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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 16  |  Issue : 3  |  Page : 328-330

Simultaneous live-related kidney transplant and mesenteric cyst excision - A case report


Department of Kidney Transplantation, Wockhardt Hospitals, Nagpur, Maharashtra, India

Date of Submission30-Apr-2021
Date of Acceptance14-May-2022
Date of Web Publication30-Sep-2022

Correspondence Address:
Dr. Sanjay P Kolte
Wockhardt Hospitals and Sparsh Urology and Kidney Hospitals, Nagpur, Nagpur - 440 012, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_39_21

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  Abstract 


Mesenteric cysts of the abdomen affecting patients of end-stage renal disease (ESRD) are not common. In the absence of symptoms, they may remain undetected unless large in size. When present, the cysts have to be treated by surgical excision. In patients awaiting kidney transplantation, surgery for the cyst can be a potential hindrance in the planning of transplantation as morbidity and mortality of surgery in patients of ESRD is very high. We report a 27-year-old male awaiting kidney transplantation, who presented to us with a large mesenteric cyst. We conducted a simultaneous surgery of mesenteric cyst and kidney transplantation successfully.

Keywords: Abdomen, kidney transplantation, mesenteric cyst


How to cite this article:
Kolte SP, Chaubey S, Hazra S, Kolte M. Simultaneous live-related kidney transplant and mesenteric cyst excision - A case report. Indian J Transplant 2022;16:328-30

How to cite this URL:
Kolte SP, Chaubey S, Hazra S, Kolte M. Simultaneous live-related kidney transplant and mesenteric cyst excision - A case report. Indian J Transplant [serial online] 2022 [cited 2022 Nov 27];16:328-30. Available from: https://www.ijtonline.in/text.asp?2022/16/3/328/357608




  Introduction Top


Benign abdominal cysts and masses are not uncommon in adults. In patients of end-stage renal disease (ESRD), the presence of such masses needs attention before transplantation so as to exclude malignancy, plan timing of surgery if required, and ensure a favorable outcome of transplantation.[1],[2] Ascites when present often cloud clinical attention and delay diagnosis. Surgery for excision is not without morbidity and may jeopardize chances of kidney transplantation subsequently. Herein, we report a case of mesenteric cyst excision and kidney transplantation carried out simultaneously in a patient of ESRD.


  Case Report Top


A 27-year-old male presented with ESRD. He was on maintenance hemodialysis for the last 3 years. He had hypertension and a history of pulmonary Koch's 2 years ago, for which a 9-month regimen of anti kochs therapy was already received by him. He did not have diabetes. Residual renal glomerular filtration rate on diethylene triamine penta-acetic acid renal scan was 10 ml/min and urine output was negligible for the past 6 months. He also had ascites. Biochemical analysis and cytology of ascitic fluid were negative for malignancy or tuberculosis. Ascites partially resolved with aspiration and treatment in due course of time. However, it was noticed that he had a cystic collection in the umbilical and infraumbilical region extending partially into the right iliac region. During aspiration, the wall of the cyst was felt to be tough and thick and contained dark straw-colored clear fluid. Ultrasound was suggestive of a cyst with wall thickness of 8–9 mm and internal loculation. Pretransplant surgery for the cyst was not considered appropriate for reasons of morbidity associated with the procedure. A live-related kidney transplantation was planned when his 53-year-old mother decided to donate. He was taken for surgery with a plan of simultaneous surgical excision of the cyst and kidney transplantation. The likelihood of risks of postoperative infection, delayed wound healing, graft dysfunction, graft pyelonephritis, and urinary leakage were elaborately explained to him before the surgery. A possibility of transplanting the kidney in the left iliac fossa was kept as an alternative plan if the lesion was found to be infected. On exploration, it was found to be an oval cyst of size 15 cm × 12 cm × 10 cm located in the mesentery of the ileum abutting its mesenteric border [Figure 1]. It was dissected free of the adherent loops and was successfully enucleated leaving no raw area and without any disruption of the bowel lumen [Figure 2]. On cut section, it was found to have a tough wall of about 8–10 mm thickness all over. Contents were straw-colored fluid and some necrotic septa, running longitudinally along the walls of the cyst [Figure 3]. There was no pus or any gross features of malignancy; hence, no further action was taken. Ascites was drained and adhesions in adjoining loops of intestine were released. A thorough lavage with normal saline was given to the entire peritoneal cavity. The peritoneum was closed leaving an intraperitoneal drain. The kidney was then transplanted into the right iliac fossa, retroperitoneally through a separate Gibson's incision. Renal artery was anastomosed end to end with the right internal iliac artery, while renal vein anastomosed end to side with the external iliac vein [Figure 4]. The cold ischemia time was 45 min. On achieving prompt diuresis, the ureter was anastomosed to the bladder by the Lich Gregoir technique. A 6 F/16 cm double J (DJ) stent was kept in the ureter.
Figure 1: Intraoperative picture of the cyst before excision

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Figure 2: Specimen of cyst after excision

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Figure 3: Cut section of the cyst

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Figure 4: The transplanted kidney after anastomoses

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Another drain was kept near the graft and the wound closed in layers.

He had a smooth recovery and was discharged on day 12 after removal of drains, sutures, and the DJ stent, with a serum creatinine of 0.6 mg/dL.

The histopathological report of the cyst was found to be nonspecific inflammatory changes. There were no features of Koch's malignancy or dysplasia. The culture and sensitivity of the fluid revealed no growth of organisms.


