Thoracic Duct Research Articles

Coil or Plug-Assisted Ethylene Vinyl Alcohol Copolymer (EVOH) Thoracic Duct Embolization in the Treatment of Postoperative Chylothorax

Eleven patients (5 men, 6 women) with post-operative thoracic duct injuries and high output chylothorax were treated with thoracic duct embolization (TDE). Six patients underwent intraprocedural thoracic duct ligation at the time of original procedure. In all cases, the pleural fluid demonstrated high triglyceride levels (414 mg/dL; interquartile range [IQR], 345 mg/dL). Median daily (IQR) chest tube outputs before and after TDE were 900 mL (1,200 mL) and 325 mL (630 mL), respectively. Coil- or plug-assisted ethylene vinyl alcohol (EVOH) copolymer was used as embolic agent in all patients. Technical and clinical success rates were 100% and 82%, respectively. Nontarget venous embolization of EVOH copolymer was not identified on subsequent imaging.

Abstract 16011: Lymphatic Intervention Following Superior Cavo-Pulmonary Anastomosis Potentially Allows for Successful Fontan Completion

Introduction: Superior cavopulmonary anastomosis (SCPC) inevitably exposes the thoracic duct to higher venous pressure, potentially triggering disordered lymphatic perfusion manifesting as chylothorax (CT) and/or plastic bronchitis (PB) . Though outcomes following lymphatic interventions after Fontan completion (FC) are well described, they are not well described in patients after SCPC. Methods: A single-center retrospective study of patients who underwent lymphatic intervention for PB or CT following SCPC 1/1/2011-12/31/2021 was performed, excluding those with planned two ventricle or 1.5 ventricle repair, patients who underwent thoracic duct ligation, and those in whom interventions were performed either prior to SCPC or following FC. Results: In total, 27 patients (56% male) were studied, of which 22% had PB and 78% with CT, 7% with Noonan’s syndrome and 19% with heterotaxy syndrome. Median age at intervention was 11.3 months (IQR 7.4 - 33.5). Median time following SCPC was 3.5 months (IQR 2.1 - 24.2). In terms of interventions, 41% (n=11) underwent selective lymphatic channel embolization. Of these 36% (4/11) underwent subsequent thoracic duct embolization (TDE). The remaining 59% (n=16) patients underwent TDE. The thoracic duct was able to be accessed in 23 patients (85.2%). Twenty-four patients (19/21 with CT, 5/6 with PB) had resolution of symptoms following transcatheter intervention at our center. Following intervention, seven patients (all of whom were of the type IV lymphatic subtype) were successfully referred for FC, ten are currently awaiting FC, five are not Fontan candidates and five passed away from non-procedural comorbidities. Median duration of post-operative chest tubes following FC was 7 days (IQR 6-8) and median follow up is 39.1 months (IQR 15.1 - 45.1). Conclusions: Selective lymphatic embolization and TDE are feasible in SCPC recipients with CT and PB, with most patients experiencing symptomatic improvement. Subsequent FC has been achieved in some patients with type IV lymphatic abnormalities, suggesting that these interventions may alter the unnatural history of lymphatic dysfunction in single ventricle patients. Future research is needed to define longer term outcomes of this high-risk cohort.

The Use of Indocyanine Green to Visualize the Thoracic Duct and Evaluate Gastric Conduit Perfusion in Esophagectomy

