Post Transplant Lymphocele

Case presentation.57 yrs old Female,Hypertensive , CKD stage

V HD on twice weekly HD since 6 yearsUnderwent - LIVE DONOR RELATED

TRANSPLANT (DONOR - BROTHER) on 20/12/13.

Intraoperatively kidney turned blue in patches post anastomosis and was pink post papaverin injection.

WIT= 4 mins. CIT = 1 hour 15 mins.

Case presentation.DELAYED GRAFT FUNCTION

postoperatively as patient developed ATN (on USG and Doppler, Renal scan- biopsy was not done)and required lasix infusion for urine output initially. Patient`s urine output gradually improved and Sr.creatinine decreased from 6.9 to 2.4 mg/dL from post op day 1 to day 11.

Case presentation.She had URINARY TRACT INFECTION (ESBL E-coli)

which required Inj.Imipenem + Cilastatin for 10 days.PROLONGED ABDOMINAL DRAINAGE -150 ml day

continued till day of discharge ie POST OP Day 25. Measures like tab DEC, AKT was tried for reducing the drain output. Urine leak, Chyle was ruled out and drain fluid was sterile on cultures.

Patient was discharged with Drain and DJ stent in situ with Sr.Creatinine decreased to 1.4 mg/dL on post operative day 25.On Discharge – Triple immunosupression, INH, ETB, DEC and Tab Ceftum was given

Case presentation.Meanwhile she followed in OPD. Drain Catheter

manipulation .Found to have NODAT on follow up and started on insulin.

Patient got readmitted on 8/2 /2014 with fever, loose motions , severe dysuria and poor oral intake.

Investigations on admission showed a creatinine of 2.2 mg %, Sodium -122 without leucocytosis. Drain fluid was turbid on examination and Gram stain showed Gram Negative Bacteria. Urine showed > 200 PC. Drain fluid and Urine C/S was sent. Patient was started on inj Meropenem I gm q8h. Drain fluid culture and urine C/S grew kleibsiella sensitive to colistin, tigecycline and amikacin. (Heavy and scanty growth respectively).

Case presentation.Hence Inj Colistin 6 MU followed by 2 MU

q8h was added. She responded symptomatically and turbidity of the drain fluid decreased. USG showed a preperitoneal collection of 200 ml with ? tiny cyst/liquefied abscess at lower pole of the transplanted kidney. Left Jugular CVP line (Triple lumen) was inserted on 10/02/2014.Drain fluid gram stain +c/s was normal on 12/02/2014 and creatinine declined to 1.4 mg % on 13/03/2014

Case presentation.With subsiding infection, she was posted for

exploration of wound on 14/02/2014 by under GA. Intraoperative large wound defect with dehiscenced muscle layer and thick peritoneum noted . The peritoneum was excised and muscle layer approximated . Post operatively she was shifted to SICU and extubated the same day.

Case presentation.She was later shifted to Wards the next day, and

Meropenem and colistin were continued to day 10. (19/02/2014). Patient though hemodynamically stable, had severe stomatitis and odynophagia, and 2-3 episodes of loose motions and abdominal discomfort. Hence tab. Ciplox 250 mg bdwas started orally which she did not tolerate and hence tab Levofloxacin was started 500 mg OD . She had oral candidiasis hence to r/o esophageal candidiasis her OGD scopy was done on 23/04/2014 which confirmed the same. She was started on Tab Fluconazole 200 mg OD. Dr Amit Desai consult was sought due to major depression due to the medical illness.Histopathology from OGD scopy biopsy showed e/o HSV esophagitis and hence Tab Acyclovir 400 mg q8h was added since 27/02/2014 for 10 days

Case presentation.Since 18/02/2014 there was a slow rise in serum creatinine

(with good urine output) from 1.8 mg% to 2.5 mg% on 27 /02/2014. Doses of Tacrolimus were adjusted as per the trough levels. Repeat USG was showing persistent preperitoneal collection and drain output about 500 ml/day with peri drain leak. Gradual pulling out of the drain was planned. Repeat Drain fluid and urine cultures were again showing heavy growth of Kliebsiella pneumonia and Enterococcus hence injImipenemCilastatin 500 mg q8h, inj Colistin 2 Mu q12h and tab. Linospan 600 mg q12h was started . The increment in the creatinine was attributed to the underlying infection . Kidney biopsy to rule out a possibility of rejection was not possible due to ongoing infection.

Case presentation.Antibiotics were stopped after 14 days with documented

sterile drain fluid and urine c/s on two occasion 3 days apart. Meanwhile the drain was persistly 500- 800 ml/day with occasional drop to least 150 ml/day. Patient improved symptomatically after above. Removal of the drain which was done on 21/02/2014 and colostomy bag was put. Before removal drain fluid and urine c/s done again grew Kliebsiella Pneumonia (Heavy Growth). Hence for recurrent UTI, Dr OM Srivastava reference was taken who advised inj Colistin 1 mu OD anjinjsulbactan 500 mg q8h. which were started on 21/03/2014. Since she had an allergic reaction to Inj Sulbactam it was changed to injTigecycline 50 mg q12h.

