Mesenteric Lymphangiography Research Articles

Hybrid Lymphovenous Anastomosis Surgery Guided by Intraoperative Mesenteric Intranodal Lymphangiography for Refractory Nontraumatic Chylous Ascites: A Case Report.

Refractory chylous ascites can cause significant nutritional and immunologic morbidity, but no clear treatment has been established. This article introduces a case of a 22-year-old female patient with an underlying lymphatic anomaly who presented with refractory chylous ascites after laparoscopic adnexectomy for ovarian teratoma which aggravated after thoracic duct embolization. Ascites (>3,000 mL/d) had to be drained via a percutaneous catheter to relieve abdominal distention and consequent dyspnea, leading to significant cachexia and weight loss. Two sessions of hybrid lymphovenous anastomosis (LVA) surgery with intraoperative mesenteric lymphangiography guidance were performed to decompress the lymphatics. The first LVA was done between inferior mesenteric vein and left para-aortic enlarged lymphatics in a side-to-side manner. The daily drainage of chylous ascites significantly decreased to 130 mL/day immediately following surgery but increased 6 days later. An additional LVA was performed between right ovarian vein and enlarged lymphatics in aortocaval area in side-to-side and end-to-side manner. The chylous ascites resolved subsequently without any complications, and the patient was discharged after 2 weeks. The patient regained weight without ascites recurrence after 22 months of follow-up. This case shares a successful experience of treating refractory chylous ascites with lymphatic anomaly through LVA, reversing the patient's life-threatening weight loss. LVA was applied with a multidisciplinary approach using intraoperative mesenteric lipiodol, and results showed the possibility of expanding its use to challenging problems in the intraperitoneal cavity.

Abstract No. 37 Value of the mesenteric lymphangiography as a new diagnostic and treatment tool in the management of chylous ascites and protein-losing enteropathy

Abdominal lymphatics are traditionally very challenging to visualize due to difficulty in accessing the mesenteric lymphatic vessels. Intraoperative mesenteric lymphangiography was recently described for its better visualization. This study evaluated the technical feasibility and additional diagnostic value of intraoperative and percutaneous mesenteric lymphangiography in patients with chylous ascites or PLE.

Abstract No. 614 Intranodal intraoperative mesenteric lymphangiography and embolization for chylous ascites: technical and safety features

Abstract No. 614 Intranodal intraoperative mesenteric lymphangiography and embolization for chylous ascites: technical and safety features

Successful Surgical Treatment of Idiopathic Chylothorax in a Cat

Background: Chylothorax in cats represents a challenge due to the possibility of involvement of multiple etiologies and the harmful consequences resulting of the presence of the chylous effusion in the thorax. The causes include neoplasms in the thoracic cavity, heart disease and thoracic injuries. It is imperative that clinical nutritional and therapeutic and / or surgical management be immediate and directed to the treatment of the cause. The objective of this work was to report a case of idiopathic chylothorax in a domestic cat solved through surgical intervention and dietary maintenance applied.Case: A 4-year-old male cat, fed with diet for the age range of adult cats, was attended at the Veterinary Hospital of the Federal Rural University of Rio de Janeiro (HV - UFRRJ), with clinical complaint of difficulty breathing, inappetence, prostration and weight loss. In the clinical examination was verified intense tachypnea, presence of heart murmur, normocoratedmucosae, dehydration 7%. The animal was sedated to be submitted to radiographic examination of the thorax with pethidine and midazolam. Thoracic radiographs on the lateral, ventral-dorsal and orthostatic positions were realized and severe pleural effusion was observed in both hemitorax with drainage of 180 mL of lactescent fluid from the right hemithorax and 120 mL of left hemithorax liquid. Through analysis of cavity liquids the effusion was classified as chylous effusion. The hemogram showed a neutrophilic leukocytosis. Serum cholesterol and triglyceride concentrations (28 mg/dL and 43 mg/dL, respectively) were lower than the concentrations of the cavity liquid (67 mg/dL and 722 mg/dL, respectively).Ultrasound examination revealed no mass in the thoracic cavity and no changes in the pulmonary parenchyma. The echocardiographic examination was also performed and did not reveal any cardiac alterations. The initial treatment consisted of the clinical approach, through the exclusive alimentary management with low fat diet, in order to reduce toreduce the amount of chylous in the thorax. The rutine was administered at a dose of 250 mg/cat every 8 h orally. After 15 days, due to an unsatisfactory response to conservative treatment, surgical intervention was indicated. The technique used was pleural omentalization with block ligation of the thoracic duct without mesenteric lymphangiography together with pericardectomy and placement of the thoracic drain. During the postoperative period the animal remained under intensive care, with nasal oxygen therapy and intense analgesia during the first 72 h. After 20 days, the production of the chylous liquid was 2 mL/kg/ day, which made it possible to remove the drain. The cat received continuously with the exclusive diet of low fat to reduce the production of the chylous, without recurrence of chylous up to the present moment.Discussion: It is important to establish in a first approach of animals with chylous exudation the management of low-fat foods, along with appropriate pharmacological therapy, monitoring the patient in a constant and cautious way. If conservative clinical intervention is not satisfactory within 5 to 10 days, rapid surgical treatment is essential, due to the risk offibrosing pleuritis with consequent involvement of the pulmonary parenchyma, as occurred in this report. Duct ligation surgery and the pericardectomy was satisfactory for the resolution of the constant chylous production in the thorax of the animal, as well as the use of the low fat diet was essential to reduce the chylous effusion and fibrosing pleurisy, both the interventions made possible the maintenance of the patient’s health and well-being.Keywords: feline, cavitary fluid, quilting effusion, thoracic duct.