Background: In this study, we investigate indocyanine green (ICG) dye visualization of the thoracic duct (TD) and conduit perfusion during esophagectomy to reduce anastomotic leak (AL) and chylothorax adverse events (AEs). Methods: Retrospective data of adult patients who underwent esophagectomy for esophageal carcinoma between July 2019 and 2022 were included (n = 105). ICG was delivered intravenously (2 mL, 2.5 mg/mL) to assess conduit perfusion into the small bowel mesentery, inguinal lymph nodes, or foot web spaces for TD visualization using fluorescence imaging. Incidence of TD injury, chylothorax, AL, and AEs were collected. Results: A total of 23 patients received ICG (ICG for TD and perfusion (n = 12) and perfusion only (n = 11)), while 82 patients were controls. TD was visualized in 6 of 12 patients who received ICG for TD. No intraoperative TD injuries or postoperative chylothoraces occurred in these patients. Non-ICG patients had 1 (1.22%) intraoperative TD injury and 10 (12.2%) postoperative chylothoraces (grade I–IIIb). While 10 non-ICG patients (12.2%) developed AL (grade I–IVb), only 2 (8.7%) ICG patients developed AL (grade IIIa). Conclusions: This study demonstrates the utility of ICG fluorescence in intraoperative TD and conduit perfusion assessment for limiting AEs. Standard incorporation of ICG in esophagectomy may help surgeons improve the quality of care in this patient population.

Review article: Feasibility of brachiocephalic vein central venous access for the resuscitation of shocked adult trauma patients: A literature review.

Venous access is a key component of managing haemorrhagic shock. Obtaining intravenous access in trauma patients is challenging due to circulatory collapse in shock. This literature review examines the feasibility of direct puncture and cannulation of the brachiocephalic veins (BCVs) for intravenous access in shocked adult trauma patients. Three literature searches were conducted. OVID Medline was searched for articles on the use of the BCVs for venous access in adults and on the BCVs in shock. A third systematic search of OVID Medline, OVID Embase and Cochrane Library was conducted on the use of the BCVs for access in shocked trauma patients. After full-text review, 18 studies were selected for inclusion for the search on the use of the BCVs for access in adults. No studies met the inclusion criteria for the search on the BCVs in shock and BCV access in shocked trauma patients. The BCVs are currently used for central venous access, haemodialysis and totally implantable venous access devices (TIVADs) in adults. There is a preference for the right BCV (RBCV) over the left as the RBCV is more superficial, straighter, larger, has less anatomical variation and avoids the risk of thoracic duct puncture. The BCVs appear to be stabilised in shock by surrounding bony structures. The BCVs may provide a site for initial, rapid access in trauma resuscitation. Further research is required to determine if the BCVs collapse in shock and if venous access using the BCVs is feasible in a trauma resuscitation setting.

Impact of fluorescent thoracic duct lymphography via intranodal approach in minimal access esophageal cancer surgery.

Chyle leak resulting from thoracic duct (TD) injury poses significant morbidity and mortality challenges. We assessed the feasibility of using near-infrared (NIR) indocyanine green (ICG) imaging for intraoperative fluorescence TD lymphography during minimal access esophagectomy (MAE) in a semiprone position with inguinal nodal injection of ICG dye. Ninety-nine patients with esophageal or gastroesophageal junctional cancer undergoing MAE received inguinal node injections of 2.5mg ICG dye (total 5mg) under sonographic guidance during anesthesia induction. Stryker's 1688 AIM HD system was used in 76 cases, Karl Storz OPAL 1 S in 20, and in three cases the Karl Storz Rubina. In 93 patients (94%), the TD was clearly delineated along its entire length; it was not visualized in 6 patients (6%). Fluorescence guidance facilitated TD ligation in 16 cases, while 3 cases required clipping of duct tributaries for oncological considerations. Twenty-eight patients exhibited minor duct variations. Fluorescence was sustained throughout surgery (median observation time 60minpost-injection; range 30-330). No patient experienced any chyle leak within 30days post-surgery and no adverse reactions to ICG was evident. Intraoperative fluorescence TD lymphography using ICG during MAE in a semiprone position with inguinal nodal injection proved safe, feasible, and effective, allowing clear visualization of the TD in almost all cases. This approach aids safe ligation and reduces chyle leak risk. It offers real-time imaging of TD anatomy and variations, providing valuable feedback to surgeons for managing TD injuries during MAE procedures and represents an excellent educational tool.

