treatment

Drain output graduallydecreased. Patient wasdischarged on 14th POD

2 45/M Renal allograft transplantrecipient status post B/Llaparoscopic pretransplantnative kidney nephrectomyfor ADPKD

Chylous fluid on 1st PODfrom drain

NBM with TPN and octreotide Continued the sameconservative treatment

Drain output graduallydecreased. Patient wasdischarged on 22nd POD

3 59/M Laparoscopic left donornephrectomy

Abdominal distentionand gross ascites on21st POD

Drain placement with statoutput of 4500 mL andsubsequent daily outputwas <500 mL/day. Inaddition, patient was keptNBM and TPN was given for1 week

Octreotide with dietaryrestriction

Drain output graduallydecreased. Patient wasdischarged on 14th postdrain placement

4 45/F Laparoscopic left donornephrectomy

Abdominal distentionand gross ascites on28th POD

Drain placement with statoutput of 5000 mL andsubsequent daily output was1500 mL/day

Surgical intervention withoctreotide and dietarymodification

Drain was removed on 3rd dayafter ligations of lymphaticsand patient was dischargedon 4th POD

5 42/M Renal allograft transplantrecipient status post B/Llaparoscopic native kidneynephrectomy for recurrentpyelonephritis

Accidental peritonealrent during transplant1 month after B/Lpretransplantnephrectomy

On table drain placement withstat output of 2000 mL andsubsequent daily outputwas <500 mL/day

Octreotide with dietaryrestriction

Drain output graduallydecreased. Drain wasremoved on 14th day postplacement

6 44/F Laparoscopic left simplenephrectomy done fornonfunctioning kidneysecondary to stone disease

Abdominal distentionand mild-to-moderateascites on 24th POD

Octreotide with dietaryrestriction

Octreotide with dietaryrestriction

Ascites resolved over 6 weeks

7 24/M Laparoscopic left donornephrectomy

Abdominal discomfortand moderate asciteson 14th POD

Octreotide with dietaryrestriction for 3 weeks butdiscomfort and ascitesincreased

Surgical intervention withoctreotide and dietarymodification

Drain was removed on 4th dayafter ligations of lymphaticsand patient was dischargedon 5th day.

8 72/F Laparoscopic left radicalnephrectomy

Mild abdominaldiscomfort and mildascites on 30th POD

Octreotide with dietaryrestriction

Octreotide with dietaryrestriction

Ascites resolved over 4 weeks

9 52/F Laparoscopic left donornephrectomy

Abdominal distentionwith port site milkydischarge

Patient was kept NBM, TPNwas started in additionto subcutaneoussomatostatin but

Required surgical interventionin view of difficult woundmanagement and persistentdischarge

Patient was discharged on 4thPOD after surgical ligation oflymphatics

ADPKD, autosomal dominant polycystic disease; B/L, bilateral; F, female; M, male; MCT, medium-chain triglycerides; NBM, nil by mouth; POD, postoperative day; TPN, total parenteral nutrition.

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Figure 1. (A) Hilar area demonstrating oozing lymphatics. (B) After clipping, CT-1 needle is used to ligate oozing lymphatics.(C) Surgicel bolster placed over hilar area to reinforce clipping and ligation area. (D) Finally, the area is secured with Floseal.(Color version available online.)

Several strategies were used (Table 1) and the choicewas made by the clinical judgment of the urology team incharge. Among the 9 patients diagnosed to have chylousascites (Table 1), 2 were diagnosed on the evaluation offluid from a preplaced drain. One of the patients was atransplant recipient who had undergone bilateral pre-transplant nephrectomy, and on first postoperative dayafter right iliac fossa transplant started draining chylousfluid from drain (Fig. 1A), with a daily output of around500 mL/day. The patient was managed with TPN withoctreotide injection followed by dietary management.The other patient responded well to octreotide and di-etary modification.

Another patient who was also a prospective transplantrecipient (had undergone a bilateral pretransplant ne-phrectomy, asymptomatic in postnephrectomy and pre-transplant period), was diagnosed with chylous ascitesduring renal transplant intraoperatively when acciden-tally peritoneum got opened. In this patient a drain waskept intraoperatively, dietary modification and octreotidewere started postoperatively and the patient settled withthis management.