Case presentation.Progressively the drain output in the

colostomy bag declined and stopped completely on 28/03/2014. There was collection of the drain fluid in subcutaneous tissue about 600 ml on USG and decision to aspirate it was done on 31/03/2014. About 1500 cc of clear fluid was tapped which was negative for gram stain and cultures had no growth. The collection wouldn’t stop from forming and CT scan was done on 4/4/14

Case presentation.Patient underwent Laparoscopic

Marsupilisation on 7/4/14.

Review of literature.Definition: Lymphocele is a pseudocystic

entity with lymph content covered with a hard fi brous capsule.

It can be a complication of any surgery involvingthe lymphatic system.

Review of literature.Lymphocele occurs 2 weeks to 6 months after

transplantation with its peak incidence being at 6 weeks. On the other hand, its development following trauma to the kidney and delayed formation 8 years after transplantation has been reported, too

Review of literature.The incidence of clinically significant

lymphocele is about 20%, but it may develop in 12% to 40% of transplant recipients.(3,4) Since the introduction of ultrasonography, in about half of transplanted kidneys, collections smaller than 50 cm3 can be detected, most of which are less than 3 cm in diameter and resolve spontaneously. Most of the lymphatic collections are subclinical.

Review of literature.Etiology:Radioisotope studies suggest that most lymphoceles

originate from leakage of lymph from unligated iliac vessel lymphatics of the recipient.

Lymphocele can also originate from transplanted kidney lymphatic vessels.

In a study by Goel and colleagues, combination of sirolimus, mycophenolate mofetil, and prednisone was an independent factor for lymphocele occurrence by a mechanism of delayed healing of wound and injured lymphatic vessels.

obesity (body mass index greater than 30 kg/m2) is an independent risk factor for lymphocele formation

Review of literature.Prophylaxis with highmolecular weight

heparin can increase the incidence of lymphocele.

Lundin and colleagues reported a higher frequency of lymphocele with heparin prophylaxis (43% versus 20%) in a group of 130 kidney allograft recipients.Such an increase was not associated with hemorrhagic events.

Allograft rejection was most important contributing factor in lymphocele formation.

Review of literature.Presentation:Most lymphoceles are clinically silent, but the

most common manifestation is impaired graft function in the presence of perigraft collection and unilateral leg edema. Many other presentations have been recognized including:hypertension, pain, fever, frequency, ipsilateral thrombophlebitis, palpable mass, and lymphatic fistula.(1) even, a case of urinary retention due to compressive effect of lymphocele on the bladder neck has been reported.

Treatment:Conservative Management. Small

asymptomatic collections are common and usually resolve spontaneously. Therefore, conservative management can be satisfactory.

Simple AspirationSimple Aspiration. Ultrasonography-guidedaspiration is not only diagnostic, but alsotherapeutic in selected cases. It can be the initialtreatment modality that allows relief of urinaryobstruction, recovery of kidney function, andprevention of emergency situation. Althoughsimple aspiration is sometimes therapeutic, itmay be necessary to perform multiple sessions ofaspiration and the rate of spontaneous recoveryreduces after 3 recurrences. In addition, eachaspiration brings about a low risk of infection.

Sclerotherapy.Sclerotherapy. Prolonged external drainage

via percutaneous catheter and administration of a sclerosing agent (instillation) is also used. Recurrences have been reported in up to 20% of cases following sclerotherapy. Agents like ethanol, povidone iodine, and tetracycline have been used for this purpose.

SurgerySurgery for lymphocele is needed in thepresence of local symptoms, graft

dysfunction, orboth. Surgical treatment is named

incorrectly asmarsupialization, but unroofing or

fenestration ismore precise.(1) This therapy is an

intraperitonealdrainage of lymphocele. Because of itseffectiveness and safety, surgery should be

thefirst line of the treatment.

SurgeryLaparoscopy is the procedure of choice for

surgical management of lymphocele. In different series, the rate of recurrence

following laparoscopic marsupialization has been reported between 5% to 13%, and it has been noted that there is a risk of injury to other organs.

SurgeryIn a study on laparoscopicLymphocele After Kidney Transplantation—Ebadzadeh and

Tavakkoli - treatment of lymphocele, the mean operativetime was 123 minutes and the mean blood losswas 43 mL. The authors reported an averageduration of hospitalization of 1.5 days. Onlyminor complications were seen. They concludedthat laparoscopy is an effective minimally invasivetreatment and an excellent alternative for opensurgery.Hsu TH, Gill IS, Grune MT, et al. Laparoscopiclymphocelectomy: a

multi-institutional analysis. J Urol. 2000;163:1096-8; discussion 8-9

SurgeryOpen surgery may be required in patients witha previous abdominal surgery, for lymphoceleswith inappropriate characteristics or location, orwhen other simultaneous procedures should bedone. For deep lymphoceles around the lowerpole of the kidney, it seems that open surgeryis safer. In other unusual cases, including thickwall of lymphocele or bladder rupture duringlaparoscopy, open surgery may be necessary.(1)In a study by Fuller and colleagues, the mostcommon indication for open drainage wasuninfected wound complication and highprobability of injury to the ureter or the vesselsbecause of proximity to the hillar structures.

SurgeryIn children, prophylactic fenestration

between the two cavities at the end of the operation is recommended by some authors.

A new method named intraperitoneal catheter drainage of lymphocele as an outpatient Procedure with local anesthesia and Seledinger method.