Thoracic Duct Research Articles

Thoracic duct leakage in a patient with Type B-Non-Hodgkin lymphoma treated with transvenous retrograde access embolization: a case report.

Thoracic duct (TD) is the largest lymphatic vessel in the body and drains the lymph at the junction between the left subclavian and jugular veins. Chylothorax (CTX) represents an accumulation of lymphatic fluid in the pleural space. We present a case of a 65 years-old man with an histologically diagnosed mediastinal type B non-Hodgkin Lymphoma, treated with chemo-immunotherapy. CT scan during follow up showed significant left side pleural effusion, amounting to 2.8 litres after drainage. Conservative treatment with low fat parenteral nutrition was started without reduction of drainage output, then lymphangiography (LP) with Lipiodol was performed demonstrating a leak in the distal TD. CTX increased in the following days, and a further LP was performed. Using transvenous retrograde access we catheterized TD at the left subclavian jugular veins using a microcatheter. The leak was treated with multiple conventional and controlled delivery microcroils and cyanoacrylate, obtaining complete embolization without residual leak.

Lesions of the visceral mediastinum

The visceral or middle mediastinum contains nonvascular (trachea, carina, esophagus, and lymph nodes) and vascular structures (heart, ascending aorta, aortic arch, descending aorta, superior vena cava, intrapericardial pulmonary arteries, thoracic duct). The various pathologies of the visceral mediastinum and imaging features are presented. Plain film radiography shows the gross anatomy and allows visualization of larger pathologies. However, for detailed anatomic and structural classification more sophisticated imaging techniques are required. Especially computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET) are well suited for structural and functional assessment of mediastinal lesions. This article summarizes the major pathologies of the visceral mediastinum.

An Uncommon Case Report of a Punctured SVC through a Chemo Port

Chemo port implantation has enhanced the quality of life for cancer patients. Interventional radiologists or surgeons may implant chemo ports via the Internal Jugular Vein (IJV) or Subclavian Vein (SCV). A central catheter that is implanted into the central venous system is connected to a port chamber (subcutaneous) to form a venous port system. The catheter chamber's subcutaneous position enhances the patient quality of life and has a lower infection rate than non-totally implanted central venous devices. To avoid both immediate and long-term difficulties, a port system must be implanted, used, and cared for properly. Pneumothorax, hemothorax, thoracic duct damage, cardiac tamponade, venous malpositioning of the catheter, and perforation with arterial injury are the most frequent early complications (30 days). Infection, catheter thrombosis, vascular thrombosis and stenosis, catheter fracture with extravasation, or fracture with migration or catheter material embolization, are examples of delayed problems. To detect potential issues and plan therapeutic interventions, such as in the event of catheter migration, radiologic imaging has become more important in both intra-procedural assessment and postoperative follow-up.

Development and application of a simple pharmacokinetic model that quantitatively describes the distribution and elimination of the commonly measured proteins.

Increased plasma concentrations of a variety of cellular enzymes (alanine transaminase, aspartate aminotransferase, alkaline phosphatase, amylase, etc.) are commonly used as routine screening tests for a range of conditions. An increased concentration usually is assumed to result from an increased rate of delivery to the plasma. Factors such as decreased metabolism or excretion or altered extravascular distribution usually are ignored. As a prelude to a detailed analysis of all the factors producing altered plasma enzyme levels, we have reviewed the relevant literature describing the pharmacokinetics (PK) of 13 of the commonly measured plasma proteins and developed a PK model that provides a simple physiological description of all the data. Our model starts with the general 3-compartment, 6-parameter system previously developed for albumin and interprets the fluxes in terms of unidirectional sieved protein convectional volume flows from the plasma to the two tissue compartments and equal lymph flows returning to the plasma. This greatly constrains the model such that each protein is characterized by only two adjustable parameters (plasma clearance and sieving factor). In addition to accurately fitting the plasma kinetics, the model can accurately describe the tissue and lymph protein PK. For example, it can describe the thoracic duct lymph protein concentration following an intravenous infusion or the plasma concentration following a subcutaneous tissue injection. This simple model provides a satisfactory framework for the PK of 12 of the 13 proteins investigated. The glycoprotein intestinal alkaline phosphatase is the exception, requiring the addition of a liver recycling compartment involving the asialoglycoprotein receptor.