Four patients presented with abdominal distension.Ultrasonography was suggestive of ascites in all thesecases. Out of these, 2 patients underwent a percutaneousdrain placement under local anesthesia as they hadmoderate-to-severe ascites and drain fluid was furtherevaluated to confirm chyle. One of them was managed

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initially by TPN but finally required surgical intervention.The other one was successfully managed on TPN. Thethird patient underwent paracentesis as he had mild-to-moderate ascites. Fluid evaluation confirmed the diag-nosis, and he was successfully managed with octreotideand dietary restrictions. Fourth patient presented withmilky discharge from one of the port site 2 weeksfollowing laparoscopic live donor nephrectomy. He wasinitially managed conservatively on TPN and octreotide(given for a week), but in view of persistent discharge,nonimprovement of symptoms, and difficult local woundmanagement finally required laparoscopic explorationand ligation of lymphatics.

Two patients presented with vague abdominaldiscomfort, feeling of fullness in abdomen, and earlysatiety. On ultrasonography both were found to haveascites and underwent paracentesis and fluid evaluation toconfirm the diagnosis. They were started on dietarymanagement and octreotide. One responded favorably;however, the other patient had progressive increase inascites that necessitated lymphatic ligation (Fig. 1A-D).

COMMENTAlthough the principal cause of postoperative chylous as-cites is abdominal aortic surgery,1 transabdominal spinalapproaches as well as gynecologic and urologic procedureshave also beendescribed as case series and single case reports.

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The incidence of chylous ascites following laparoscopicnephrectomies varies from 0.6% to 5.9% and is usuallyrelated to radical procedures that include wide dissectionand sometimes lymphadenectomy or with living donornephrectomies in which extensive dissection is made overthe aorta and/or inferior vena cava in order to obtain themaximal length of the renal vessels. In the series pub-lished by Kim et al in 2010, the incidence stratified by thetype of procedure showed a clear higher risk in these twoprocedures that reached more than 6%; while simple andpartial nephrectomies had incidence of 1.1% and 2.6%,respectively.2

The proposed cause for the increased incidence inlaparoscopic nephrectomy is attributed to the inability totie all the tissue and use of hook with cautery to clear thefibro-fatty tissue around the renal vessels. While dissect-ing the fibro-fatty tissue the plan should be to split thetissue with sequential clipping. When large lymphaticsare encountered they are split into smaller chunks, thenclipped and further divided.

When the patients from endemic areas (where tropicaldiseases affecting the lymphatic system are common)undergo these procedures, the rate of lymphatic leak maybe significantly higher. In our series, 2 out of 9 patientsbelonged to endemic areas where filariasis was common.Obvious lymphatic leak on table while doing a laparo-scopic surgery may also indicate propensity of develop-ment of chylous ascites.

In our series 4 patients underwent simple nephrectomy(3 being bilateral procedures), 4 underwent donornephrectomy, and 1 radical procedure. This discrepancywith previous reports may be as a result of the smallnumber of cases evaluated or the fact that many simplenephrectomies performed in our center are due to kidneysseverely damaged because of stone disease and repeatedinfections, often requiring wide dissections, includinglymph nodes and lymphatic vessels. This is in contrast toopen surgery where we can go subcapsular or seriallyclamp, cut, and ligate in difficult cases.

Majority of our patients presented with abdominalsymptoms or with high characteristic output through thepreplaced abdominal drain. One patient presented withchylous discharge through the surgical wound. In somecenters the abdominal drain is placed routinely after everylaparoscopic nephrectomy,2 allowing the prompt diag-nosis and treatment of this condition. We routinely donot place a drain but believe that drain should be placedin high-risk individual, that is, patients having prominentlymphatic, milky discharge on transection of lymphatics,patients with bulky nodal tissue, and extensive dissection.

