Chylous ascites secondary to laparoscopic donor nephrectomy

Chylous Ascites After Robot-Assisted Laparoscopic Donor Nephrectomy: Is Early Surgical Intervention Necessary?

OBJECTIVES

Chylous ascites is a rare complication that may occur after living donor nephrectomy. The continuous loss of lymphatics, which carries a high risk of morbidity, may ensue in possible immunodeficiency and protein-calorie malnutrition. Here, we presented patients who developed chylous ascites after robotassisted living donor nephrectomy and reviewed the current literature of therapeutic strategies for chylous ascites.

MATERIALS AND METHODS

We reviewed the medical records of 424 laparoscopic living donor nephrectomies performed at a single transplant center; among these, we studied the records of 3 patients who developed chylous ascites following robot-assisted living donor nephrectomy.

RESULTS

Among 438 living donor nephrectomies, 359 (81.9%) were laparoscopic and 77 (18.1%) were by robotic assistance. In the 3 cases highlighted in our study, patient 1 did not respond to conservative therapy, which consisted of diet optimization, total parenteral nutrition, and octreotide (somatostatin). Patient 1 subsequently underwent robotic-assisted laparoscopy with suture ligation and clipping of leaking lymphatic vessels, allowing the chylous ascites to subside. Patient 2 similarly did not respond to conservative treatment and developed ascites. Despite initial improvement after wound interrogation and drainage, patient 2 had continued symptoms, resulting in diagnostic laparoscopy and repair of leaky channels leading to the cisterna chyli. Patient 3 developed chylous ascites 4 weeks postoperatively and received ultrasonographic-guided paracentesis by interventional radiology, with results showing an aspirate consistent with chyle. The patient's diet was optimized, allowing for initial improvement and eventual return to normal diet.

CONCLUSIONS

Our case series and literature review demonstrate the importance of early surgical intervention after failed conservative management for resolution of chylous ascites in patients after robotassisted donor laparoscopic nephrectomy.

Massive Chylous Ascites After Living Donor Nephrectomy Successfully Treated With Lymphatic Embolization

Chylous ascites may result from a variety of pathological conditions, most of them from nontraumatic causes, such as congenital defects of the lymphatic system, infections, liver cirrhosis, and malignancy. Rarely, chylous ascites occurs as an iatrogenic complication after left-sided laparoscopic donor nephrectomy (LDN). Injury to the cisterna chyli and its main lymphatic tributaries around the para-aortic region intraoperatively can cause the lymphatic fluid to accumulate. There is currently no standardized treatment for chylous ascites as there have only been 54 cases documented to date. Most patients can be managed with conservative therapy. Recommended guidelines include high-protein and low-fat diet with medium-chain triglycerides. Paracentesis is often used as a diagnostic and therapeutic first-line measure with total parenteral nutrition (TPN), bowel rest, and somatostatin analogue as adjunct therapies. We present a case of massive chylous ascites refractory to conservative therapy. The patient had progressive abdominal distention and unintentional weight gain 2 weeks postoperatively warranting multiple paracenteses of >7 L of chylous fluid. Ultimately, the patient was successfully treated with lymphatic embolization using N-butyl cyanoacrylate glue.

Management of Chylous Ascites After Laparoscopic Nephrectomy for Living Kidney Donor: A Case Report and Literature Review

Kidney transplant is currently the elective treatment of choice for end-stage renal disease. Laparoscopic living donor nephrectomy (LLDN) has substantial advantages over open nephrectomy. Chylous ascites (CA) is a rare surgical complication after the LLDN; there are few reports in the literature. We present a case report of a 58-year-old woman who started CA on the 21st day post operation. The recommended initial therapeutic approach to suspend the fat in the diet and place percutaneous drainage was not enough. It was decided to jointly introduce fasting and total parenteral nutrition with the administration of octreotide, resolving the complication completely in 15 days with no need for the patient to undergo surgery. The conservative management, during the first 4 to 8 weeks after the diagnosis is the best option. Surgery is generally recommended if conservative management fails. The prevalence of CA varied between 0% and 6.2% of LLDNs. In our experience of 87 LLDNs, we only presented 1.15% for this complication. There are 62 cases reported in the international literature. The mean presentation was 14 days after LLDN. All patients underwent conservative treatment, and only 15 patients (24%) went to surgery after the failure of conservative management. It would be highly useful, considering the disparity of the prevalence, if the bibliographic reports detail what hemostatic and sealing techniques are used in an LLDN. In this way it would be possible to identify which factor affects a complication like this one.