COMPARATIVE POPLITEAL AND MESENTERIC COMPUTED TOMOGRAPHY LYMPHANGIOGRAPHY OF THE CANINE THORACIC DUCT

Thoracic duct computed tomography (CT) lymphangiograms were performed on seven clinically normal dogs. The appearance of the thoracic duct system was compared following administration of contrast medium through a mesenteric lymphatic vessel vs. ultrasound guided percutaneous injection into a popliteal lymph node using helical and sequential CT acquisition modes. The number of visible thoracic duct branches and the largest thoracic duct branch cross-sectional area and mean Hounsfield units (HU) were determined from thoracic vertebra 9 to lumbar vertebra 1. Procedural time and patient discomfort were also assessed. Popliteal administration produced a successful thoracic duct lymphangiogram in eight of 11 dogs (73%) after two attempts, while mesenteric administration was successful in eight of 10 dogs (80%) after a single attempt. Popliteal lymphography required 46% of the time and was associated with less patient discomfort than mesenteric lymphangiography. The number of thoracic duct branches seen was not significantly different for either administration technique (P=0.256) or CT acquisition mode (P=0.417). However, the cross-sectional area and mean HU of the largest thoracic duct branch were greater with mesenteric administration (P<0.001), and helical image acquisition (P<0.001). The thoracic duct branch number, size, and location were highly variable between dogs. Percutaneous popliteal lymphography appears to be an acceptable alternative to mesenteric lymphangiography for the detection of thoracic duct branches in the dog when using either helical or sequential CT acquisition modes.

Efficacy of En Bloc Ligation of the Thoracic Duct: Descriptive Study in 14 Dogs

To assess whether en bloc ligation of all caudal mediastinal tissue between the aorta and thoracic vertebrae will occlude all branches of the thoracic duct. Descriptive study. Canine cadavers (n=15). The cisterna chyli was approached through a right paralumbar abdominal incision and cannulated. A right 10th intercostal thoracotomy was performed and the tissue of the caudal mediastinum dorsal to the aorta and ventral to the thoracic vertebrae was ligated. Radio-opaque contrast material was injected into the cisterna chyli during fluoroscopic imaging of the thorax and cranial abdomen. Still images were obtained before and after contrast injection and a subtraction image produced. Gray values were measured from these images, cranial and caudal to the ligature site. Cannulation of the cisterna chyli in 1 cadaver was impossible and it was, therefore, excluded. In 13 (93%) cadavers contrast material did not pass cranial to the ligature site. In 1 cadaver, an intact thoracic duct was identified on lymphangiography outside the en bloc ligation. En bloc ligation of the caudal mediastinal tissue dorsal to the aorta was successful in preventing opacification with contrast material of all branches of the thoracic duct in 93% of cadavers. En bloc ligation is successful in 93% of cadavers and reduces the operative time compared with techniques requiring some type of mesenteric lymphangiography to aid identification of the thoracic duct.

Chylothorax in cats: is there a role for surgery?

Chylothorax is a complex disease with many identified underlying causes including cardiac disease, mediastinal masses, heartworm disease and trauma. Management of this disease should be directed at identifying the cause, if possible, and treating the underlying disorder. In cats with idiopathic chylothorax, medical management is recommended initially because the condition may resolve spontaneously. Owners should be made aware of the potential development of fibrosing pleuritis in affected cats. When medical management is impractical or unsuccessful, surgical intervention should be considered. Surgical options include mesenteric lymphangiography and thoracic duct ligation, pericardiectomy, omentalisation, passive pleuroperitoneal shunting, active pleuroperitoneal or pleurovenous shunting, and pleurodesis. Of these, only thoracic duct ligation and pericardiectomy are preferred by the author because, if successful, the result is complete resolution of the chylothorax, thereby reducing the risk of developing fibrosing pleuritis. Omentalisation may be beneficial in some animals as adjuvant therapy, but this procedure may still allow fibrosing pleuritis to occur. Until the aetiology of the effusion in cats with idiopathic chylothorax is understood, the treatment success rate will be less than ideal. Future research needs to be directed at determining the pathophysiologic mechanisms underlying this disease in cats.

