A case of severe retroperitoneal chyle leakage and subsequent chylothorax secondary to partial laparoscopic nephrectomy

Abstract

Retroperitoneal chyle leakage combined with chylothorax after nephrectomy is rare in clinical practice. We report a 41-year-old female who developed severe chyloretroperitoneum along with subsequent chylothorax after partial nephrectomy. The patient underwent nutritional control, received octreotide treatment and had a complete recovery after 58 days. A damage to the cisterna chylic could account for the leakage. The chylothorax was a displacement through the diaphragmatic hiatus. Comprehensive review showed that near 30 % of such patients would require re-surgery or interventional treatment. The current case stresses the importance of careful examination, timely diagnostic test and appropriate treatment of abnormal drainage after nephrectomy.

Highlights

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Retroperitoneal chyle leakage is a rare but severe adverse event of nephrectomy.
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Chylothorax can occur as a displacement of retroperitoneal leakage.
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Medium chain triglyceride diet or total parenteral nutrition is recommended for patients with chyle leakage.
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Re-surgery or interventional treatment should be considered if nutritional management shows unsatisfactory response.

1 Introduction

Laparoscopic technology has been widely applied in most types of surgical operations. While minimal invasive surgery (MIS) brings benefit to the patients, intraoperative adverse events (iAEs) hold a significant impact on the patients’ postoperative recovery, increasing postoperative length of stay and costs for medical care at the same time. Chyle leakage is an important type of iAEs caused by damage to the lymphatic duct system and has been reported in various types of pelvic, abdominal, thoracic and cervical surgeries. In addition to nutritional management, severe post-operational chyle leakage would require either interventional embolization or surgical correction.

Laparoscopic nephrectomy (LN) is a procedure widely used in the treatment of benign and malignant kidney lesions as well as in kidney transplantation. LN can be performed via either intraperitoneal or retroperitoneal approach. Due to the anatomical adjacency with the cisterna chyli and the thoracic duct, the risk of chyle leakage post LN cannot be ignored. Reports of chyle ascites after LN or laparoscopic donor nephrectomy (LDN) can be found as early as 20 years ago. However, case reports of retroperitoneal chyle leakage combined with chylothorax remain scarce.

Here, we report a female patient who developed severe chyloretroperitoneum along with subsequent chylothorax after left partial LN. The case was unique regarding to the amount of the leakage, the combination of chylothorax and the success of conservative treatment. The clinical course of the patient was recorded and presented in detail.

2 Case presentation

A 41-year-old female was admitted to Peking Union Medical College Hospital (PUMCH) due to a mass on the left kidney. The mass was detected in 2014. The mass initially appeared in ultrasound as a 1.9 cm medium-high echo. It gradually grew in volume. In November 2024, the patient came to the outpatient department for examination due to left lumbago. Ultrasound showed a 6.6 × 3.8 × 4.7 cm medium-high echo on the left kidney ( Fig. 1 a). Computed tomography urography (CTU) demonstrated a 3.1 × 6.1 × 6.3 cm mixed-density lesion in the upper pole of the left kidney ( Fig. 1 b). The patient underwent laparoscopic left partial nephrectomy on Dec 11th, 2024. The operation went on for 1h34m. 600 ml Ringer’s solution was infused. 50 ml of urine and minimal bleeding were recorded. A perirenal drainage tube was placed. The volume of the drainage was 50 ml, 20 ml, 50 ml and 40 ml from 0 to 3 days post operation (POD) ( Fig. 1 c). The drainage fluid was light bloody and clear. The tube was removed at POD 4 and the patient was discharged with no remaining discomfort. The pathology diagnose of the mass was renal angiomyolipoma.

After discharge, the patient reported mild left flank pain which aggravated when lying flat. The pain became unendurable on Dec 29th, 2024 (POD 18) with a score of 7–8 on the Numerical Rating Scale (NRS). The patient took an abdominal and pelvic CT scan, revealing a large cystic mass containing liquid density in the left abdominal-pelvic cavity, approximately 19.1 × 17.5 × 27.0 cm in size. The patient returned to our institution for evaluation on Dec 31st, 2024, and was re-admitted on the same day.

Abdominal ultrasound demonstrated a huge anechoic area in the left retroperitoneal cavity with hyperechoic content ( Fig. 2 a). A fluid sonolucent area in the pelvic cavity with a depth of 4.9 cm could also be observed ( Fig. 2 b). Thoraco-abdominopelvic CT demonstrated that both the left thoracic cavity and the left retroperitoneal cavity were flooded by liquid ( Fig. 2 c and d). Retrograde ureterography of the left ureter and kidney indicated a severe displacement of the left kidney due to occupancy effect of the encapsulated mass of fluid ( Fig. 2 e). In the meantime, no leakage of the contrast was observed. A percutaneous drainage tube was placed under CT guidance to drain the retroperitoneal fluid. Slightly viscous, chyle like liquid was obtained ( Fig. 2 f).

