Thoracic Duct Injury Research Articles

Thoracic Duct Injury Following Cervical Spine Surgery: A Multicenter Retrospective Review.

Study Design:Multicenter retrospective case series.Objective:To determine the rate of thoracic duct injury during cervical spine operations.Methods:A retrospective case series study was conducted among 21 high-volume surgical centers to identify instances of thoracic duct injury during anterior cervical spine surgery. Staff at each center abstracted data for each identified case into case report forms. All case report forms were collected by the AOSpine North America Clinical Research Network Methodological Core for data processing, cleaning, and analysis.Results:Of a total of 9591 patients reviewed that underwent cervical spine surgery, 2 (0.02%) incurred iatrogenic injury to the thoracic duct. Both patients underwent a left-sided anterior cervical discectomy and fusion. The interruption of the thoracic duct was addressed intraoperatively in one patient with no residual postoperative effects. The second individual developed a chylous fluid collection approximately 2 months after the operation that required drainage via needle aspiration.Conclusions:Damage to the thoracic duct during cervical spine surgery is a relatively rare occurrence. Rapid identification of the disruption of this lymphatic vessel is critical to minimize deleterious effects of this complication.

Mediastinal lymph node dissection in open thoracic surgery

Nodal staging is well established in management of lung cancer. Hence, any lung resection should be combined with dissection of at least 3 nodal stations. Open access is gained via thoracotomy. The lymphadenectomy should precede lung resection. Station 2 is dissected by extending the planes from Station 4 superiorly. The left side demands special maneuvers and remains challenging. The recurrent nerve should be protected and therefore diathermy needs to be avoided in this position. Station 4 is routinely dissected on right side and rarely on left. Trachea, azygos vein and superior vena cava (SVC) define the dissection triangle. Special attention is required to tributaries from SVC and aberrant chyle duct branches to avoid complications when dissecting this nodal station. Station 5 is defined by the arch and main pulmonary artery roof. The commonest complication is recurrent nerve injury; hence, dissection should be gentle with no use of diathermy at the proximity of the vagus nerve close to the arch. Lateral dissection towards the arch, offers access to Station 6. Attention should be exercised to avoid injury to an aberrant superior intercostal vein. Station 7 becomes evident following the main bronchus to the carinal origin. Main attention to bronchial arteries should be exercised at the floor of the carina or descending aorta tributaries on the left to avoid disturbing bleeding. Clips and not diathermy should be used. Moderate bleeding is managed with packing and patience. Station 8 lies adjacent to esophagus. Gentle dissection is required to avoid esophageal and thoracic duct injuries. Station 9 is contained in the inferior pulmonary ligament and is dissected at hilar mobilisation. Attention to fat pad mediastinal vessel is mandatory.

A study of the efficacy of stellate ganglion blocks in complex regional pain syndromes of the upper body.

Background and Aims:The effect of stellate ganglion blocks (SGBs) was examined in complex regional pain syndromes (CRPS) of the upper body.Material and Methods:A total of 287 SGB were given to patients with documented CRPS on medications. Spontaneous and provoked pain assessment was done with numeric pain rating scale (NPRS). The Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire and range of motion (ROM) was recorded before and after each blockade. Difference between a 15-point “global rating of change” scale determined the minimal clinically important difference of the DASH score.Results:The overall mean pain reduction was 73.2% (r = 0.83, P < 0.001) considering spontaneous and 55.8% (r = 0.77, P < 0.001) on provoked pain. Mean DASH score decreased from 53 (range 36–63; P = 0.14) to 10.4 (range 10–49.2; P = 0.005). The sensitivity to change was 6.9 for spontaneous and 4.9 for provoked pain. Increase in ipsilateral limb temperature has a good correlation with Horner's syndrome (HS) and sympathetic blockade. Minor, self-limiting complications, such as hoarseness, dysphagia, local hematoma, and ipsilateral brachial plexus block occurred in 11.5%. A rare complication of contralateral HS was documented. One patient developed a small pneumothorax, but it did not require intervention.Conclusions:SGB are relatively safe and effective management in patients with neuropathic conditions already on pharmacotherapy. Serial blocks attained an average reduction in pain by >3 NPRS points from the baseline for both spontaneous and provoked pain with a decrease in mean DASH score and improvement in ROM.

