Chylous Ascites: A Rare Complication Following Laparoscopic Donor Nephrectomy

Introduction: Chylous ascites is a rare complication following laparoscopic donor nephrectomy (LDN) with 0-1.83% incidence range and results from iatrogenic injury to cisterna chyli and its main tributaries. This complication is reported more with left LDN since cisterna chyli located near the aorta may get injured during left LDN. Case Description: A 41-year-old female presented 2 weeks after successful hand-assisted left LDN with fatigue, early satiety, nausea, abdominal distension and dyspnea. She denied fever or chills. On examination vital signs were stable, and the abdomen was distended with some tenderness. Serum creatinine was 0.91 mg/dL and albumin 3.0 g/dL (3.5-5.0). Computed tomography of the abdomen and pelvis showed surgically absent left kidney and large ascites (figure 1). Abdominal paracentesis yielded 450 ml of milky fluid with analysis showing the following values: triglycerides 4885 mg/dL (<60), protein 4.4 g/dL (<3) and amylase 65 U/L (<400). Fluid culture returned negative, and cytology was negative for malignant cells. A diagnosis of chylous ascites was made. The patient was prescribed low fat, high protein, salt-restricted diet. She required ascitic fluid drainage 3 more times over the next 4 weeks. A subsequent intranodal lymphangiogram showed no evidence for abdominal or pelvic lymphatic leak. She required no further treatment. Discussion: Meticulous clipping of perihilar and retroperitoneal tissue during renal pedicle dissection is recommended to minimize the incidence of chylous ascites. Early detection and intervention are important when chylous ascites develops following LDN to minimize complications including malnutrition and immunodeficiency. Most patients respond to conservative management including salt restriction, low-fat, high-protein and medium-chain triglyceride diet. Refractory cases may need interventions such as lympho-embolization or direct surgical ligation of the leaking lymphatics.