Association between underweight status and chylothorax after esophagectomy for esophageal cancer: A propensity score–matched analysis

ObjectiveTo use a nationwide database of hospitalizations to investigate underweight status as a risk factor for postesophagectomy complications. MethodsWe identified all patients who underwent esophagectomy with a diagnosis of esophageal cancer and known body mass index in the 2018-2020 Nationwide Readmissions Database. All hospital visits for esophagectomy and within 30 days of initial discharge were analyzed for postoperative complications, including chylothorax. Patients who were underweight were propensity score matched with patients who were not. Multivariable logistic regression was performed to identify complications that were significantly associated with underweight status. ResultsThere were 1877 patients with esophageal cancer meeting inclusion criteria. Following propensity score matching, 433 patients who were underweight were matched to 433 patients who were not. In the multivariable model of the matched sample, which adjusted for age, sex, Charlson Comorbidity Index, history of chemotherapy or radiation therapy, and preoperative surgical feeding access, patients who were underweight were estimated to have 2.06 times the odds for chylothorax (95% confidence interval [CI], 1.07-4.25, P = .035). Underweight status was also significantly associated with acute bleed (odds ratio [OR], 1.52; 95% CI, 1.12-2.05, P = .007), pneumothorax (OR, 2.33; 95% CI, 1.19-4.85; P = .017), pneumonia (OR, 2.30; 95% CI, 1.53-3.50, P < .001), and in-hospital mortality (OR, 2.42; 95% CI, 1.31-4.69, P = .006). ConclusionsUnderweight status was found to be a risk factor for chylothorax after esophagectomy, which may have implications for perioperative care of esophageal cancer patients. Future studies should assess whether using feeding tubes or total parenteral nutrition preoperatively or thoracic duct ligation intraoperatively decreases risk of chylothorax among patients who were underweight.

Surgical Management of Central Lymphatic Conduction Disorders: A Review

AimRecent advances in lymphatic imaging allow understanding the pathophysiology of lymphatic central conduction disorders with great accuracy. This new imaging data is leading to a wide range of novel surgical interventions. We present here the state-of-the-art imaging technology and current spectrum of surgical procedures available for patients with these conditions. MethodDescriptive report of the newest lymphatic imaging technology and surgical procedures and retrospective review of outcome data. ResultsThere are currently two high-resolution imaging modalities for the central lymphatic system: multi-access dynamic contrast-enhanced MR lymphangiogram (DCMRL) and central lymphangiography (CL). DCMRL is done by accessing percutaneously inguinal and mesenteric lymph nodes and periportal lymphatics vessels. DCMRL provides accurate anatomical and dynamic data on the progression, or lack thereof, of the lymphatic fluid throughout the central lymphatic system. CL is done by placing a catheter percutaneously in the thoracic duct (TD). Pleural effusions are managed by pleurectomy and intraoperative lymphatic glue embolization guided by CL. Anomalies of the TD are managed by TD-to-vein anastomosis and/or ligation of aberrant TD branches. Chylous ascites and organ-specific chylous leaks are managed by intraoperative glue embolization, surgical lymphocutaneous fistulas, and ligation of aberrant peripheral lymphatic channels, among several other procedures. ConclusionThe surgical management of lymphatic conduction disorders is a new growing field within pediatric general surgery. Pediatric surgeons should be familiar with the newest imaging modalities of the lymphatic system and with the surgical options available for patients with these complex surgical conditions to provide prompt treatment or referral. Level of EvidenceV.

Non-Contrast MR Lymphography and Intranodal Dynamic Contrast MR Lymphangiography in Children with Congenital Heart Disease-Imaging Findings as well as Impact on Patient Management and Outcome.