Chylous Ascites: Complication of Laparoscopic Donor Nephrectomy. Case Report and Review of Literature

BACKGROUND

Chylous ascites (CA) is an extremely rare complication after laparoscopic donor nephrectomy (LDN). It can increase the hospital stay, morbidity in postoperative period and thus negating the benefits of laparoscopic surgery. Most of the cases were managed conservatively, but surgical intervention may be occasionally required. This report describes the importance of accurate localization of the leaking chyle duct and its repair by endosuturing in a renal donor not responding to conservative treatment.

METHODS

A comprehensive review of literature regarding this rare complication after LDN was performed with Pubmed/Medline and Google Scholar using "chyle," "complications," and "laparoscopic donor nephrectomy" as keywords. The demographic profile and management of patients is discussed in detail. The various surgical modalities used to manage these patients are described.

RESULTS

Fifty-four cases of chyle leak/ascites have been reported after LDN in literature to date. Around 77% donors with CA could be successfully managed conservatively with dietary measures and total parenteral nutrition. Surgical intervention was required in nearly 23% donors ranging from clip application, use of argon coagulation, endosuturing with application of glue after 36.1 ± 19.07 days of failed conservative treatment. Donors with massive ascites or requiring frequent large-volume paracentesis on conservative treatment are likely to require surgical therapy. The present case was successfully managed with laparoscopic endosuturing and has no recurrence at 6 month follow-up.

CONCLUSIONS

Chylous ascites is a rare complication after donor nephrectomy in experienced centers. Although conservative management remains the first line of treatment, early surgical treatment shall be undertaken in cases of massive ascites.

A Proposed Classification System and Therapeutic Strategy for Chyle Leak After Laparoscopic Living-Donor Nephrectomy: A Single-Center Experience and Review of the Literature

OBJECTIVES

Chyle leak or chylous ascites remains a rare complication after laparoscopic living-donor nephrectomy. Its cause and management have not been well elucidated in the literature. Thus, the aim of this study was to review the incidence of chyle leak/chylous ascites after laparoscopic living-donor nephrectomy in our institute and in the literature to propose a classification system with its associated treatment strategy.

MATERILAS AND METHODS

In this retrospective review of laparoscopic living-donor nephrectomy patients from January 2005 to April 2016, we identified patients with chyle leak/chylous ascites along with the care performed. A proposed classification system based on our experience and literature is described.

RESULTS

Chylous leak developed in 4 donors (2.25%). Of the 4 donors, 3 were treated nonoperatively with diet modification and subcutaneous octreotide injection. One patient required surgical intervention after not responding to second-line therapy with total parenteral nutrition.

CONCLUSIONS

Chyle leak/chylous ascites after laparoscopic living-donor nephrectomy is rare, but a delayed diagnosis may lead to morbidity secondary to malnutrition and immunosuppression. Meticulous surgical dissection is essential to seal the lymphatic tubes during laparoscopic living-donor nephrectomy. The proposed classification system provides a practical and tailored guide to management based on the drainage volume of chyle leak and a guide to the earlier identification of refractory cases.

