Retained Malecot's Drain Tip after Percutaneous Drainage of Post-transplant Lymphocele: A Case Report
Correspondence Address :
Dr. Madhur Anand,
A 1104, Celebrity Greens, Sushant Golf City, Near Damson Plum Hotel, Lucknow-226030, Uttar Pradesh, India.
E-mail: drmadhuronline@gmail.com
Percutaneous drains are commonly used to drain collections in surgical patients. The choice of drain can determine the potential complications. Herein, the authors presented a case of a 32-year-old female with a drain complication and its management in a post-transplant patient. The patient developed a post-transplant perigraft lymphocele and underwent drainage using Malecot’s catheter. However, during the removal of drain, the Malecot catheter accidentally broke, leaving the tip inside the perigraft region. To locate the tip, a non-contrast Computed Tomography (CT) scan was performed. Subsequently, the patient underwent a transperitoneal re-exploration, successfully removing the tip. It was discovered that the catheter tip had ingrown tissue between the prongs, impeding its removal. It is crucial to exercise caution in such situations as Malecot catheters may sometimes have ingrown tissue between the prongs, hindering their removal.
Catheters, Foreign bodies, Grafting, Lymphocele, Transplantation
A 32-year-old female presented to department of urology and renal transplant Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow with a two-year history of chronic kidney disease. After complete evaluation, she underwent a right iliac fossa live-related renal transplantation. The graft kidney had double renal vessels, anastomosed to the right external iliac artery, and the graft ureter was anastomosed to the bladder using 4-0 polydioxanone sutures in a modified Lich Gregoir fashion. On the seventh postoperative day, perigraft lymphocele was observed (Table/Fig 1) along with an increase in creatinine levels. Percutaneous drainage of the lymphocele was planned and a 10 Fr Malecot catheter was inserted under ultrasound guidance, followed by sclerotherapy. The lymphorrhoea decreased over the next four days. At six weeks, the drain output decreased, and the Malecot catheter was clamped. However, during removal, the catheter broke, leaving the tip in place.
A CT scan confirmed the location of the drain tip in the retroperitoneum (Table/Fig 2). Due to the patient’s immunosuppressed status, surgical re-exploration under general anaesthesia after fluoroscopic localisation of the drain tip was performed. A right paramedian incision centered over the drain tip with a transperitoneal approach was chosen to avoid dissection around the properly functioning graft kidney and to access virgin planes for dissection. The prong of the Malecot flower prong was visualised and dissection was carried out towards the tip (Table/Fig 3). Soft tissue ingrowth between the prongs contributed to the difficulty in removing it. The lymphocele was not considered significant and was not marsupialised (Table/Fig 4). The patient recovered well postoperatively.
Post-transplant lymphoceles typically present as asymptomatic perinephric collections but can cause various signs and symptoms. Only a small percentage of cases require intervention (1). The underlying causes of lymphoceles include lymphatic injury resulting from subcapsular lymphatic rupture, diffuse oozing from the kidney surface, or retrograde lymph flow from the graft hilum to the subcapsular region due to fibrosis and subsequent obstruction of hilar lymphatics [2-5]. Treatment options range from close monitoring to interventions like aspiration, drainage, sclerotherapy, or surgical procedures. The literature describes various treatment methods for post-transplant lymphoceles. Asymptomatic and small collections without renal function impairment can be closely monitored over time. Symptomatic lymphoceles or those causing renal function impairment often require interventions such as aspiration, drainage, sclerotherapy, or surgical procedures like laparoscopic or open deroofing (1),(6).
Sclerotherapy requires the insertion of a percutaneous drain, which can be achieved using either a pigtail or Malecot catheter. Malecot catheters, with prongs arranged in a flower-shaped pattern, carry a higher risk of tissue ingrowth due to the gaps between the prongs (7),(8). Pigtail catheters, though easier to remove, can be accidentally dislodged (7). The present case report describes the surgical management of a Malecot catheter complication in a post-transplant patient, highlighting the potential for infections in immunocompromised individuals (9). There is a lack of published literature comparing the different drainage catheters, making it challenging to provide definitive recommendations. However, it is important to be aware of the potential complications associated with all catheter types.
The utilisation of Malecot catheters for percutaneous drainage can be complicated by granulation tissue ingrowth between the prongs. The present case report is the first documented instance of such a complication in a post-transplant patient. Surgical removal remains the primary treatment approach in these cases.
DOI: 10.7860/JCDR/2023/64620.18441
Date of Submission: Apr 10, 2023
Date of Peer Review: Jun 01, 2023
Date of Acceptance: Jun 18, 2023
Date of Publishing: Sep 01, 2023
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Apr 14, 2023
• Manual Googling: Jun 10, 2023
• iThenticate Software: Jun 16, 2023 (3%)
ETYMOLOGY: Author Origin
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