Chylous ascites following laparoscopic live donor nephrectomy: A new improved treatment paradigm

Chylous ascites is a difficult, albeit uncommon complication of laparoscopic live donor nephrectomy (LLDN). Lymphatic leak is believed to be a result of injury to the cisterna chyli, regional lymph nodes, or other peri-aortic lymphatics intraoperatively. Recommended management with dietary modifications can result in malnutrition and immunodeficiency. We present four patients who developed chylous ascites following LLDN. Approach to these patients evolved over time. Our initial two patients were successfully treated with a combination of surgical intervention followed by drain placement, after the failure of conservative management. The latter two cases were successfully treated with prompt intra-abdominal drain placement, without dietary modifications. Our cohort challenges the standard of care for treatment of chylous ascites after LLDN. We believe that prompt diagnosis and placement of an intra-abdominal drain can be used safely in select patients that develop this complication. We hypothesize that continuously draining the lymphatic leak, thus avoiding the re-accumulation of ascites, allows bowel and mesentery to make contact and adhere to the retroperitoneal tissue. We believe that prompt, initial, percutaneous drain placement is a viable alternative to both conservative and reoperative management in the treatment of chylous ascites after LLDN and should be considered as a reasonable first-line therapy.