An uncommon case of late-onset chylothorax in blunt thoracic trauma in the emergency department

Blunt chest trauma is a rare cause of chylothorax because thoracic duct is well protected by the spine posteriorly and mediastinal contents anteriorly. Ribs or vertebral fractures are often associated but isolated chylothorax has been described. Thoracic duct injury may be due to stretching over the spine, or to shearing of the duct by the right crus of the diaphragm. Chylothorax can be associated with high rates of morbidity and mortality and early diagnosis is of paramount importance in order to adequate and prompt therapy. Chilothorax is well distinguishable in CT scan but the diagnosis must be confirmed by analysis of the pleural fluid. The optimal treatment for traumatic chylothorax is unclear and a challenging clinical problem. In this article, we describe the clinical manifestations, radiologic findings, and successful medical treatment of a patient with post traumatic chylothorax diagnosed in an emergency setting.

Abstract No. 543 - Growing role of interventional radiology in managing thoracic duct injuries: a pictorial essay depicting the latest developments and interventional approaches

Abstract No. 543 - Growing role of interventional radiology in managing thoracic duct injuries: a pictorial essay depicting the latest developments and interventional approaches

Abstract No. 587 - Thoracic duct interventions: a review of the imaging modalities and interventional techniques for managing traumatic thoracic duct injuries

Abstract No. 587 - Thoracic duct interventions: a review of the imaging modalities and interventional techniques for managing traumatic thoracic duct injuries

Medicolegal implications of surgical errors and complications in neck surgery: A review based on the Italian current legislation.

Aim of the present paper is the review of the principal complications associated to endocrine neck surgery considering how expertise, full adoption of guidelines, appropriate technology and proper informed consent may limit the medicolegal claims at the light of the incoming new regulation of the medical professional legal responsibility. A literature search, using the Medline/PubMed database for full-length papers, was used. Postoperative recurrent laryngeal nerve (RLN) palsy and hypoparathy-roidism remain the principal causes of surgical malpractice claims . In the procedure of neck lymphadenctomy intra-operative haemorrhage, thoracic duct injury, injuries to loco-regional nerves can be observed and can be source of claims. After many years of increased medicolegal litigations, the Italian government is proposing a drastic change in the regulations of supposed medical malpractice in order to guarantee the patient’s right to a safe treatment and in the meantime to defend clinicians from often unmotivated and prejudicial legal cases. Surgical errors and complications in neck surgery are a relevant clinical issue. Only the combination of surgical and clinical expertise, application of guidelines, appropriate technology and a routinely use of specific informed consent can contain potential medicolegal implications.

Thoracic Duct Ligation: Right Video-assisted Thoracoscopic Surgery Approach

Thoracic duct (TD) injuries can carry significant morbidity and mortality to patients. When medical and percutaneous interventions are unsuccessful at cure, open surgical ligation is often necessary but limited by poor visualization of the TD and all the morbidities associated with thoracotomy. We describe here a video-assisted thoracoscopic surgery (VATS) approach to TD ligation that offers the benefits of minimally invasive surgery in addition to improved visualization to optimize success rates.

Chylothorax in practice of thoracic and cardiovascular surgeon

to improve the results and current pathogenetic treatment of chylorrhea. Thirty seven patients with chylothorax have been treated for the period 2004-2014. In 34 cases traumatic chylothorax developed after surgery and in 3 cases - after intensive care for therapeutic diseases and great veins catheterization. Chylothorax was predominantly diagnosed by X-ray method. Herewith, hydrothorax was established and its nature was defined using laboratory survey. Presence of neutral fat in pleural drainage is the sign of chylothorax. Pathogenetic treatment was often delayed (up to 4.5 months) due to poor awareness of physicians about this pathological process. 6 patients underwent thoracic duct ligation above diaphragm due to ineffective therapy. Medical therapy had good clinical effect in 83.8% of cases. Postoperatively 1 patient died for single lung inflammation on background of postoperative chylothorax after right-sided pneumonectomy. In other cases chylothora was eliminated with no recurrence in remote postoperative period. It is difficult to recognize injury of thoracic duct or its great branches during surgery. In these cases prolonged thoracic duct ligation above diaphragm is indicated.