Chylous Leakage After a Laparoscopic Live-Donor Nephrectomy: Case Report and Literature Review

Laparoscopic donor nephrectomy is an established operation for organ procurement in living-donor transplant. Minimal access approach for organ procurement from living donors ensures early convalescence and improved patient participation. Chylous leakage is a rare complication of laparoscopic living-donor nephrectomy. Chylous leakage is mostly determined by iatrogenic injury of cisterna chyli and its main tributaries. It may lead to malnutrition and immunologic deficits because of protein and lymphocyte depletion. An 18-year-old woman underwent left-hand-assisted laparoscopic donor nephrectomy for living donor transplant. She developed chylosus leakage in third postoperative day. A conservative manage-ment with total parenteral nutrition total paren-teral nutrition and subcutaneous somatostatin was immediately initiated. The patient had an abatement of drainage daily output in 4 days of therapy. Chylous leakage is a potentially insidious and perhaps misdiagnosed complication of laparoscopic donor nephrectomy. Conservative therapy is effective in most donors and should be initially attempted. Surgical ligatures or fibrin sealants may be indicated in case of refractory chylous leakage before the arising of malnutrition and/or relevant immunodeficiency.

Chylous ascites after laparoscopic donor nephrectomy

INTRODUCTION

The aim of this study was to determine the incidence, presentation, management, and outcomes of chylous ascites following laparoscopic donor nephrectomy.

METHODS

An Internet-based, multi-institutional survey was performed using http://www.surveymonkey.com. An email invitation to the voluntary survey was sent to 30 transplant centers and posted on CenterSpan, an email forum for transplant surgeons. The number of living donor transplantations and the number of cases of chylous ascites with clinical information, treatment and outcomes were sought from the questionnaire.

RESULTS

A total of 12 centers responded and reported 7683 cases of live donor nephrectomy. The reported incidence of postoperative chylous ascites was 0.013% (n = 12). Six centers reported 10 cases of chylous ascites following laparoscopic donor nephrectomy and 2 cases after open donor nephrectomy. Among the eight patients who developed chylous ascites following laparoscopic donor nephrectomy, presentation was typically 2 weeks after the date of initial surgery. Conservative therapy was successful in 50% of cases. Refractory ascites managed secondarily with surgical intervention had a success rate of 100%.

CONCLUSION

Chylous ascites is a rare complication following laparoscopic donor nephrectomy. Initial treatment should be conservative, with surgical therapy reserved for refractory cases.

Chylous ascites after laparoscopic hand-assisted donor nephrectomy: Is it specific for the left-side?

We describe a case-report of a chylous ascites after laparoscopic donor nephrectomy, summarize the current literature, and hypothesize on the etiology of this complication.

Chyle Leak following Open Donor Nephrectomy: A Rare Complication-A Case Report

Introduction. Donor workup in renal transplantation is extensive. Despite this, chyle leakage following donor nephrectomy, a rare complication, has been reported in the literature. We encountered two cases of chyle leak in kidney donors in our series of open donor nephrectomies. Summary of Cases. After complete workup, standard open retroperitoneal donor nephrectomy with drain placement was performed in 684 living renal donors. We encountered chyle leak in two cases. The first case was a 33-year-old female who underwent an otherwise uneventful left donor nephrectomy but continued to have high drain output (upto 300–400 mL/24 hrs) in the postoperative period. The drain fluid was milky, raising the suspicion of chyle which was confirmed on biochemical analysis. The second case was a 42-year-old female with a similar case history. Both were managed conservatively with low-fat diet. The leak subsided spontaneously in three weeks and one week in the first and second patients, respectively. The drain was removed, and the patients remained symptom-free on followup. Conclusions. Both of our cases of chyle leak following open donor nephrectomy were managed successfully with conservative management. The management options and the experience of other centers are reviewed and discussed.

Laparoscopic donor nephrectomy

BACKGROUND

Kidney transplantation is a definitive treatment of end-stage renal disease. Laparoscopic donor nephrectomy (LDN) has been widely accepted around the world since its introduction in 1995 as a minimum invasive procedure. We report our clinical experience of 141 consecutive LDNs performed in two tertiary hospitals in Western Australia.