The time to presentation is not mentioned in many ofthe series, but a few published reports show that it isextremely variable and can range from several days toseveral weeks or even months after the surgery.1 In ourseries all the cases presented during the first postoperativemonth. The prompt diagnosis is one of the key to preventnutritional and infectious complications that can affectthe outcome of these patients. Three mortalities reported

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in the series by Pabst et al7 in cases of chylous ascites afterabdominal aortic surgery were due to sepsis and nutri-tional deterioration.

Conservative management is the primary modality oftreatment with success rates ranging from 67% to100%.1,5 Its objective is to reduce the mesentericlymphatic flow, restore the nutritional losses, and alle-viate the symptoms.

When patients present with abdominal distension andsymptoms of compression such as early satiety and dys-pnea, paracentesis is both diagnostic and therapeutic.However, it should be used judiciously as it carries the riskof infectious complications, which can further deterioratenutritional and immunological status of the patient. Theplacement of a percutaneous drain is often necessary butshould always be coupled with other conservative mea-sures, otherwise the permanent drain can prolong theleakage.

Dietary modification is the simplest and first treatmentusually adopted. It includes high-protein, MCT diet,low-fat intake, and salt restriction. As an only treatment,it can solve up to 50% of the mild cases of chylous as-cites. This dietary intervention should be continued forseveral months after resolution in order to preventrecurrences.1

Some authors recommend the use of TPN from thetime of diagnosis.2 Our tendency is to avoid it as long asthe patient is tolerating an adequate calorie intake as theparenteral nutrition itself carries some risk. Nevertheless,in cases not responding to dietary modification or in thosepatients with poor nutritional status, TPN is highlyadvised.

The use of somatostatin and its analogs is gainingpopularity, although its mechanism of action is yet un-clear. The analogs, octreotide and lanreotide, effectivelyreduce the lymphatic drainage and lead to early resolu-tion.8 The dose of octreotide can be started at 100 mgTDS and can be progressively increased up to 200 mcgaccording to the response.9 In our series, all the patientswere treated with somatostatin analog as one of the pri-mary measures.

Other drugs such as etilefrine and iodinated dye havebeen described in isolated cases but still there is noenough evidence to recommend them. Their use iscurrently restricted to clinical trials only.10,11

Surgical intervention is reserved for those patients whodo not respond to conservative measures, but its timingremains controversial. Many authors agree that anonoperative approach for at least 4 weeks is warranted,while some advice to wait even for 12 weeks.2

In cases with chylous ascites after bilateral nephrec-tomy, intraoperative findings, such as oozing lymphatics,dense fibro-fatty tissue, site of more extensive lymphaticdissection, or removal, during the primary surgery cangive a clue about the site of leakage whether left or right.Moreover, if a drain is kept it can give a fair idea of side ofleak. In the absence of the above, a lymphoscintigraphyand lymphangiogram should be done.

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Table 2. Demographic data and management protocol used in different patients based on review of literature

AuthorNo. ofCases

Age(Years)/Sex Primary Intervention Presentation Management Outcome

Sharma et al15 1 60/F Left laparoscopicdonor nephrectomy

7th POD with abdominalsymptoms

MCT with elementary diet Resolved over 4 weeks

Gagliano et al16 1 44/F Left laparoscopicdonor nephrectomy

Abdominal distention, pain, anddyspnea on 16th PODdiagnosed with gross ascites

Percutaneous drain placement with MCT,diet modification, and spironolactone

Resolved over 4 weeks

Bachmann et al17 1 59/F Left laparoscopicRetroperitoneoscopydonor nephrectomy

Abdominal pain, diarrhea,and gross ascites on 8th POD

Initial percutaneous drain placement butrequires laparoscopic drainage withdiet modification and somatostatin

Success

Geary et al13 1 44/F Hand-assisted donornephrectomy

Abdominal distention andloss of appetite with grossascites on 14th POD

Initially MCT, TPN, and somatostatin,but in view of nonimprovement after1 week of conservative management,hand-assisted ligation of lymphaticswas done

Patient was discharged on4th POD

Molina et al12 1 45/F Left laparoscopicdonor nephrectomy

Abdominal distention, dyspnea,and gross ascites on 13thPOD

Initially started TPN with somatostatinthen percutaneous drain placementfollowed by laparoscopic lymphaticligation in view of nonimprovementeven after 10 weeks