ASO Visual Abstract: Is Thoracic Duct Resection Necessary for Esophageal Squamous Cell Carcinoma Patients Treated with Neoadjuvant Chemoradiotherapy? A Propensity-Matched Analysis Based on the Comprehensive Registry of Esophageal Cancer in Japan.

ASO Visual Abstract: Is Thoracic Duct Resection Necessary for Esophageal Squamous Cell Carcinoma Patients Treated with Neoadjuvant Chemoradiotherapy? A Propensity-Matched Analysis Based on the Comprehensive Registry of Esophageal Cancer in Japan.

Efficacy of modified thoraco-laparoscopic Ivor-Lewis versus traditional thoraco-laparoscopic Ivor-Lewis for esophageal cancer: Propensity score-matched analysis.

To compare the clinical results of the modified Ivor-Lewis procedure, which preserves the azygous vein, thoracic duct and surrounding tissues, with the traditional Ivor-Lewis procedure, which removes these tissues, for treating esophageal squamous cell carcinoma, and evaluating whether the azygous vein, thoracic duct and surrounding tissues are required to be removed for the surgery of esophageal cancer. To retrospectively analyze the clinical data of patients suffering from esophageal cancer treated by thoracic-laparoscopic Ivor-Lewis procedure admitted to the Department of Thoracic Surgery of Gansu Provincial People's Hospital from September 2017 to September 2019. According to the surgical method, they were divided into the modified thoracolaparoscopic Ivor-Lewis (modified group) and the traditional thoracolaparoscopic Ivor-Lewis (traditional group). Propensity score matching analysis (PSM) was applied to reduce the selection bias of confounding factors. A total of 245 patients who suffered from esophageal cancer and underwent thoracic-laparoscopic Ivor-Lewis were enrolled in the study. There were 124 cases in the modified group and 121 cases in the traditional group. The discrepancies in the age and T-stage among patients in the traditional and modified groups were statistically significant. After PSM, the above-mentioned factors became statistically insignificant. There were 86 patients in each group after PSM. Compared with the traditional group, the modified group has shorter operative time (p=0.007), less intraoperative bleeding (p=0.003) and less postoperative 3 days chest drainage(p=0.001), with a statistically significant difference. No significant difference in local recurrence (p=0.721) and distant metastasis (p=0.742) after surgery were found in the two groups, and the difference was not statistically significant. There was also no statistically significant difference in the 3-year postoperative survival rate (44.2% vs. 41.9%, p=0.605) between the modified and traditional groups. The modified Ivor-Lewis procedure, which preserves the azygous vein, thoracic duct, and surrounding tissue, reduces surgical trauma in esophageal cancer, has not increased postoperative recurrent metastases, while achieved the same long-term outcomes as expanded surgery.

Chylothorax and chylopericardial tamponade following lobectomy and lymphadenectomy: a rare presentation

BackgroundAlthough postoperative chylothorax following lung cancer surgery is rare, it is a recognized complication in 0.25–3% of patients. However, cases of cardiac tamponade caused by chylopericardium after lung cancer surgery are extremely rare.Case presentationWe describe hitherto unreported sequelae of chyle leak following lobectomy and systematic mediastinal lymph node dissection (SLND) causing pericardial tamponade and cardiovascular compromise. The patient was successfully treated with minimally invasive surgical repair and ligation. We also discuss the development of chylopericardium as a potential complication of lobectomy and SLND.ConclusionsThe anatomical characteristics of the thoracic duct warrant special attention in postoperative chyle leak management in patients who undergo definitive mediastinal lymph node dissection. Surgeons should be aware that chylopericardium is a rare but potential complication of lobectomy and SLND as it may help with early diagnosis, management, and prevention of cardiac tamponade.

Lymphangiomatosis presented with melena and chylous ascites: A case report.