  Discussion Top


Although kidney transplantation is the optimal treatment for ESRD, these patients often have to overcome various health challenges that may be associated before receiving a kidney transplantation.[1] Life on dialysis is not straightforward; these patients have a higher risk of developing comorbidities such as stroke, acute coronary events, heart failure, vascular access-related infection, endocarditis, cancer, bowel ischemia/bleeding, limb ischemia/necrosis, and bone fractures requiring emergent medical or surgical interventions. Five-year mortality rates range from 39% to 60%. The literature consistently demonstrates a higher risk of mortality in ESRD patients compared with non-ESRD patients.[2] Gajdos et al.[3] demonstrated that the 30-day mortality rates of patients with ESRD undergoing elective procedures were fourfold higher than those of their non-ESRD cohorts.[3] Thus, any elective surgery for a benign tumor before kidney transplantation must be weighed against these considerations. However, great improvement in survival and quality of life is derived from kidney transplantation when compared to those who remain on dialysis. Hence, it remains the primary aim in such patients. Associated problems have to be dealt with, according to prevailing circumstances and risk versus benefit assessment.

A significant body of literature discussing the effects of comorbid conditions on patients with ESRD exists, but the consequences of comorbidities on transplant outcomes have not been well studied. These are common in transplant recipients and have a significant impact on posttransplantation quality of life; thus, continued assessment of the comorbidity provides an opportunity to identify issues that are essential for optimizing the continued care of the recipients.[4] A small number of studies have demonstrated overall detrimental effect of comorbidities on transplant outcomes using various indices. However, this does not allow characterization of the risks associated with specific comorbid conditions. Retrospective registry analyses have identified several comorbidities as risk factors for transplant outcomes, but the results show considerable heterogeneity and are limited by the reliability of the data.[5] We could not find any reports of benign intra-abdominal cysts in ESRD patients being operated simultaneously with kidney transplantation, although there were many surgeries for native nephrectomies and transplantation. Intra-abdominal primary peritoneal cysts have to be differentiated from intra-abdominal collections which may be abscesses, seromas, bilomas, urinomas, or lymphoceles. Clinical history and imaging features help in this differentiation. Lymphangiomas and multilocular cystic masses can virtually occur in any location within the abdomen and insinuate between structures. Ultrasound helps differentiate enteric duplications cysts from mesenteric and omental cysts in the abdomen.[6] The causes of collections are neoplastic, peritonitis, ascites, and hematomas or collections following invasive procedures of the peritoneal cavity. The patient had no previous peritoneal interventions such as peritoneal dialysis or drainage of ascitic fluid. Diagnostic tapping did not reveal any evidence of an infective cause, tuberculosis, or malignancy. The wall thickness and septate nature of the cyst made it mandatory for excision. Simultaneous cyst excision and kidney transplant were thus planned. On exploration, the cyst was thick walled and located in the mesentery abutting the inner border of the ileum. There was no continuity of the cyst wall with the adjoining loop of ileum to suggest its origin from the intestinal wall. It was meticulously dissected and removed without any damage to the bowel continuity. It bore the appearance and size of the “copra” of a tender coconut. There was no vascular pedicle supplying the cyst which needed ligation confirming its nonneoplastic origin. Having removed it completely, adhesiolysis of some loops of intestine was done and a thorough saline lavage to the entire peritoneal cavity was given. The peritoneum was closed after keeping a drain. The iliac vessels were found to be clean and healthy. Hence, the kidney was transplanted into the right iliac fossa. The anastomoses could be done smoothly. Cold ischemia time was 45 min. The kidney functioned immediately, and the recovery of the recipient was uneventful. He was discharged on day 12.

Our case demonstrates that surgery for benign intra-abdominal cysts can be successfully carried out simultaneously with kidney transplantation, thus reducing the time to transplantation and morbidity of an additional surgery to the patient.


  Conclusions Top


In cases of coexistent benign abdominal cysts requiring surgical attention in a recipient of kidney transplant, simultaneous extirpative surgery and kidney transplant can be safely contemplated, if malignancy is ruled out beforehand. This spares the patient of an added set of complications that may be associated with the surgery in the run up to the transplant while relieving him of the coexisting pathology in a single surgery.

Declaration of patient consent

The authors certify that patient consent has been taken for participation in the study and for publication of clinical details and images. Patients understand that the names, initials would not be published, and all standard protocols will be followed to conceal their identity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Harhay MN, Rao MK, Woodside KJ, Johansen KL, Lentine KL, Tullius SG, et al. An overview of frailty in kidney transplantation: Measurement, management and future considerations. Nephrol Dial Transplant 2020;35:1099-112.  Back to cited text no. 1
    
2.
Kanda H, Hirasaki Y, Iida T, Kanao-Kanda M, Toyama Y, Chiba T, et al. Perioperative management of patients with end-stage renal disease. J Cardiothorac Vasc Anaesth 2017;31:2251-67.  Back to cited text no. 2
    
3.
Gajdos C, Hawn MT, Kile D, Henderson WG, Robinson T, McCarter M, et al. The risk of major elective vascular surgical procedures in patients with end-stage renal disease. Ann Surg 2013;257:766-73.  Back to cited text no. 3
    
4.
Wu C, Evans I, Joseph R, Shapiro R, Tan H, Basu A, et al. Comorbid conditions in kidney transplantation: Association with graft and patient survival. J Am Soc Nephrol 2005;16:3437-44.  Back to cited text no. 4
    
5.
Wu DA, Robb ML, Forsythe JL, Bradley C, Cairns J, Draper H, et al. Recipient comorbidity and survival outcomes after kidney transplantation: A UK-wide prospective cohort study. Transplantation 2020;104:1246-55.  Back to cited text no. 5
    
6.
Arraiza M, Metser U, Vajpeyi R, Khalili K, Hanbidge A, Kennedy E, et al. Primary cystic peritoneal masses and mimickers: Spectrum of diseases with pathologic correlation. Abdom Imaging 2015;40:875-906.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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