Success after surgicalintervention

Caumartin et al18 1 48/F Left laparoscopicdonor nephrectomy

Abdominal distention anddyspnea on 10th PODdiagnosed with gross ascites

Initially managed by TPN andsomatostatin. Patient respondedand was discharged on MCT withdiet modification. But patient readmitteddue to reaccumulation of ascites fluidand finally required laparoscopiclymphatics ligation. Postoperativerecurrence of ascites was managedby paracentesis, MCT, and dietarymodification

Success after surgicalintervention andparacentesis thereafter

Aerts et al19 1 50/M Left laparoscopichand-assisteddonor nephrectomy

Abdominal distention, painwith gross ascites on 26thPOD

Initially managed by percutaneous drainplacement (12.275 L output over first24 hours), MCT, and diet for 1 weekfollowed by TPN after failure for 3 weeks.But required laparoscopic lymphaticsligation

Success after surgicalintervention

Sharma et al20 1 48/M Left retroperitoneoscopicdonor nephrectomy

Left flank pain, swelling, fever,nausea, and vomiting on14th POD

Initially drain placement with immediateoutput of 1.6 L and subsequent500 mL/day. This was followed byoctreotide and dietary management

Resolves over a week

Meulen et al21 1 34/F Laparoscopichand-assisted leftdonor nephrectomy

Abdominal bloating andconstipation on 12th POD

Initially paracentesis followed by octreotide,MCT, and dietary modification

Resolves over a week

Abbreviations as in Table 1.

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Figure 2. Proposed management protocol to manage chylous ascites. (Color version available online.)

In general (on the basis of review of literature com-bined with our own experience), it has been observedthat patients with a constant drain output of more than1000 mL per 24 hours are the candidates that are unlikelyto respond to conservative management and eventuallyneeded surgical intervention.

In our series, 3 patients needed surgery: first one thatdid not respond after 1 week of conservative therapy, thesecond patient who presented with port site chylousdischarge along with difficult local wound management,and the third one who had progressive ascites even after3 weeks on octreotide and dietary management.

All the 3 patients were successfully managed by lapa-roscopy, clipping all the perihiliar lymphatic tissue. In

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these cases we prepared the patient by giving them 50 gbutter orally, a night prior to surgery to delineate oozinglymphatics better during surgery. Intraoperatively, afterperitoneoscopy all the chyle was sucked out. The colonwas reflected medially. In 1 case colon was densely stucklaterally. In this particular case, bowel was freed and re-flected medially by sharp dissection using scissors. Carewas taken to dissect away from lateral border of colon.Resultant bleeding was managed using diathermy oncecolon was away. Slowly landmarks were identified. Firstpsoas was seen and gradually dissection proceeded fromlateral to medial aspect of psoas sheath till medial marginof psoas was visualized. This was done at the level fewcentimeters above the pelvic brim and then medial edge

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of psoas was followed cranially till oozing lymphatics wereseen (Fig. 1A). However, there were dense adhesionsencountered in all the cases. After oozing lymphatics werevisualized, they were clipped using Weck clips. All thefibro-fatty tissues around the great vessels and the renalhilum were clipped. Larger oozing lymphatics were su-tured using Vicryl on CT-1 needle with Weck clipattached at one end (Fig. 1B). Surgicel bolster (Fig. 1C)and Floseal (Fig. 1D) were also used in 2 cases. Post-operative outcome was uneventful and the patients weredischarged after the surgery when drain output becameinsignificant following the restart of restricted enteralnutrition and the discontinuation of octreotide.

Molina et al12 presented the first report of laparoscopicmanagement of chylous ascites after donor nephrectomy.As no obvious chyle leakage was evident, they appliedseveral clips in the perihiliar area followed by argon beamcoagulation and fibrin glue. In 2004, Geary et al13 alsodescribed a case of laparoscopic management of chylousascites in which they were able to identify the source of theleak and the leak was controlled by intracorporeal suturingand bipolar electrocautery. As the expertise in laparo-scopic approach continues to increase, and considering theadvantages of the magnified view and the minimal inva-sion, the indication of laparoscopy in the management ofthese cases becomes more evident each day.

