Chylous ascites following radical nephrectomy: a case report

Shahzad S Shah 0 Kamran Ahmed 0 Richard Smith 0 Ravi Mallina 0 Pouya Akhbari 0 Mohammad S Khan 0 0 Address: Department of Urology, Guy's Hospital, Guy's & St Thomas' NHS Foundation Trust & GKT School of Medicine , London SE1 9RT , UK Introduction: Chylous ascites may result from diverse pathologies. Ascites results either due to blockage of the lymphatics or leak secondary to inadvertent trauma during surgery. Case presentation: We report the first case of chylous ascites following radical nephrectomy for a renal cell carcinoma involving the right half of a crossed fused renal ectopia. The patient was managed conservatively. Conclusion: Post-operative chylous ascites is a rare complication of retroperitoneal and mediastinal surgery. Most cases resolve with conservative treatment which aims at decreasing lymph production and optimizing nutritional requirements along with palliative measures. Refractory cases need either open or laparoscopic ligation of the leaking lymphatic channels. A review of the current literature on the management of post-operative chylous ascites is presented. - Introduction Chylous ascites results from either blockage of the lymphatics or leakage secondary to inadvertent trauma during surgery. Most cases of traumatic chylous ascites resolve with conservative treatment but refractory cases may need surgical ligation of lymphatics. We report the first reported case of chylous ascites following radical nephrectomy for a renal cell carcinoma involving the right half of a crossed fused renal ectopia. The chylous ascites resolved with conservative management. A brief review of the literature on the management of post-operative chylous ascites is presented. Case presentation A 60-year old male presented with acute right loin pain and frank haematuria. He was hypertensive but well controlled on medication. He had undergone coronary artery bypass grafting 9 years earlier. Physical examination was normal apart from a median sternotomy scar. Urine was sterile on culture and showed no malignant cells on cytology. Urea, creatinine and electrolytes were within normal range. Ultrasound scan showed no kidney in the left renal area and a 7 5 5 cm heterogenous irregular mass arising from the mid-pole of the right kidney. CT scan confirmed the presence of a large complex mass measuring 11.6 8 6.5 cm arising from the mid and upper pole of the right kidney. In addition it showed a cross fused left kidney in the right iliac fossa (Fig. 1). There was a single aorto-caval lymph node measuring 8 mm but no pulmonary metastases. An open right radical nephrectomy was performed. The dissection of the kidney was straightforward. The isthmus between the right and left kidney was transected without fFCuiTsgeusdcrraeenn1sahloewctiongpitaumour in the upper moiety of the crossed CT scan showing tumour in the upper moiety of the crossed fused renal ectopia. any complications and the raw surface of the left kidney over-sewn with surgical bolsters. A para-aortic lymph node dissection was undertaken between the superior mesenteric artery and bifurcation of the aorta. The surgical procedure did not differ from a standard radical nephrectomy except for the division of the isthmus. On histology, the tumour was a classical clear cell adeno-carcinoma with no nodal metastases (pT2N0). Post-operatively the patient had copious (150200 mls daily) drainage via a retroperitoneal drain which on biochemical analysis was consistent with serum. Hence the drain was removed. The patient was discharged on day 5 but was readmitted three weeks later with abdominal distension and pain. Clinically he had ascites. This was confirmed on CT scan (Fig. 2). Paracentesis and biochemical analysis were consistent with chylous ascites. The patient was initially managed with oral diuretics (Furosemide 40 mg twice daily & Spironolactone 25 mg 8 hourly). Treatment resulted in hyponatraemia and hypotension without any improvement in ascites and hence was discontinued. A therapeutic paracentesis was performed to alleviate abdominal discomfort. The patient was then commenced on parenteral nutrition and medium chain triglycerides. This resulted in gradual resolution of ascites and no reaccumulation during two months of follow up (Fig. 3). Discussion Chylous ascites is a rare condition. Its etiological factors can be broadly classified as congenital, infective, neoplastic and traumatic or post surgical. The majority of cases are caused by diseases that interfere with abdominal or retroperitoneal lymphatic drainage. Amongst surgical procedures, vascular operations account for the majority of post-operative chylous ascites [1]. This complication may become evident within a few days following surgery or take several months [2]. The lymphatic drainage from the kidney and testes is to the retroperitoneal para-aortic nodes. Thus chylous ascites is a well recognized complication of retroperitoneal node FReigsuorlueti3on of ascites following conservative treatment Resolution of ascites following conservative treatment. dissection (RPLND) for testicular cancer. However, only 34 cases of chylous ascites have been reported in the English medical literature following renal surgery for diverse indications. These included twelve (n = 12) after radical nephrectomy for Wilm's tumour, nine (n = 9) for renal cell carcinoma, eight (n = 8) after laparoscopic donor nephrectomy, two (n = 2) following nephro-ureterectomy and one each for renal abscess, renal trauma and nonfunctioning kidney. Presentation of post-operative chylous ascites is similar to ascites due to other causes including progressive abdominal distention and weight gain. The patient may complain of dyspnoea due to reduced diaphragmatic movements or chylothorax. Non-specific symptoms include nausea, vomiting or post operative wound leakage. The diagnosis can be confirmed by abdominal paracentesis. The aspirate is typically milky white and stains positive for fat with Sudan III. Its specific gravity is greater than 1.012 and has alkaline pH. Cytology shows predominantly lymphocytes. Chemical analysis reveals high triglyceride levels 28 fold that of plasma (range 0.44 gm/dl) and protein content greater than 3 gm/dl. Serum abnormalities include hypoalbuminaemia, lymphocytopenia and anemia secondary to protein loss and malnutrition. Occasionally the diagnosis is evident only on exploration. Bipedal lymphangiography with ethiodized oil injected into lymphatic vessels on the dorsum of the foot has been the traditional way of mapping the lymphatic tree. Lymphangiography however, is technically challenging, time consuming and has the additional disadvantage of staining the operative field. Therefore lymphangiography has been abandoned in favour of newer radiological techniques [3]. Pui and Yueh report their experience with 99mtechnetium (Tc)-antimony sulfide colloid, human albumin or dextran-scintigraphy for chylous collections. They claim that lymphoscintigraphy ca (...truncated)