Lymphangioma, a rare benign tumor of the lymphatic system, is called lymphangiomatosis when it involves >1 organ, which is more rarely complicated with thoracic obstruction, the relationship between them remains unclear. With the development of enteroscopy, clinicians know more about small intestinal lymphangioma and attempt to treat it through enteroscopic injection sclerotherapy(EIS). A 59-year-old male firstly manifested with gastrointestinal bleeding after a gastric perforation, who was diagnosed with lymphangiomatosis by balloon-assisted enteroscopy and abdomen CT showing >1 organ with multiple cysts besides the small intestine. The patient received an EIS, then the melena disappeared. Surprisingly he came back because of refractory ascites confirmed to be chylous by chemical tests 7 months later. Lymphangiography could not determine the location of lymphatic leakage, Ultrasonography showed stenosis of the left cervical part of the thoracic duct. On the condition that medical treatment is ineffective, thoracic duct exploration and lysis of fibrous adhesion were performed. Ascites significantly reduced at last. Lymphangiomatosis is the malformation of the lymphatic system involving multiple organs, it has a possibility to be associated with thoracic obstruction. Capsule endoscopy and enteroscopy are effective methods to diagnose small intestinal lymphangioma, and EIS is an effective therapy.

Computed tomographic lymphangiography following percutaneous intrahepatic injection of iopamidol in cats

To determine if computed tomographic lymphangiography (CTL) after ultrasound-guided percutaneous injection of intrahepatic iopamidol (Isovue 370) in healthy cats would safely and effectively lead to opacification of the hepatic lymphatics, cisterna chyli, and thoracic ducts (TDs). A prospective pilot study design with randomization of the sides of the liver injected. 6 purpose-bred cats. Cats were anesthetized and based on random assignment, and the left or right liver was injected with iodinated contrast material. CTL images were taken at 5, 10, and 15 minutes postinjection to determine the quality of opacification of the cisterna chyli and TDs. Eleven hepatic injections from 6 cats were available for review. One CT file was corrupted and unusable. Seven out of 11 hepatic contrast injections yielded a diagnostic study. Five out of 11 were graded as excellent, 0/11 were graded as good, and 2/11 were graded as fair. Opacification of the cisterna chyli and TDs was absent in 4/11 studies. Three out of 6 cats had mild to moderate increases in hepatocellular enzymes when assayed 3 months postprocedure. The hepatic lymphatics, cisterna chyli, and TDs were opacified in all studies deemed diagnostic. Intrahepatic contrast injection offers a novel portal for thoracic duct lymphangiography that documents the hepatic contribution to the mesenteric lymphatics, cisterna chyli, and thoracic duct. The procedure may be helpful in the preoperative diagnostic evaluation of cats with chylothorax.

Feasibility study of percutaneous thoracic duct embolization with lower-limb intermittent pneumatic compression devices

To demonstrate intranodal thoracic duct embolization (TDE) for treating chyle leaks following thoracic surgery and the feasibility of applying lower-limb intermittent pneumatic compression devices during TDE. Between December 2017 and October 2020, 12 consecutive TDEs for post-operative chyle leaks were performed in 11 patients using intranodal lymphangiogram (IL) with an intermittent pneumatic compressive device applied to the lower limb. The procedure's duration, technical/clinical success, and complications were retrospectively evaluated. IL was successful at imaging the thoracic duct in all procedures (100%), and TDE had an intention- to-treat success rate of 92% (11/12). No related complications were observed during follow-up, which took place at a mean of 27 days. The time from the commencement of lymphangiogram until visualization of the thoracic duct was a mean of 21.6 min, and the mean overall procedure time was 87.3 min. This study supports IL-guided TDE as a safe and effective option to treat post-thoracic surgery chyle leaks. We revealed shorter lymphangiogram times compared with previously published studies, and we postulate that the application of intermittent lower-limb pneumatic compressive devices contributed toward this study's results by expediting the return of lymph from the lower limb. This study is the first to illustrate this approach in TDE and advocates for randomized controlled studies to further evaluate the influence of intermittent pneumatic compressive devices on the procedure.

ASO Author Reflections: Preservation of the Thoracic Duct is Feasible for Esophageal Squamous Cell Carcinoma Patients Treated with Esophagectomy After Neoadjuvant Chemoradiotherapy.

ASO Author Reflections: Preservation of the Thoracic Duct is Feasible for Esophageal Squamous Cell Carcinoma Patients Treated with Esophagectomy After Neoadjuvant Chemoradiotherapy.