The thoracic duct: clinical importance, anatomic variation, imaging, and embolization.

The thoracic duct is the body's largest lymphatic conduit, draining upwards of 75% of lymphatic fluid and extending from the cisterna chyli to the left jugulovenous angle. While a typical course has been described, it is estimated that it is present in only 40-60% of patients, often complicating already challenging interventional procedures. The lengthy course predisposes the thoracic duct to injury from a variety of iatrogenic disruptions, as well as spontaneous benign and malignant lymphatic obstructions and idiopathic causes. Disruption of the thoracic duct frequently results in chylothoraces, which subsequently cause an immunocompromised state, contribute to nutritional depletion, and impair respiratory function. Although conservative dietary treatments exist, the majority of thoracic duct disruptions require embolization in the interventional suite. This article provides a comprehensive review of the clinical importance of the thoracic duct, relevant anatomic variants, imaging, and embolization techniques for both diagnostic and interventional radiologists as well as for the general medical practitioner. • Describe clinical importance, embryologic origin, and typical course of the thoracic duct. • Depict common/lesser-known thoracic duct anatomic variants and discuss their clinical significance. • Outline the common causes of thoracic duct injury and indications for embolization. • Review the thoracic duct embolization procedure including both pedal and intranodal approaches. • Present and illustrate the success rates and complications associated with the procedure.

Lymphoscintigraphy SPECT/CT: Instrumental Navigator in Repair of Thoracic Duct Injury

A 25-year-old female underwent resection of a large mediastinal tumour which was complicated by copious chylothorax, being worse on the left side. Minimally-invasive video-assisted thoracoscopic surgery (VATS) via a left-sided approach was performed and the severed ends of the thoracic duct were ligated. This only achieved temporary reduction of the amount of chylothorax, leading to a second attempt to repair the persistent leak. A hightriglyceride diet was prescribed for the patient 1-day prior to an open left thoracotomy to improve visualization of the leak. Intra-operatively, the previously repaired sites were intact, but there were several leaky points which were tackled by under-running the leaky channels. Again, the chylothorax improved only temporarily before it recurred and worsened 2 days post-repair. Magnetic resonance imaging (MRI) of the thorax to search for the leak site/s causing persistent chylothorax only demonstrated bilateral pleural effusions without providing a clue as to the the potential site of injury. We performed Tc-99 m nanocolloid lymphoscintigraphy, which demonstrated normal kinetics of lymphatic flow from the pedal injection sites to the cisterna chyli. The propagation of tracer slowed down and the lymphatic channel delineation was hardly discernible beyond the cisterna chyli on planar images (Fig. 1a-b). However, SPECT/CT images acquired at 9 h post-injection revealed and depicted the sites of leakage into bilateral pleural spaces at the juncture where the thoracic duct courses obliquely, from the right hemithorax across to the left hemithorax. Leakage into the right pleural and left mediastinal pleural spaces were localized at the level of the inferior endplate and superior endplate of T6 vertebra, respectively (Fig. 1c-e). This prompted the surgeon to take a different approach from the previous two attempts. It was deemed too risky and potentially futile to further attempt to go after the leakage sites bilaterally. Hence, the surgeon performed a right thoracotomy to ligate the thoracic duct proximal to the leakage sites at the aortic hiatus. This successfully stopped the leak permanently. Planar lymphoscintigraphy lacks accurate anatomical depiction which SPECT-CT could offer. Conversely, anatomical imaging failed to locate the site of the leak. SPECT/CT lymphoscintigraphy overcomes the limitation of either imaging alone, and has been reported to be valuable in documenting and depicting sites of injury [1–3]. In this case, the SPECT-CT depiction and confirmation of bilateral leakage sites was pivotal in guiding the surgeon to take a We confirm that the manuscript has not been published before or is not under consideration for publication anywhere else and has been approved by all co-authors.

