Right lumbar lymph trunk injury after right laparoscopic donor nephrectomy: a case report

Abstract

Laparoscopic donor nephrectomy (LDN) is increasingly popular because of its advantages over open surgery. Chyle leak after donor nephrectomy is a rare but potentially lethal complication if not treated appropriately. We describe a case of a 43-year-old female patient with no remarkable history who presented a chyle leak on day 2 after right transperitoneal LDN. Since conservative treatment failed, the patient underwent magnetic resonance imaging (MRI) and intranodal lipiodol lymphangiography, which confirmed the chyle leak from the right lumbar lymph trunk into the right renal fossa. The chyle leak was percutaneously embolized twice, on postoperative day (POD) 5 and POD 10, by a mixture of N-butyl-2-cyanoacrylate and lipiodol. The drainage fluid decreased significantly after the second embolization. The subhepatic drainage tube was withdrawn on POD 14, and the patient was discharged on POD 17. MRI lymphangiography and intranodal lipiodol lymphangiography effectively identified the chyle leak point. Percutaneous embolization seems to be a safe, effective method for treating high-output chyle leaks.

Keywords: Cyanoacrylate; Embolization; Lymphangiography; Lymphatic vessels; Nephrectomy.

Fig. 1

Magnetic resonance imaging (MRI) lymphangiography. (A, B) T1 Viber fat-sat in the axial images and (C) coronal maximum intensity projection (MIP) image showing extravasation of contrast from the right lumbar lymph trunk to the right renal fossa (black arrows). The cisterna chyli was not seen. Right and left lumbar lymph trunks (white arrows).

Fig. 2

(A) Intranodal lymphangiography on postoperative day 5, confirming the extravasation of lipiodol from the right lumbar lymph trunk (black arrow) to the right renal fossa (asterisk). White arrows: thoracic duct. Arrowheads: subhepatic drainage. (B) Single-shot image after the first embolization, showing glue in the right lumbar lymph trunk (arrowheads) and right renal fossa (asterisk).

Fig. 3

(A) Fluoroscopy on postoperative day 10 showing that most of the mixture of N-butyl-2-cyanoacrylate (NBCA) and lipiodol was washed from the right lumbar trunk (black arrows) into the right renal fossa (asterisk). (B) Single-shot image after the second embolization: the right lymph trunk (arrowheads) was completely embolized by a mixture of NBCA and lipiodol (1:2 ratio) through a 22G Chiba needle (white arrows). Asterisk: lipiodol in the right renal fossa.

Fig. 4

XperCT (Philips) on the table before (A) and after (B) glue injection in the second embolization. (A) The right lumbar lymph trunk (black arrow) was accurately accessed by a Chiba needle (22G; white arrows). (B) After the second embolization, the right lumbar lymph trunk (arrow) was completely embolized.