METHODS

From December 2000 (Royal Perth Hospital) and January 2005 (Sir Charles Gairdner Hospital) to January 2009, 141 LDNs were performed in two tertiary hospitals by four urologists. All donors underwent rigorous work-up prior to surgery. Donor age ranged from 23 years to 81 years (49.85 ± 11.30 years). The male to female ratio was 1 to 1.3. Donor body mass index (BMI) was 26.77 ± 4.31, and glomerular filtration rate was 96.25 ± 12.33 mL/min/1.73 sqm. The laparoscopic technique was transperitoneal approach exclusively.

RESULTS

All LDNs were performed successfully without hand assistance. The warm ischaemic time ranged from 3 to 11 min. The hospital stay was 4.16 ± 1.30 days. The overall complication rate was 17.0%, with three major complications (2.1%): a splenetic infarction, a chylous ascites and a pulmonary embolism occurred. Donors' demographic data (age, sex, BMI, side of surgery) did not show a statistically significant association with surgical complications.

CONCLUSIONS

Transperitoneal laparoscopic live donor nephrectomy is a safe and effective procedure. Combined use of vascular stapler and Hem-o-Lok is very important for management of the renal artery stump. It is our current practice to administer anticoagulants during and post-surgery for at least 2 weeks.

Chylous ascites as a complication of laparoscopic nephrectomy

PURPOSE

Chylous ascites is a rare complication after major retroperitoneal surgery. Recently chylous ascites has developed more often after laparoscopic nephrectomy since that is increasingly done for various indications at many centers. We reviewed our cases of chylous ascites after laparoscopic nephrectomy.

MATERIALS AND METHODS

Between January 2002 and December 2008 we performed 622 transperitoneal laparoscopic nephrectomies. We retrospectively analyzed factors related to chylous ascites as a complication of laparoscopic nephrectomy.

RESULTS

The overall incidence of chylous ascites was 5.1% (32 of 622 cases), including 4 severe refractory cases (0.6%). The difference in incidence by operation type was not statistically different (p = 0.251). Chylous ascites developed more often after left than right nephrectomy (7.3% or 25 of 343 cases vs 2.5% or 7 of 279, p = 0.010). In patients with radical nephrectomy and nephroureterectomy the incidence was higher in those who did vs did not undergo lymphadenectomy (13.9% or 10 of 72 vs 4.0% or 11 of 275, p = 0.027). Only 1 patient underwent explorative laparotomy due to persistent severe chylous ascites despite 8-week conservative management. The other cases were successfully managed conservatively by total parenteral nutrition and a low fat diet.

CONCLUSIONS

Chylous ascites is not a rare complication after laparoscopic nephrectomy and most cases can be managed conservatively. To prospectively prevent this complication we recommend meticulous clipping of all perihilar and retroperitoneal fibrous fatty tissue during major vessel dissection, especially for left nephrectomy or extensive lymphadenectomy.

Experience with 750 consecutive laparoscopic donor nephrectomies--is it time to use a standardized classification of complications?

PURPOSE

Laparoscopic living donor nephrectomy offers patients the benefits of decreased morbidity and improved cosmesis, while maintaining equivalent graft outcomes and complication rates similar to those of open donor surgery. With expressed concern for donor safety, using a standardized complication scale would allow combining data in a donor registry so potential donors could be adequately followed and counseled. We present the largest series to our knowledge of laparoscopic living donor nephrectomy by a single surgeon.

MATERIALS AND METHODS

The institution's initial 750 laparoscopic living donor nephrectomies were included in the study, and a retrospective and prospective chart and database analysis was performed.

RESULTS

Mean donor age was 40.5 years and average body mass index was 25.7 kg/m(2). There were 175 patients (23%) with 2 or more renal arteries while 161 (21.5%) had early arterial bifurcations. There were 3 open conversions (0.4%) and the overall complication rate was 5.46%. Median hospital stay was 1 day and the readmission rate was 1.2%. There were 5 reoperations (0.67%), none of which was for the control of bleeding. No patients required a blood transfusion and there were no mortalities. Using a modified Clavien classification of complications for living donor nephrectomy 65.8% were grade 1, 31.7% grade 2 (12.2% grade 2a, 14.6% grade 2b, 4.9% grade 2c) and 2.4% grade 3. There were no grade 4 complications.