Chylothorax after esophagectomy for esophageal cancer: risk factors and management.

Chylothorax is an uncommon complication of esophagectomy. It carries significant morbidity and mortality. The predisposing factors are ill-defined. We retrospectively evaluated the data of 45 patients of carcinoma esophagus who underwent esophagectomy after neoadjuvant chemoradiotherapy (NACRT) from January 2010 to July 2012 in our tertiary health care center. Four patients (8.88 %) had chylothorax. On analysis of perioperative factors, it was found that patients with chylothorax had tumor in middle third of thoracic esophagus (100 %), shown partial response to neoadjuvant chemoradiation (NACRT) (100 %) and were associated with difficult mediastinal dissection (75 %) leading to higher blood loss requiring transfusion unlike those without chylothorax. There was no significant difference in the incidence of chylothorax following transhiatal, 3/35 = 8.57 % or transthoracic esophagectomy 1/10 = 10 % (p = 0.898). Three patients were managed by transabdominal en masse ligation of tissue between aorta and azygos vein while one patient was managed conservatively. Patients were discharged after a mean hospital stay of 15.5 days. The 30-day mortality rates in the two groups were similar (0 % vs. 4.8 %). Difficult mediastinal dissection during esophagectomy in middle esophageal cancer may lead to thoracic duct injury. Complete response to NACRT may reduce the risk of chylothorax. Early transabdominal en masse ligation carries excellent results. Low output fistula following thoracic duct injury can be managed conservatively.

Post-thyroidectomy hypocalcemia exacerbated by chyle leak.

SummaryTransient hypocalcemia after thyroidectomy is not uncommon and the risk increases with the extent of neck surgery. We report a case of severe and prolonged hypocalcemia after total thyroidectomy complicated by thoracic duct injury. Hypoparathyroidism and thoracic duct injury are potential complications following total thyroidectomy with extensive lymph node dissection. This case suggested that having both conditions may complicate treatment of hypoparathyroid-induced hypocalcemia by way of losses of calcium and vitamin D in the chyle leak.Learning points This report highlights chyle leak as an uncommon cause of prolonged hypocalcemia in patients who have undergone extensive neck surgery.Chyle has an electrolyte concentration similar to that of plasma.Medical treatment options for a chyle leak include fat-free oral diet or parenteral nutrition without oral intake, pharmacological treatment (primarily octreotide).

Prevention and treatment of intraoperative complications of thoracic surgery

In order to achieve a minimal complication rate there is a need for a comprehensive strategy. This means in the first line preventive steps which include patient positioning, suitable approaches and access, an appropriately qualified surgical team as well as a carefully planned dissection and preparation. Furthermore, a supply of additional instrumentation, such as thrombectomy catheters, special vascular clamps and even extracorporeal membrane oxygenation (ECMO) and a heart-lung machine (HLM) in cases of centrally located lesions should be on stand-by. Control instruments, such as a bronchoscope and esophagoscope should not be forgotten. In selected cases a preoperative embolization (vascular malformation) or cream swallow (thoracic duct injury) can be helpful. Special interventions to overcome complications arising are described for the chest wall, lung parenchyma, pulmonary vessels, great vessels, bronchial arteries, trachea and bronchi, esophagus, thoracic duct, heart, vertebral column and sternum corresponding to the topography.