Gastrointestinal cancer metastasis and lymphogenous spread: viewpoint of animal models of lymphatic obstruction.

Primary gastrointestinal cancer frequently spreads to the mesentery, omentum and other parts of the peritoneum and these deposits are generally considered to be induced by intraperitoneal seeding from the primary lesion. In this work, we examined the spread of gastrointestinal cancer from the viewpoint of lymphogenous metastasis using a rat model of mesenteric lymph vessel obstruction. With these models, we carried out mesenteric lymphangiography on the fourth and sixth postoperative days (five animals each) to examine morphological changes in the lymph vessels and lymph flow. In model animals with mesenteric lymph vessel obstruction, re-celiotomy, performed on the fourth postoperative day, revealed marked mesenteric edema and enlargement of the mesenteric lymph nodes, suggestive of lymph retention. We also carried out mesenteric lymphangiography and obtained images of extensive mesenteric lymph vessels and reflux of lymph distal to the obstruction point in all five animals. On the sixth postoperative day, we obtained lymphangiographic images of lymphatico-venous communication in the mesentery in all five animals. Thus in animals with lymph vessel obstruction, the lymph flow appeared to change to lymphatico-venous communication or reverse lateral flow. In clinical cases, it is conceivable that lymph retention and reflux of lymph induced by lymph vessel obstruction sometimes play a role in the mechanism of intraperitoneal cancer dissemination and hematogenous metastasis.

Blockage of mesenteric lymphatic flow in rats.

An experimental model of blockage of the mesenteric lymphatic flow (MLF) in rats was designed, and morphologic changes of mesenteric lymphatic vessels (MLV) and lymph nodes were investigated by mesenteric lymphangiography and histopathologic examination. Body weight in rats with blockage of MLF did not increase normally. Mesenteric lymphangiography revealed dilation of the MLV, reverse flow into the peripheral MLV, and leakage of contrast medium, resulting in chylous ascites. Remarkable dilation of the lymphatic sinuses and dilated and increased rough endoplasmic reticulum in lymphocytes in the mesenteric lymph nodes due to lymph stagnation were observed by light and electron microscopic examination, respectively.

Use of mesenteric lymphangiography in a calf with chylothorax and chyloperitoneum

Use of mesenteric lymphangiography in a calf with chylothorax and chyloperitoneum

Evaluation of mesenteric lymphangiography and thoracic duct ligation in cats with chylothorax: 19 cases (1987–1992)

Summary Mesenteric lymphangiography and thoracic duct ligation were performed on 19 cats with chylothorax between 1987 to 1992. Chylothorax was diagnosed on the basis of detection of chylomicrons in the pleural effusion or determination of a cholesterol concentration:triglyceride concentration ratio of &lt; 1 in the pleural fluid. Preoperative medical treatment consisted of thoracentesis (19 of 19 cats) and feeding a fat-restricted diet (14 of 19 cats). Positive-contrast mesenteric lymphangiography was performed before thoracic duct ligation to identify an underlying cause for the effusion. Lymphangiectasia was diagnosed by use of radiography in 17 cats, none of which had evidence of a thoracic duct rupture. Thoracic duct ligation was performed via an incision made through the left 10th intercostal space. Lymphangiography was repeated immediately after ligation of the thoracic duct to document occlusion of all branches. Follow-up monitoring was done for 12 to 47 months (median, 28 months) and consisted of physical examination, evaluation for clinical signs related to pleural effusion, and thoracic radiography. Ten of 19 (53%) cats had complete resolution of pleural effusion. Nonchylous effusion, localized in the right hemithorax, was detected in 1 cat 2 months after thoracic duct ligation, but resolved after thoracotomy, breakdown of thoracic adhesions, and expansion of the right cranial lung lobe. Chylous effusion resolved 3 to 7 days (mean, 5.4 days) after surgery in the 10 cats that survived &gt; 12 months after surgery. Four cats died between 2 and 13 days after thoracic duct ligation, but pleural effusion had resolved in 3 of these 4 cats at the time of death. Five cats were euthanatized 8 to 36 days after surgery because of persistent chylous effusion after thoracic duct ligation.

Regeneration of mesenteric lymphatic vessels in a new experimental model of orthotopic intestinal transplantation in rats

A new experimental model of orthotopic intestinal transplantation was performed using microsurgical techniques in rats; the physiological flow of blood, lymph, and food was reconstructed. Regeneration of mesenteric lymphatic vessels, which plays an extremely important role in lipid absorption of the transplanted intestine, was studied by mesenteric lymphangiography. Regeneration of mesenteric lymphatic vessels was first confirmed on the seventh postoperative day by mesenteric lymphangiography, and favorable regenerative patterns, without obstruction, were observed on the 32nd, 58th, and 93rd postoperative days.

