Chapter 38

### INTRODUCTION

Organ transplantation involves dissection of vascular and lymphatic channels in the targeted areas of implantation in both the recipient and the donor. This process together with the derangements resulting from antecedent pathophysiologic processes associated with end-organ failure necessitating transplantation in the first place invites a specific set of venous and lymphatic disorders that complicate the care of transplant patients in both the pre- and posttransplant phases. Although seemingly unrelated because of different anatomical locations and organ systems; these disorders are linked by the disorders of coagulation that eventually govern their occurrence. The scope of discussion in this chapter addresses only disorders that are common and vexing.

### VENOUS AND LYMPHATIC ANOMALIES IN RENAL TRANSPLANTATION

#### Lymphocele after Kidney Transplantation

Lymphocele is a lymphatic fluid collection in the postoperative field outside of the parietal peritoneum, which is a non-epithelized cavity. This complication has been believed to be from inadequate ligation of lymphatic vessels coursing over the recipient's iliac vessels or lying over the hilum of the renal allograft. In the early literature, the incidence of lymphoceles, based on clinical presentation, was estimated around 2%.1,2 As ultrasonographic surveillance has become part of routine postoperative follow-up, the incidence has been shown to be as high as 50%.3 Diagnosis of lymphocele can be made with ultrasonography and computed tomography (CT) scan to document the size, location, and compression of adjacent structures.4

Meticulous ligation of overlying lymphatics during mobilization of iliac vessels is crucial for prevention of lymphocele.5 Increased incidence of lymphocele seems to be associated with recipient obesity and use of mammalian target of rapamycin (mTOR) inhibitors as part of the immunosuppression regimen.6,7

Although most lymphoceles are asymptomatic, some of them become clinically significant because of pressure on adjacent structures, including the ureter, iliac vein, or lower extremity lymphatics. In severe cases, the patient may develop hydronephrosis and resultant azotemia, urinary frequency, a protruding mass, or ipsilateral leg edema. Less frequent presentations are deep venous thrombosis (DVT) caused by compression of iliac vein and infected lymphocutaneous fistula through the incision.8,9,10,11 Larger collections may become clinically evident at 2 weeks to 6 months after transplantation (peak incidence, 6 weeks).

Small and asymptomatic lymphoceles may resolve without treatment.12 Unnecessary intervention may lead to infective complications. Although simple image-guided aspiration may be curative, prolonged drainage through a percutaneous catheter often becomes necessary.13 Use of sclerosing agents such as tetracycline or povidone–iodine has been advocated by some authors.14 The major drawback of both prolonged percutaneous drainage and injection of sclerosing agents is an increased risk of infectious complications. After a failure of percutaneous drainage, the most preferred approach is surgical drainage of lymphocele into the peritoneal cavity by fenestration of lymphocele through a transperitoneal approach to drain lymphatic fluid into the peritoneal cavity, ...

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