Abstract No. 380 - Review of techniques for percutaneous lymphangiography and thoracic duct cannulation for treatment of chylothorax

There are multiple methods used to access the thoracic duct in attempt for embolization in the setting of traumatic or spontaneous chylous leak. We will review the indications and technique in three differing methods; traditional pedal lymphangiography, intranodal lymphangiography and retrograde transvenous cannulation. The prevalence of thoracic duct injury is 0.5-2.0% following major thoracic or neck surgery. Thoracic duct injury leading to unremitting chylothorax can have a mortality rate of 25-50%. Patients with thoracic duct leaks who fail conservative management, have been historically treated with surgery. However the thoracic duct can be difficult to identify by the surgeon. Lymphangiography serves two purposes, first to identify the leak and evaluate the anatomic course of the thoracic duct, and second to provide access for percutaneous treatment. Traditional pedal lymphangiography involves cannulating lymphatic ducts in the foot and injecting Ethiodized oil to opacify the cisterna chyli and thoracic duct. This method requires substantial procedure time for the contrast to travel from the foot to thoracic duct. Direct intranodal injection involves ultrasound guided puncture of the inguinal lymph nodes into which Ethiodized oil is injected. This method bypasses the lower extremity lymphatics. In both of these techniques, once the thoracic duct is opacified, it can be cannulated percutaneously in the upper abdomen under fluoroscopic guidance. Retrograde cannulation of the thoracic duct involves transvenous cannulation where the duct drains to the systemic circulation, usually at the confluence of left internal jugular and subclavian veins. The presence of a valve makes this technique challenging. Given the high mortality rate and difficulty of surgical treatment, percutaneous lymphangiography with thoracic duct embolization remains an important treatment option for chylothorax. Knowledge of various techniques can increase success of thoracic duct cannulation and embolization.

Pathogenesis of bilateral chylothorax after injury of thoracic duct during central venous catheterization.

Pathogenesis of bilateral chylothorax after injury of thoracic duct during central venous catheterization.

Bilateral chylothorax as a complication of internal jugular vein cannulation.

Sir, We thank the reader for the interest shown and an incisive analysis of our article.[1] We would like to clarify the queries raised as follows:- The mechanism of bilateral chylothorax after thoracic duct injury is not clearly known but has been hypothesized based on the various case reports that have been described in the past and in our article. Paw described a case of bilateral pleural effusion as a complication of left internal jugular venous catheterization for total parenteral nutrition.[2] The author had suggested that the tip of the catheter might have migrated into the mediastinum and that fluid from the mediastinum had entered both the pleural spaces via anatomical communications, which have not yet been described. Similar instances where contralateral or bilateral effusions have occurred after central line insertion have been reported.[34567] Varache attributed it to a possible mediastinal pleural ruture.[7] Naquib et al. have ascribed the phenomenon to the pressure difference between the mediastinal compartment and the pleural compartments, which leads to the extravasation of fluid from the mediastinum to bilateral pleural spaces. They also demonstrated the same with instillation of a radio-opaque dye through the central line and its appearance in the mediastinum[4]As described in our article, after the inadvertent injury to thoracic duct, during central venous cannulation, the chyle first leaks out either into the ipsilateral pleural space through a pleural breach that occurred during cannulation (which would explain the development of unilateral chylothorax), or the chyle could extravasate into the mediastinal compartment. From there, after a latent period of about two days, the chyle enters one or both pleural spaces because of the pressure difference between the compartments. This would explain the instances of the contralateral and bilateral chylothoraces. The authors agree with the various mechanisms proposed by the reader except that occlusion or near occlusion of the thoracic duct (post-injury) were unlikely in our case considering the early and complete resolution that occurred. All the other stated mechanisms were plausible.During our literature search we found five case reports where the mechanism of chylothorax was a direct injury to thoracic duct or lymphatic vessels. We had listed the same in our article and as shown in the table, all had either ipsilateral or bilateral chylothoraces. Contralateral chylothoraces have been described in those cases where the central venous cannulation had led to thrombosis of central veins. The extension of thrombi and back pressure effects may lead to ipsilateral, contralateral or bilateral chylothorax The origin of the swelling in the supraclavicular fossa has not been conclusively determined, but has been observed in other reports too. Most experts believe that when the duct starts to leak, a mediastinal chyloma is first formed below the pleura which tracks up to appear above the sibson's fascia and causes the supraclavicular swelling. The same mediastinal chyloma may enter the pleural space to cause chylothorax.[8910] However, as mentioned earlier, the mechanism has not been conclusively elucidated. We thank the reader again for bringing out these important anatomical considerations which are intuitively unclear and may require experimental studies for understanding the mechanism more explicitly.

