Thoracic Duct Research Articles

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.

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.

The thoracic duct (TD) plays an important role in nutrition and immunity but is often resected with the esophagus when dissecting surrounding lymph nodes in patients with esophageal squamous cell carcinoma (ESCC). We examined whether indiscriminate TD resection improved the prognosis of patients with ESCC treated with neoadjuvant chemoradiotherapy (NACRT) followed by esophagectomy. A total of 440 patients treated with NACRT followed by esophagectomy between 2007 and 2012 were analyzed using data from the Comprehensive Registry of Esophageal Cancer in Japan. The propensity score-matched TD resection and TD preservation groups were compared in terms of short- and long-term outcomes. After matching, there were 85 patients in both groups. No significant differences were found between groups in either overall survival or cause-specific survival rates at 5years: 44.2% and 49.0% in the TD resection group, and 39.8% and 47.2% in the TD preservation group, respectively. Furthermore, the number of retrieved mediastinal lymph nodes was significantly greater in the TD resection group than in the TD preservation group (26 vs. 15, p < 0.0001). In contrast, TD resection was associated with metastasis to a significantly greater number of distant organs than TD preservation (49 vs. 32, p = 0.049). TD resection did not contribute to improved survival in patients with ESCC but did lead to metastases in more organs than TD preservation. Consequently, indiscriminate TD resection might be avoided in patients with ESCC treated with NACRT followed by esophagectomy.

Pre-operative oil ingestion reduces the probability of thoracic duct trunk ligation during esophagectomy.

Chylothorax is an important complication after esophagectomy. Ligation of the injured thoracic duct is the main method to prevent chylothorax after esophagectomy, but may be associated with adverse effects. Whether ligation of the injured tributary alone, keeping the main trunk intact, may suffice to prevent post-operative chylothorax is not well known. Since March 2017, 40mL of olive oil was administered to patients posted for esophagectomy. We compared patients admitted between March 2017 and December 2019 with patients admitted between July 2014 and February 2017, who had not received pre-operative oil. The outcome measures were the need for thoracic duct main trunk or tributary ligation, development of chylothorax and missed ligation. There were 371 patients in the oil ingestion group and 308 patients in the standard control group. Chylothorax in the oil ingestion group was significantly lower than that in the standard control group (1.3% vs. 4.5%, P = 0.012). Chyle leak from thoracic duct tributaries was diagnosed in a significantly higher percentage (5.7% vs. 0.0%, P < 0.001) and missed ligation of the injured thoracic duct was significantly lower (0.3% vs. 3.9%, P = 0.002) in the oil ingestion group compared with the standard control group. The incidence of post-operative chylothorax was not statistically different (6.3% vs. 10.0%, P = 1.000) between the tributary and the trunk ligation group. Pre-operative oil ingestion can help visualize the thoracic duct trunk and its tributaries during esophagectomy. Thus, non-selected thoracic duct trunk ligation and missed ligation during esophagectomy can be reduced. Precise ligation of the injured tributary while the main trunk is intact can also prevent post-operative chylothorax.

Chylothorax treatment with thoracic duct embolization

The authors present a case of a patient with non-traumatic right-sided chylothorax which was successfully treated by thoracic duct embolization. The procedure was performed through the cisterna chyli which was visualised by intranodal lymphography. The coils and acrylic tissue glues were used for embolization. The patient has been followed for 5 months and is free of recurrence of chylothorax.

Thoracic Duct Lymphovenous Bypass: A Preliminary Case Series, Surgical Techniques, and Expected Physiologic Outcomes.

A retrospective review of adult patients who underwent thoracic duct lymphovenous bypass by a single surgeon and interventional radiologist from 2019 to 2022 was performed. Demographics, comorbidities, perioperative data, and postoperative outcomes were collected. Nine patients were included in the study. Immediate postoperative heart rate increased significantly among this heterogeneous patient population, but within 4-6 hours the change in heart rate was no longer significant. Mean arterial pressure and oxygen requirement were not significantly different before and after bypass. Thoracic duct lymphovenous bypass seem to be well tolerated in the short-term even in patients with cardiopulmonary comorbidities. Further data are necessary to continue to better understand the resulting physiologic changes and to optimize patient outcomes.

Analysis of the unplanned reoperation following surgical treatment of pulmonary tumor

BackgroundIn this study, we aimed to summarize the extremely important lesson and experience in the whole process of surgical treatments of lung tumors for the benefit of steps taken to prevent against unplanned reoperation.MethodsDemographical and clinical information of 7732 patients were retrospectively retrieved and reviewed, who were diagnosed with pulmonary tumor and underwent surgical treatments from January 2016 to March 2021. Those patients who underwent unplanned reoperation for the treatment of severe complications were focused carefully and analyzed meticulously.ResultsA total of forty-one patients (41/7732) received 44 unplanned reoperations. Among them, eight and thirty-three patients were diagnosed with benign and malignant tumor, respectively. The incidence of unplanned reoperations seemed to be similar on both sides (Left vs. Right: 12/3231 vs. 29/4501, p = 0.103). Lobectomy plus segmentectomy is prone to reoperation (2/16, 12.5%) as compared to the other types of surgery. The complications leading to reoperation was hemothorax, including active hemorrhage (23/44, 52.3%) and clotted hemothorax (6/44, 13.6%), chylothorax (8/44, 18.2%), and the others (7/44, 15.9%) including bronchopleural fistula, torsion, or injury of right middle bronchus and pulmonary bulla rupture. The morbidity and mortality after unplanned reoperation were 17.1% (7/41) and 12.2% (5/41), respectively.ConclusionsBronchi or vessel stumps, the surgical edges of the lung parenchyma, and pleural adhesions should be checked to avoid postoperative bleeding. Prophylactic ligation of the thoracic duct should be recommended in case of the suspected oily-like exudation in the lymph node bed. Smooth expansion of the middle lobe is important to avoid narrowing and torsion before transection of the bronchus.

SURGICAL ASPECTS OF THE TREATMENT OF CHYLOTHORAX (CLINICAL OBSERVATIONS AND LITERATURE REVIEW)

Chylothorax is a rare disease that occurs due to damage to the thoracic lymphatic duct with the outflow of chyle from the lymphatic system into the pleural cavity, usually on the right.Establishing a final diagnosis for this disease is often associated with additional time costs, due to its relatively low prevalence. Currently, 65 scientific articles in Russian have been written on this topic.A necessary condition for the successful treatment of this disease is the identification of the root cause of its occurrence with its subsequent elimination.Despite the available scientific publications on this topic with a description of algorithmic approaches to diagnosis and treatment, sometimes, due to objective circumstances, it is necessary to correct these recommendations to ensure the most adequate treatment for a particular patient.