CONCLUSIONS

With appropriate patient selection and operative experience, laparoscopic living donor nephrectomy is a safe procedure associated with low morbidity. The use of a standardized complication system specific for this procedure is encouraged and could aid in counseling potential donors in the future.

Chylous ascites requiring surgical intervention after donor nephrectomy: case series and single center experience

Chylous ascites as a result of laparoscopic donor nephrectomy (LDN) is a rare complication that carries significant morbidity, including severe protein-calorie malnutrition and an associated immunocompromised state. We report a patient who underwent hand-assisted left LDN and subsequently developed chylous ascites. He failed conservative therapy including low-fat diet with medium-chain triglycerides (LFD/MCT) and oral protein supplementation as well as strict NPO status with intravenous (IV) total parenteral nutrition (TPN) and subcutaneous (SQ) somatostatin analogue administration. Laparoscopic re-exploration and intracorporeal suture ligation and clipping of leaking lymph channels successfully sealed the chyle leak. We review the literature to date including diagnosis, incidence, management options, psychosocial aspects and clinical outcomes of chylous ascites after LDN.

Chylous ascites requiring surgical intervention after donor nephrectomy: case series and single center experience

Chylous ascites as a result of laparoscopic donor nephrectomy (LDN) is a rare complication that carries significant morbidity, including severe protein-calorie malnutrition and an associated immunocompromised state. We report a patient who underwent hand-assisted left LDN and subsequently developed chylous ascites. He failed conservative therapy including low-fat diet with medium-chain triglycerides (LFD/MCT) and oral protein supplementation as well as strict NPO status with intravenous (IV) total parenteral nutrition (TPN) and subcutaneous (SQ) somatostatin analogue administration. Laparoscopic re-exploration and intracorporeal suture ligation and clipping of leaking lymph channels successfully sealed the chyle leak. We review the literature to date including diagnosis, incidence, management options, psychosocial aspects and clinical outcomes of chylous ascites after LDN.

Complications of transperitoneal laparoscopic nephrectomy: a single-center experience

OBJECTIVES

To present the incidence of complications of transperitoneal laparoscopic nephrectomy performed for various indications during a 6-year period.

METHODS

From 2002 to 2007, 505 transperitoneal laparoscopic nephrectomies were performed, consisting of 125 live donor, 212 radical, 80 simple, and 28 partial nephrectomies and 60 nephroureterectomies. We retrospectively analyzed the factors related to perioperative complications, including the type of operation, body mass index, history of abdominal surgery, and American Society of Anesthesiologists score.

RESULTS

The overall complication rate was 13.7% (69/505). Major complications requiring open conversion or reoperation occurred in 15 patients (3.0%). The remaining 54 patients experienced minor surgical or postoperative medical problems. The mortality rate in our series was 0%. The complication rates by the type of operation were not significantly different. Patients with a history of abdominal surgery demonstrated slightly greater complication rates (19.2% vs 12.6%, P = .069). When stratified by a body mass index of <25 kg/m(2) and <25 kg/m(2), no statistically significant difference was found in the complication rates (13.1% vs 15.6%, respectively, P = .067). Patients with greater American Society of Anesthesiologists scores had greater complication rates (P = .038). The intraoperative complication rates decreased as our experience with laparoscopic surgery increased (P = .042); however, the total complication rates remained constant throughout the study period.

CONCLUSIONS

In consideration of the contributing factors, the complication rates of transperitoneal laparoscopic nephrectomy were not related to the type of operation, body mass index, or history of abdominal operation but to the American Society for Anesthesiologists score. Complications unique to laparoscopic nephrectomy exist but they decrease with experience.