Postoperative chylothorax after left pulmonary wedge resection without mediastinal lymph node dissection: a case report

Postoperative chylothorax is a rare but serious complication after pulmonary resection. In previous studies, we have found no reports of postoperative chylothorax after left pulmonary wedge resection. Considering the many variations in the route of the thoracic duct, it also has the risk of postoperative chylothorax. We describe a case of refractory chylothorax after left pulmonary wedge resection without mediastinal lymph node dissection. Conservative treatment and supradiaphragmatic thoracic duct ligation did not obtain satisfactory results in this patient. Finally, under the guidance of magnetic resonance-thoracic ductography (MRTD), we successfully ligated the thoracic duct fistula. Thus, MRTD may contribute positively to being used to locate the thoracic duct and its fistula to support precise surgical intervention.

Lymphatic Intervention, the Frontline of Modern Lymphatic Medicine: Part II. Classification and Treatment of the Lymphatic Disorders.

Lymphatic disorders encompass a broad spectrum of diseases involving the lymphatic system, ranging from traumatic lymphatic leaks to lymphatic malformations. Lymphatic disorders can be categorized into traumatic and non-traumatic disorders according to their etiology. These two categories may be further divided into subgroups depending on the anatomical location of the lymphatic pathology and their association with clinical syndromes. Thoracic duct embolization was a milestone in the field of lymphatic intervention that encouraged the application of percutaneous embolization techniques to treat leaks and reflux disorders in the lymphatic system. Additional access routes for embolization, including retrograde thoracic duct and transhepatic lymphatic access, have also been developed. This article comprehensively reviews a variety of options for the treatment of lymphatic disorders, from conservative management to the most recent embolization techniques.

Central lymphatic surgery

In recent years, microsurgical reconstruction of the lymphatic system has opened new frontiers in the treatment of central lymphatic lesions. Central lymphatic lesions can be congenital or acquired. While the latter can result from any surgery or trauma in the area of the thoracic duct, congenital lymphatic lesions can show a plethora of manifestations, ranging from singular thoracic duct abnormalities to complex multifocal malformations. Regardless of the anatomical location of the thoracic duct lesion, these conditions cause recurrent chylous effusions and downstream lymphatic congestion and are associated with increased mortality due to the permanent loss of protein and fluid. In case of disruption of the lymphatic flow, microsurgical reconstructive surgery is indicated to treat downstream congestion leading to bronchitis plastica, protein-loosing enteropathy, chylothorax, and chylascites. Thoracic duct-vein anastomoses can reconstruct the physiological lymphatic flow.

Chylothorax in the Setting of Lung Malignancy.

Chylothorax refers to chyle within the pleural space, which frequently arises from an interruption in the thoracic duct or because of reduced lymphatic drainage. Pleural fluid that is white/milky in appearance, with a triglyceride concentration of greater than 110 mg/dL, strongly supports the diagnosis of chylothorax. Chylothorax is nearly always exudative. Transudative chylothorax is extremely rare and typically presents due to a secondary cause, such as liver cirrhosis, nephrotic syndrome, or congestive heart failure. We present a case of chylothorax that occurs in the setting of lung adenocarcinoma. A 65-year-old African American man with a past medical history of metastatic right lung adenocarcinoma presented with dyspnea and palpitations. He denied fever, orthopnea, and paroxysmal nocturnal dyspnea. Therapeutic drainage of the left pleural effusion resulted in 650 mL of milky-white fluid. Pleural fluid analysis demonstrated a triglyceride concentration of 520 mg/dL, a pleural/serum protein ratio of 0.41, a pleural/serum lactate dehydrogenase (LDH) ratio of 0.26, a total pleural LDH of 127 IU/L, and a cholesterol level of 58 mg/dL. This effusion can be classified as transudative as per Light's criteria and exudative as per Heffner's and pleural cholesterol criteria. A subsequent pleural fluid cytology found malignant cells consistent with lung adenocarcinoma. Malignancy is the most common cause of nontraumatic, exudative chylothorax. Light's criteria misinterpret about 25% of transudative effusions as exudative. Therefore, to minimize this error, a combination of the 3-criterial consideration is ideal.