Management of Chyle Leak in the Neck Following Thyroid Cancer Surgery: A Single Center Experience

ABSTRACT Introduction Surgery for thyroid cancers often necessitates a neck dissection. This is usually a safe procedure, but can be associated with complications. Chyle leak is one such complication, fortunately rare. There is a dearth of literature with regard to the management of chyle leak in the neck. We present a single center experience in the management of chyle leak in the neck, to improve the understanding of its management. Materials and methods A retrospective analysis of patients with thyroid cancer, managed between January 1st 2005 and December 31st 2011, in a single institution was performed. Among these, patients with chyle leak were identified. All pertinent data collected and results analyzed using STATA (v10). Results Three hundred and seventy-three/eight hundred and twenty-one (45.4%) patients surgically managed for thyroid cancer underwent a neck dissection. Thoracic duct injury was recog- nized and managed intraoperatively in 20/373 (5.4%) patients. The leak was prevented in the majority (66.6%) of patients in whom a combination of methods were employed. 25/373 (6.7%) patients were diagnosed and managed for chyle leak postoperatively. Seven patients required re-exploration. This included patients with low output chyle leaks who may have settled in a week to 10 days with conservative management. A combination of techniques was successful in the majority (71.4%). The remaining patients were successfully managed conservatively. Conclusion We conclude that using a combination of methods to manage thoracic duct injury may be better than using a single modality alone. Early re-exploration was more economical and acceptable for a subset of our patients, as they come from long distances at personal cost. How to cite this article Cherian a, Ramakant P, Paul MJ, Abraham DT. Management of Chyle Leak in the Neck Following Thyroid Cancer Surgery: A Single Center Experience. World J Endoc Surg 2015;7(1):6-9.

Comparison between Femoral and Superior Approach Central Venous Pressure Measurements in Critically Ill - Mechanically Ventilated Patients

Central venous catheterization is one of the most commonly used invasive procedures in critically ill patients. Superior approach (internal jugular and subclavian veins) is the most frequently anatomical site used for central venous catheter (CVC) insertion. However, access through it may lead to several substantial serious and life threatening complications such as pneumothorax, haemothorax, air embolism, arterial puncture, bleeding, dysrhythmias and thoracic duct injury. In contrast, femoral route is safe, standard and popular procedure as it avoids many of the potential peri-insertion and mechanical complications of the superior approach. In addition, the femoral route is also considered by many to be the easiest site for central venous access and can be quickly learned by inexperienced operators.(1–4) But the question that has been raised about the reliability and accuracy of central venous pressure reading obtained from the femoral vein and to what extent it equally reliable with CVP readings obtained from the superior approach ? To answer this question, the current study was conducted to compare the measures of central venous pressure (CVP) at two different sites (superior versus femoral).

Management of complications after thyroid surgery

The evolution of thyroid surgery has decreased the incidence of complications significantly. Experienced endocrine surgeons report less than 1% of complications. However, laryngeal nerve injury and hypocalcaemia still occur. Less common complications of thyroidectomy include postoperative bleeding, major thoracic duct injury, and even more rarely tracheal injury and oesophageal injury. In cases of postoperative voice change or hoarseness, the patient should be evaluated with direct laryngoscopy to define the extent of injury and the course of treatment. Steroids may be used. The patient should be followed up until complete resolution of nerve palsy. If the laryngeal nerve injury is considered permanent, operative treatment may be considered by referral centres with expertise. Swallowing studies and voice therapy should also be initiated. Post-thyroidectomy bleeding may be life-threatening and requires an emergency reoperation to decompress the upper airway. Injury of the major thoracic duct may be managed with either conservative or operative treatment based on the amount of daily lymphorrhea. Injury of the trachea and/or oesophagus usually requires surgical repair. The above complications require an immediate and stepwise therapeutic approach from the vigilant surgeon. Although the prevention of those complications remains the first goal of the surgeon, if such complications are encountered, the surgeon should implement the most appropriate intervention according to the above recommended management guidelines.