Peritoneovenous shunts have been performed as analternative to invasive approach, especially in those pa-tients with high volume losses and poor performance statusthat are not able to undergo surgery and need a promptresolution. Nevertheless, serious complications such as fatemboli, disseminated intravascular coagulation, and sepsishave been reported. For the same reason, this procedure isreserved only for those cases not suitable for surgery.7

Cope et al14 described successful embolization of themajor retroperitoneal lymphatic ducts through a trans-abdominal percutaneous puncture in 4 of 5 patientstreated with this approach, although more studies areneeded to validate this procedure.

Chylous ascites is a complication that can be pre-vented; hence, the surgeons operating in the retro-peritoneum must recognize the value of ligating andsecuring all the lymphatics with clips surrounding themajor vessels and the renal hilum.

There is a lot of nonuniformity in the managementprotocols and literature is also scant. Even in large seriespresented by Kim et al,2 where they have reported 32patients with incidence rate of 5.1%, they lack definitemanagement protocol. Therefore, based on our experi-ence (Table 1) and thorough review of the literature(Table 2), we would like to propose the algorithmdepicting management plan following chylous ascites(Fig. 2).

Prevention and early detection strategies (SupplementaryFig. 1):

1. Consider preoperative factors like endemicity forlymphatic disease.

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2. Split and clip the lymphatic tissue.3. Use Vicryl on CT-1 needle (rescue stitch-like stitch)

to suture the oozing lymphatics; Floseal may be used asan adjuvant.

4. Check high-risk individuals (obese, or patients whounderwent extensive lymphadenectomy, or obviousleaking of lymphatics on table while doing a laparo-scopic surgery) at the end using laparoscopy carefully.

5. Place drain in high-risk individuals.Operative strategies (Supplementary Fig. 1):

1. Prepare patient well with 50 g butter 6 hours prior tosurgery.

2. Expect dense adhesions.3. Clip all the hilar and perihilar lymphatic tissues.4. Use Vicryl on CT-1 needle (rescue stitch-like stitch)

to suture the oozing lymphatics. Surgicel and Flosealmay be used as adjuvants.The limitation of this study is that it is a retrospective

study, with small number of patients. Moreover, thesuggested protocol needs to be validated in multicenterstudies.

CONCLUSIONPostoperative chylous ascites, although uncommon, is ahighly morbid complication of laparoscopic nephrectomythat demands prompt recognition and early treatment, asit can have severe deleterious consequences for the pa-tient. A systematic protocol should be followed in themanagement of the same. On the basis of our experience,we would like to suggest that all patients draining morethan 1000 mL chyle per day for 48 hours or more shouldbe taken up for surgical repair and other patients shouldbe started on conservative management. It is highly rec-ommended that the careful clipping of all the perihiliarand retroperitoneal fatty tissue during the dissection ofthe great vessels should be done and drain should beplaced in high-risk patients for early identification of thedisease.

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14. Cope C. Diagnosis and treatment of postoperative chyle leakage viapercutaneous transabdominal catheterization of the cistern chili: apreliminary study. J Vasc Interv Radiol. 1998;9:727-734.

15. Sharma A, Heer M, SubramanaymMalladi SV, Minz M. Chylousascites after laparoscopic donor nephrectomy. J Endourol. 2005;19:839-840.

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16. Gagliano M, Veroux P, Corona D, et al. Chylous ascites followinglaparoscopic living donor nephrectomy. Case report. Ann Ital Chir.2011;82:499-503.

17. Bachmann A, Wyler S, Wolff T, et al. Complications of retro-peritoneoscopic living donor nephrectomy: single center experienceafter 164 cases. World J Urol. 2008;26:549-554.

18. Caumartin Y, Pouliot F, Sabbagh R, Dujardin T. Chylous ascites asa complication of laparoscopic donor nephrectomy. Transpl Int.2005;18:1378-1381.

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APPENDIX

SUPPLEMENTARY DATASupplementary data associated with this article can be found,

in the online version, at http://dx.doi.org/10.1016/j.urology.2015.06.001.

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