Colonoscopic indirect lymphangiography in a canine model.

Colorectal malignancies metastasize most frequently to mesenteric lymph nodes. Preoperative staging of these nodes by current modalities is problematic. This study evaluates the feasibility of indirect mesenteric lymphangiography as a colonoscopic technique in a canine model. Ten mongrel dogs underwent endoscopic submucosal injection of Ethiodol at various sites in the transverse, descending, and rectosigmoid areas. Serial abdominal roentgenograms were obtained up to 2 weeks postinjection. In seven of the animals, demonstration of mesenteric nodal uptake corresponding to the area(s) of injection was radiographically documented. In the remaining animals (early in the series) nodal opacification was inadequate. This lack of nodal uptake appeared to be due to nonsubmucosal contrast injection. No complications were noted. Colonoscopic indirect lymphangiography appears to be a safe and potentially useful modality in the evaluation of mesocolonic lymph nodes. Further studies to refine this technique and investigate its potential to preoperatively delineate abnormal nodal architecture are warranted.

Chylothorax in cats: 37 cases (1969-1989)

Summary Case records of 37 cats with chylothorax examined at 2 institutions were retrospectively evaluated. Dyspnea and coughing were the most common abnormalities noticed by the owners, and most cats were dyspneic on initial examination. There was no statistically significant difference in the gender distribution of cats studied when compared with reference populations; however, purebred cats appeared to be overrepresented in the study population. Four of the cats had unilateral pleural effusion (2 left side, 2 right side) and 9 cats had effusions that were primarily, but not exclusively, on the right side. Surgery was performed on 20 cats. Fifteen cats underwent thoracic duct or cisterna chyli ligation; 20% had complete resolution of pleural fluid. There was no significant difference in the survival rate of cats that underwent thoracic duct ligation and those that were treated by other means. Six cats had mesenteric lymphangiography performed; 2 cats had normal results, and the remainder had various degrees of thoracic lymphangiectasia. Two cats in which pleuroperitoneal shunts were placed and 2 of 3 cats that underwent pleurodesis were euthanatized or died after surgery.

A TECHNIQUE FOR DIRECT LYMPHANGIOGRAPHY OF THE THORACIC DUCT SYSTEM IN THE CAT

The thoracic duct system is often evaluated radiographically in animals with chylothorax. Mesenteric lymphangio‐graphy has improved contrast studies of the thoracic duct system. A technique for identifying intestinal lymphatic trunks for cannulation to perform mesenteric lymphangiography was evaluated in five cats. Evans blue solution was injected into the right colic lymph node of each cat following ventral midline celiotomy, and the flow of dye was used to identify the intestinal lymphatic ducts for cannulation. Following catheter placement, mesenteric lymphangiograms were performed on each cat and the radiographic appearance of the thoracic duct system compared with previously reported anatomic descriptions in the cat. The technique provided rapid visualization of intestinal lymphatic trunks for cannulation. The radiographic appearance of the thoracic duct system varied considerably between cats and previous anatomic descriptions. A mild inflammatory reaction to injection of lymph nodes with Evans blue dye was observed 4 weeks later.

Transdiaphragmatic approach to thoracic duct ligation in the cat.

An approach combining ventral midline celiotomy with transdiaphragmatic thoracotomy was evaluated in eight healthy cats for ligation of the thoracic duct system. Evans Blue solution was injected into the right colic lymph node to outline the intestinal lymphatic trunk and the thoracic duct system. Three cats (group 1) had mesenteric lymphangiograms and three (group 2) had only lymph node dye injection before thoracic duct ligation. The thoracic duct system was ligated with hemostatic clips just cranial to the aortic hiatus of the diaphragm, through a left transdiaphragmatic thoracotomy. Two cats (group 3) had prethoracotomy mesenteric lymphangiograms and thoracic duct isolation without ligation. Mesenteric lymphangiography was performed immediately after the surgery. In all of the cats, an absence of contrast medium in the thoracic duct system cranial to the surgical site was interpreted as complete obstruction. Four weeks after ligation, there was complete obstruction of the thoracic duct system with alternate lymphaticovenous communications in four of the six cats with ligated thoracic duct systems. Partial obstruction of the thoracic duct system with alternate lymphaticovenous communications was present in the other two cats. Both cats without thoracic duct ligation had patent thoracic duct systems. At necropsy of the six cats with ligated thoracic ducts, there was mild focal lymphadenitis of injected lymph nodes in three cats. The wall of the aorta adjacent to the hemostatic clips was normal in all six cats. The surgical technique was simple and provided excellent exposure. Vital staining with Evans Blue helped visualize the thoracic duct system, but mesenteric lymphangiography did not. Postligation lymphangiography was not of value in identifying incomplete ligation.