Successful management of chylous ascites after living donor liver transplantation with somatostatin

Chylous ascites is a rare complication following liver transplantation. A variety of treatment options have been proposed for the management of chylous ascites; however, their effectiveness following a liver transplant is unknown. A 40-year-old woman who underwent living donor liver transplantation for primary biliary cirrhosis developed chylous ascites 21 days after the transplant. A conventional treatment consisting of a low-fat diet with total parenteral nutrition failed to treat the complication for 104 days. However, the use of somatostatin in combination with total parenteral nutrition resulted in a rapid falloff in chyle output without any adverse effects. Somatostatin and total parenteral nutrition are an effective option for the treatment of chylous ascites after living donor liver transplantation.

Complications of laparoscopic living donor nephrectomy and their management: the UCLA experience

OBJECTIVES

Because of the shortage of cadaveric kidneys, laparoscopic living donor nephrectomy (LLDN) has become a more common option for transplant recipients. The complication rate has been reported at 6.4% to 16.5%. We present the initial University of California, Los Angeles experience with the complications and their management during LLDN.

METHODS

From January 2000 to December 2005, a single surgeon performed 300 consecutive LLDNs at our institution. A committee of urologists, nephrologists, and support staff approved each donor before surgery. After LLDN was completed, the patients received 30 mg of ketorolac intravenously every 6 hours until discharge. We reviewed the intraoperative and postoperative complications and their management at our institution.

RESULTS

Three patients required open conversion, for an overall conversion rate of 1%. Two of the three conversions were a result of a major vascular complication (0.6%). The first major vascular complication resulted from an endovascular stapler malfunction during transection of an accessory left renal artery. The second vascular complication was a Veress needle injury to the left common iliac artery. Three postoperative major complications (1%) occurred, including 1 case of rhabdomyolysis and 2 cases of chylous ascites. Also, 7 minor postoperative complications (2.3%) occurred. Our overall complication rate was 4%. No patients died, and the mean hospital stay was 1.1 days.

CONCLUSIONS

Our results have shown that LLDN is a safe procedure associated with low morbidity and a quick recovery. Appropriate patient selection is essential to ensure the safety of this procedure.

Two cases of chyloretroperitoneum following retroperitoneoscopic nephroureterectomy

Post-operative chyloretroperitoneum is a rare complication in urological surgery. We experienced two cases of post-operative chyloretroperitoneum following retroperitoneoscopic left nephroureterectomy. Both cases were treated successfully with drainage, low fat diet, total parenteral nutrition (case 1 only), sclerotherapy and somatostatin analog. Laparoscopic procedures are supposed to have a higher risk of chylous complications, as CO2 pressure appears to make the operator overlook suppressing the lymphatic leakage from the resected lymphatic channels.

Chylous ascites as a complication of laparoscopic donor nephrectomy

Laparoscopic living donor nephrectomy (LLDN) is a minimally invasive technique for kidney procurement and was developed with the hope of reducing the disincentives associated with live renal donation. Compared with open donor nephrectomy (ODN), this alternative has many advantages including less postoperative pain and earlier return to work. Unfortunately, these benefits are sometimes negated by postoperative complications. Among these, chylous ascites (CA) is a rare but serious problem that is usually managed conservatively. We report the case of a living donor who developed CA refractory to initial conservative management and surgical treatment. We also discuss the role of surgery in the treatment of CA following LLDN.

Lymphomas and chylous ascites: review of the literature

Chylous ascites is a rare and challenging clinical condition that occurs as a result of disruption of the abdominal lymphatics. We include a review of the literature describing the etiology, diagnosis, and therapy of chylous ascites.

Chylous ascites after laparoscopic donor nephrectomy

Laparoscopic living-donor nephrectomy has decreased the disincentives to live renal donation with a risk of complications similar to that of open donor nephrectomy. We report a patient who developed chylous ascites after an otherwise-uneventful laparoscopic donor nephrectomy. On MEDLINE search, we could find only two other cases with similar complications. This condition has the potential to cause significant morbidity in the donor, which may reduce the advantages of the minimally invasive approach. We suggest that meticulous dissection of the renal hilum and clipping of lymphatic tissue around the renal vessels could prevent this untoward complication.

