Celiac disease is a clinical condition caused by the establishment of an abnormal channel between the lymphatic vessels and the urinary system, resulting in the entry of celiac-like material from the lymphatic vessels into the urine. From August 2013 to January 2015, we treated 3 patients with celiac disease by posterior laparoscopic renal lymphatic vessel ligation with satisfactory results, which are reported below.
I. Data and methods
Clinical data: From August 2013 to the present, three patients were diagnosed with celiac disease in our center, and the clinical data of the patients are shown in Table 1. 3 patients, one female, 58 years old, had intermittent white urine for six months, and cystoscopy showed a large amount of white celiac urine spraying from the left ureteral orifice with one discharge at an interval of 15-30 seconds, and no abnormality was seen on the right side. Patient two female, 63 years old, with foamy urine for two years and edema for nine months, cystoscopy showed milky white turbid urine in the bladder, mucous membrane of the triangle was light and neat after flushing, 3 minutes later the right ureteral orifice sprayed a large amount of white celiac urine, 15s left side clear urine. Patient 3 female, 73 years old, was admitted to the hospital for more than 3 months with rice-soup-like urine, cystoscopy showed right ureteral orifice and large amount of white celiac urine sprayed from the ureteral orifice. preoperative celiac test was positive in all 3 patients and all patients were treated with posterior laparoscopic perirenal lymphadenectomy in our hospital.
Table 1. General clinical data of the three patients with celiac disease
Case 1
Case 2
Case 3
Gender (M/F)
Female
female
Female
Age
58
60
73
Symptoms
Intermittent white urine for six months
foamy urine for two years, edema for nine months
celiac disease for four months with wasting and anemia
side by side
left side
right
right side
Celiac test
+
+
+
Urine protein
++
+++
++
Surgery time
250
200
230
Blood loss
50
20
20
Complications
No
No
None
Surgical approach: Gastrointestinal decompression tube and urinary catheter were preoperatively placed. After general anesthesia, the patient was placed in the folding position on the healthy side, the retroperitoneal cavity was routinely established, the skin was incised under the umbilicus, the pneumoperitoneum was established, the 10mm Trocar was placed, and the 30° laparoscope was placed. Under direct vision, two 10 mm Trocar were placed on the affected side next to the rectus abdominis muscle and at the midpoint of the umbilicus and pubic symphysis, and a 5 mm Trocar was placed one finger above the anterior superior iliac spine on the affected side. the retroperitoneal fat was cleared, and the Gerota fascia was incised longitudinally by ultrasonic knife, and the perirenal fat, off-segment perirenal lymphatics, off-segment upper ureter and peripelvic lymphatics, off-segment perirenal vascular lymphatics were cleared in turn. The kidney, renal artery, renal vein and upper ureter were completely “skeletonized”, and finally 2-0 absorbable sutures were used to close the upper pole of the kidney to fix the kidney to the psoas major muscle. The retroperitoneal drainage tube was left in place after the operation.
II. Results
All three patients were successfully operated under laparoscopy. The operating time was 250 minutes for patient 1, 200 minutes for patient 2, and 180 minutes for patient 3; the bleeding volume was 50 ml for patient 1, 20 ml for patient 2, and 30 ml for patient 3; the drainage tube was removed on the fourth postoperative day for patient 1, the third postoperative day for patient 2, and the fourth postoperative day for patient 3, and the hospital stays were 8, 25, and 12 days, respectively. Cystoscopy was performed 3 months after surgery and no milky white cloudy urine was found in the bladder and no white celiac disease was ejected from the ureteral orifice. The average follow-up time was 12 months, and the postoperative symptoms disappeared with negative postoperative celiac test and negative urine protein.
III. Discussion
Celiac disease is a clinical condition in which an abnormal channel is established between the lymphatic vessels and the urinary system, resulting in the entry of celiac-like material from the lymphatic vessels into the urine, characterized by urine with a celiac-like appearance [1]. Celiac disease can be classified as parasitic or nonparasitic and is mainly caused by parasitic infection, a relatively rare clinical complication seen in about 2% of patients with filariasis. The most common pathogen is Bancroftian filarial parasites, while filarial worms and other parasites can also cause the disease [2].
The pathogenesis of celiac disease is characterized by lymphatic drainage from the kidney pooling into the lumbar trunk, which converges into the celiac pond in parallel with the intestinal trunk. Parasitic infection leads to occlusive lymphitis and impairment of the valve mechanism, and lymphatic reflux from the celiac pond or intestinal trunk into the lumbar trunk, along with flexion and dilation of the lymphatic vessels, which eventually leads to lymphatic ureteral fistulae caused by the rupture of the lymphatic vessels into the urinary tract, creating celiac-like urine. The fistula is most commonly found in the fornix of the calyces and can also be seen at all levels from the ureter to the bladder. The celiac fluid that breaks into the urine contains large amounts of fat, protein, and fat-soluble vitamins from dietary sources.
Clinical manifestations of celiac disease include celiac disease after a fatty meal, obstruction of the ureter by celiac masses leading to unilateral back pain or renal colic, proteinuria and hypoalbuminemia, anemia, and wasting [3]. The treatment of celiac disease includes conservative treatment, intraluminal intrapelvic perfusion treatment and surgical treatment. Surgical intervention is required when conservative treatment is ineffective and pyel perfusion therapy is ineffective. There are many surgical treatments for celiac disease, including shunts and dissection, with the best efficacy of dissection being ligation of the lymphatics of the renal tip [4].
In our unit, posterior laparoscopic perinephric lymphadenectomy was used to treat celiac disease, which is characterized by less trauma, faster recovery, and positive results. To summarize the surgical experience of our unit: (1) due to the complex anatomical relationship in the hilar region, a Trocar can be added at the level of the flat umbilicus in the anterior axillary line, and the renal artery or renal vein can be tracted with a rubber band to prevent damage to the vessels when the lymph vessels are separated from the segmental arteries and veins; (2) patients with celiac disease have a long history, and the perirenal lymph vessels are tightly wrapped in the vascular sheath, so it is necessary to carefully separate the vascular sheath with an aspirator or an electric hook to completely The lymphatic vessels in the vascular sheath should be stripped, and the lymphatic vessels in the Hem-o-lck clamp should be separated from the segment afterwards; (3) because of the thin branches of the renal artery near the hilum, it is difficult to distinguish the artery from the lymphatic vessels if the vasospasm is present when the hilum is freed, so the perirenal lymphatic vessels can be freed away from the hilum and close to the root of the renal artery, which can reduce the difficulty of the operation and prevent the occurrence of side injuries.
References
1. Saha M, Ray S, Goswami M, et al. An occult filarial infection presenting as chyluria with proteinuria: a case report and review of literature[J]. BMJ case reports, 2012, 2012: bcr0120125635.
2. Diamond E, Schapira H E. Chyluria-a review of the literature[J]. Urology, 1985, 26(5): 427-431.
3. Graziani G, Cucchiari D, Verdesca S, et al. Chyluria Associated with Nephrotic-Range Proteinuria: Pathophysiology, Clinical Picture and Therapeutic Options[J]. Nephron Clinical Practice, 2011, 119(3).
4. Puinekar S V , Kelka r A R, Prem A R, et al. Surgical disconnection of lympho renal communication for chyluria: a 15-year experience[ J] . Br J Urol , 1997 , 80 :858-863.