Thoracoscopic diagnosis and clipping of an idiopathic defect of the thoracic lymphatic duct complicated by recurrent left-sided chylothorax

Thoracoscopic diagnosis and clipping of an idiopathic defect of the thoracic lymphatic duct complicated by recurrent left-sided chylothorax

A Case of Lymphangiography for Postoperative Chylothorax Resistant to Thoracic Duct Ligation

A Case of Lymphangiography for Postoperative Chylothorax Resistant to Thoracic Duct Ligation

Значение лимфодренирующих операций в комплексном лечении неопухолевых механических желтух

The results of treatment of 118 patients with obstructive jaundice of non-tumor etiology have been analyzed. All patients were divided into control and main groups according to the volume of preoperative preparation and stages of surgical treatment. The control group consisted of 30 patients who were operated after a short-term standard preparation including cholecystectomy and biliary decompression. The main group consisted of 88 patients who underwent two- or three-stage surgical interventions on the biliary tract and lymphatic system, which included external drainage of the thoracic duct, endoscopic papillosphincterotomy and lymphovenous anastomosis. The mortality rate in the control group was 23.2%, of which 8% of patients with jaundice duration up to 10 days, 45% — with jaundice duration up to 14 days. In the main group, the overall mortality was 5.5%, which is 4.2 times lower than in the control group. Of those with a duration of cholestasis up to 10 days, there was no mortality, in patients with a duration of biliary occlusion up to 14 days, it was 7% and in patients with a duration of up to 3–6 weeks — 15%. According to the indications, lymphovenous anastomosis was performed in 39 patients; there was no mortality cases among these patients. During the study, it was confirmed that lymphatic drainage operations in combination with endoscopic biliary decompression help to reduce porto-lymphatic pressure, sanitize the biliary tract, reduce endogenous intoxication and improve treatment outcomes

Chylothorax, central venous thrombosis and pulmonary infarct in a patient of ovarian germ cell tumor: a case report

Background: Extra-abdominal presentations are rarely seen in ovarian germ cell tumors (OGCT). We report a case of a patient with OGCT who presented with systemic venous thrombosis, pulmonary infarct, and chylothorax simultaneously. Case Presentation: A 13-year-old girl presented with dyspnea, fever, and cough of 1 week duration. She was detected to have left-sided chylothorax. Carcinoma Antigen 125 and alpha fetoprotein levels were raised. Computed tomography showed a large ovarian mass, and thrombi in superior vena cava, left brachiocephalic vein, and segmental branch of right pulmonary artery. She also had a peripheral opacity in the right lung with a reverse-halo sign, suggestive of pulmonary infarct. She was diagnosed with yolk-sac tumor and managed with anticoagulation and subsequently neo-adjuvant chemotherapy and surgery. Conclusion: Prothrombotic state in OGCT can lead to systemic thrombosis which may result in chylothorax due to obstruction of thoracic duct. The phenomenon, though rare, should be kept in mind during management of OGCT.

Chylothorax associated with sarcoidosis: a review of the literature.

To review the medical literature regarding chylothorax associated with sarcoidosis. A literature review of all reported cases of sarcoidosis-associated chylothorax, we included a novel case report to the analysis. Of sixteen cases included in the study, 10 were women (62.5%), mean age 47±17years. In 6 subjects (37.5%) chylothorax was part of the initial presentation of sarcoidosis. Four subjects (25%) additionally suffered from lymphedema and chylous ascites, and one from chylous ascites only. Thoracic lymphadenopathy was reported for 13/16 subjects (81.3%) and lung parenchymal disease in 8/16 (50%). Compression of the thoracic duct was considered as a causative factor in 10 cases (62.5%). One case was attributed to granulomatous pleural inflammation, one to generalized lymphangiectasia, and no specific causative factors were identified in 4 remaining cases (25%). Overall mortality rate was 18.8% (3/16 subjects). Of note, all the subjects treated with corticosteroids survived. Since the association of sarcoidosis with chylothorax is exceedingly rare, alternative etiologies should be pursued even when chylothorax develops in a subject with preexisting sarcoidosis. However, the possibility of sarcoidosis should be entertained when other etiologies for a newly diagnosed chylothorax are ruled out. A multidisciplinary approach is required for optimal management, both for elucidating the diagnosis and for employing therapy, which could be multimodal. A trial of immunosuppressive therapy with corticosteroids should be considered.