Chyloretroperitoneum with secondary chylothorax after retroperitoneoscopic donor nephrectomy

A 59-year-old woman complained of increasing pain in the left abdomen and of diarrheal symptoms after left-sided retroperitoneoscopic living donor nephrectomy. Computed tomography revealed chyloretroperitoneum. The fluid was drained percutaneously, followed by recurrent drain replacement surgery. Her diet was changed to short-chain and medium-chain fatty acids without success. After onset of dyspnea due to chylothorax, the donor underwent thoracic drainage, fully parenteral therapy, and finally somatostatin application therapy. The postoperative management of severe chylous fistula is difficult. Therefore, we recommend an early start of maximal conservative therapy. Surgical options depend on pain occurrence or mechanical problems.

Idiopathic postoperative ascites after laparoscopic salpingectomy for ectopic pregnancy

Postoperative ascites is a rare and serious complication of laparoscopic procedures. Urinary tract injury, bowel injury, and lymph duct injury are the common causes; however, in some patients no definitive cause can be identified after an extensive diagnostic work-up. We present a case of postoperative ascites of unknown origin. The patient recovered with general treatments. We presume that diffuse peritoneal injury may have been caused by unidentified substances in our patient.

Chylous ascites: Treated with total parenteral nutrition and somatostatin

AIM: To determine the effects of total parenteral nutrition and somatostatin on patients with chylous ascites.

METHODS: Five patients were diagnosed with chylous ascites on the basis of laboratory findings of ascites sample from Nov 1999 to May 2003. Total parenteral nutrition and somatostatin or its analogue was administered to 4 patients, while the other one only received total parenteral nutrition. All the patients had persistent peritoneal drainage, with the quantity and quality of drainage fluid observed daily. Necessary supportive treatments were given to the patients individually during the therapy.

RESULTS: Two of 4 patients who received somatostatin therapy obtained complete recovery within 10 d without any recurrence while on a normal diet. In these 2 patients, the peritoneal drainage reduced to zero in one and the other's decreased from 2000 mL to 80 mL with a clear appearance and negative qualitative analysis of chyle. Recurrent chylous ascites, though relieved effectively by the same method every time, developed in one patient with advanced pancreatic cancer. The other patient's lymphatic fistula was blocked with the fibrin glue after conservative treatment. The patient who only received total parenteral nutrition was cured 24 d after therapy.

CONCLUSION: Total parenteral nutrition along with somatostatin can relieve the symptoms and close the fistula in patients with chylous ascites rapidly. It appears to be an effective therapy available for the treatment of chylous ascites caused by various disorders.

Laparoscopic donor nephrectomy

Background

Living kidney donation represents an important source of organs for patients with end-stage renal failure. Over the past decade, laparoscopic donor nephrectomy has replaced the conventional open procedure in many transplant centres. Using evidence-based methods, this study examines the current status of laparoscopic donor nephrectomy.

Method

A Medline literature search (PubMed database, 1999–2002) and manual cross-referencing were performed to identify all articles relating to laparoscopic donor nephrectomy. Safety and efficacy criteria were analysed systematically for each study. Studies included were categorized using an evidence-based level grading system.

Results

Of 687 publications, 20 studies with level I–II evidence and 12 with level III evidence were analysed. Only one level I study could be identified. Level I and level II evidence suggests superiority of the laparoscopic approach in regard to postoperative analgesic consumption, hospital stay and return to work. Other safety and efficacy criteria, including donor and recipient outcomes, were similar between the two techniques.

Conclusion

Laparoscopic donor nephrectomy has gained community acceptance by physicians and patients over the past decade. Despite a lack of strong evidence, such as large prospective randomized studies, laparoscopic donor nephrectomy is likely to become the ‘gold standard’ for donor nephrectomy in the near future.