A series of biochemical tests were conducted to determine the nature of the fluid. Creatinine in the drainage fluid was 58 μmol/L, and the chyle test had a positive result. Routine blood tests along with biochemical blood tests were also performed to exclude potential organ damage. The patient’s HGB remained stable at 131–147 g/L and no anomaly was observed in the biochemical tests. Based on the results of the abovementioned tests, the fluid was most likely a lymphatic leakage.

A systemic treatment strategy of physical drainage, medicine and nutrient control was applied. The first retroperitoneal drainage was placed on December 31st, 2024 (POD 20). Around 1000 ml fluid could be collected from the tube every day from POD 20 to POD 22. On January 3rd, 2025 (POD 23), CT revealed aggregation of the left pleural effusion ( Fig. 3 a and b) and only partial alleviation of the retroperitoneal effusion was observed ( Fig. 3 c). A closed thoracic drainage was placed on the left side on POD 23 and 1600 ml fluid was drained ( Fig. 3 d). The retroperitoneal drainage was switched to a second tube due to blockage of the first tube on POD 30. As for medicine administration, 0.1 mg octreotide acetate was subcutaneously injected every 12 hours from POD 26 to POD 40. Mild adjustment, clamping and opening of the tubes were performed on a daily basis and the amount of the drainage was recorded ( Fig. 3 e). The thoracic drainage was removed on POD 37 after thoracic CT demonstrated apparent alleviation of the thoracic effusion ( Fig. 3 f).

As for nutrient control, the patient adopted a strict low-fat, medium chain triglycerides (MCT) diet following the advice of the Department of Clinical Nutrition. Near-fat-free foods such as potatoes, vegetables, fruits, skim milk and egg whites were cooked with MCT oil (less than 20 ml per day) and consumed daily. Protein powder and small molecule peptides were chosen as nutritional supplements. The nutrition plan provided an energy intake of 1455–1698 kcal/d (30–35 kcal/kg/d) and a protein intake of 58–73 g/d (1.2–1.5 g/kg/d).

Invasive therapies including lymphangiography and lymphatic embolization (LE) were also considered for the patient. Consultation from the department of lymphatic surgery suggested that embolization may be effective. However, the cost and invasiveness of the treatment raised doubt of the patient. As the amount of the leakage was showing a decreasing trend, the patient opted to further observe the efficacy of conservative treatment before making a decision.

The patient was discharged on January 20th, 2025 (POD 40) according to alleviation of the symptoms and descendance of the drainage amount. After discharge, the patients continued to follow the nutrient-control diet and kept a diary of the retroperitoneal drainage, which gradually descended from around 100 ml/d to 0 ml/d. Abdominal CT was repeated on POD 43 and 57, showing alleviation of the retroperitoneal effusion ( Fig. 4 a and b). The retroperitoneal drainage was preserved until February 7th, 2025 (POD 58). A final CT scan was performed on March 13th, 2025 (POD 92) and no sign of relapse was observed ( Fig. 4 c).

3 Discussion

The present case is a female patient with a direct surgical history and a clear diagnosis of post-surgical chyle leakage. Although meticulous dissection was performed during surgery, chyle leakage was not avoided nor timely discovered in surgery. Presumptively, a damage to the lymphatic system, possibly the cisterna chyli, was caused when dissecting the renal hilum. Still, as conservative dietary and medicine treatment successfully alleviated the leakage, there was no need for re-explorational surgery and determining the exact damage point was thus not feasible. During the surgery, the induced pneumoperitoneum had a pressure of 12–14 mmHg, which was greater than the pressure of lymphatic vessels and might be the reason for the undetected lymphatic leakage during operation. It is our belief that the chylothorax was a displacement of the retroperitoneal chyle leakage through the diaphragmatic hiatus in the same way that ascites may manifest as pleural effusion due to displacement through the diaphragm. In a cohort of 203 patients with chylothorax in Mayo Clinic, 16 (7.88 %) were secondary to chylous ascites. The relative time course of the chylothorax and chyloretroperitoneum backed up the diagnosis of a secondary rather than primary chylothorax.

A comprehensive review of previously reported chyle leakage after kidney surgery was performed ( Table 1 ). 11 (91.67 %) out of 12 patients with reported gender were female, and all patients had surgery on the left kidney. 6 (27.27 %) patients received re-surgery, 1 (4.54 %) received interventional therapy, and the other 15 (68.18 %) patients recovered via conservative therapy, which is mainly nutritional control. The recovery time ranged from 1 week to 4 months. In most cases, a decrease of the leakage amount could be observed 3–7 days after nutritional intake was adjusted. In those patients with no apparent decrease was observed, re-surgery and other invasive treatment were large likely in need.

Table 1

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