Lymphatic flow disorders are rare but devastating complications in children with congenital heart disease. T2-weighted magnetic resonance lymphography and intranodal dynamic contrast magnetic resonance lymphangiography are imaging modalities that can depict central lymphatic anatomy and flow pattern. Our objective was to describe the technical aspects and our imaging findings of central lymphatic abnormalities and their impact on patient management and outcomes: We conducted a retrospective review of 26 children with congenital heart disease who presented for lymphatic imaging between 2015 and 2020 at our institution. Eleven had postoperative chylothorax, six had plastic bronchitis, seven had protein-losing enteropathy and three had Noonan syndrome. Our lymphatic imaging demonstrated severely abnormal lymphatic flow in all of the children, but only minor abnormalities in protein-losing enteropathy. No major procedure-related complication occurred. Lymphatic interventions were performed in six patients, thoracic duct decompression in two patients and chylothorax revision in three patients. This led to symptomatic improvements in all of the patients: Lymphatic imaging is safe and essential for the diagnosis of lymphatic flow disorders and therapy planning. Our intranodal lymphangiography depicts an abnormal lymphatic flow pattern from the central lymphatics but failed to demonstrate an abnormal lymphatic flow in protein-losing enteropathy. These imaging techniques are the basis for selective lymphatic interventions, which are promising to treat lymphatic flow disorders.

Neck mass and bilateral pleural effusions in a 53-year-old female.

Chylothorax indicates the accumulation of chyle in the pleural cavity. It is a rare cause of pleural effusion, especially bilaterally. In clinical practice, the presence of milky fluid in the pleural cavity raises the suspicion of chylothorax. The most common cause is trauma, iatrogenic or non, owing to thoracic duct injury, which transports chyle from the lymphatic system into the bloodstream. The case we describe is of a 53-year-old female who was referred to our hospital with bilateral pleural effusions and a left supraclavicular mass. From the diagnostic studies, the nontraumatic causes of chylothorax were excluded. The potential diagnosis was traumatic chylothorax, a diagnosis of exclusion, as it appeared after muscle stretch and receded with a fat-free diet and repose without any relapse.

Application of indocyanine green fluorescence imaging navigation in pediatric surgery: A single-center review

BackgroundPediatric patients often exhibit congenital disorders and rare diseases. Consequently, pediatric surgeons must frequently perform atypical surgeries, dealing with a great deal of stress. Regarding atypical surgeries, navigation is required to ensure safety and surgical precision. In this study, we report our experience with 213 indocyanine green (ICG) fluorescence navigation (ICG-nav) surgeries and introduce our newly developed protocols of ICG-nav for pediatric surgery. MethodsThe route and method of ICG administration, surgery, complications, and efficacy of ICG-nav surgery were retrospectively evaluated. Thereafter, the protocols were established. ResultsStable navigation was possible for chylothorax, cholelithiasis, primary hepatoblastoma lesions, hepatoblastoma lung metastases, nephroblastoma liver metastases, organ blood flow, the thoracic duct, lymphatic malformation, and lung segmentectomy. New protocols were established for these cases. ConclusionsICG-nav could be performed safely in children given that the total amount of ICG administered was carefully controlled. Furthermore, ICG-nav was a highly applicable navigation surgical technique that could be used for treating a wide variety of diseases. To our knowledge, this is the first report of successful ICG-nav for liver metastases from nephroblastoma presented in this series.

Tuberculous Dactilitis in Young Male, a Rare Case

Introduction : Chylothorax is an uncommon medical condition caused by the accumulation of chylous fluid in the pleural space. Chylothorax has no predilection for sex or age. The prevalence after various cardiothoracic surgeries is 0.2% to 1%. Mortality and morbidity rates are around 10%. Respiratory distress may occur due to compression of the lung by the accumulated fluid. Management and approaches to treating the condition require multidisciplinary therapy, starting from non-pharmacological, pharmacological, to interventional management. Case Report : A 57-year-old Man patient was referred to the emergency room with chief complaint of shortness of breath. Reduced breathing sound on both lung fields. No previous history of cancer or thoracic surgery were found. X-ray examination had found bilateral pleural effusion. Thoracocentesis and pleural fluid analysis was performed with total of 6800 cc serosanguinous, whitish fluid was extracted from both of the lung. The patient was diagnosed with chylothorax. Lymphangiography and embolization was performed on the leak on left thoracic duct (T10) from right lymph node. Antibiotic was also given to treat the community acquired pneumonia that could be one of the possible etiology on this patient. Dietary modification with low fat diet and Ocreotide was also given to this patient as one of the treatment modalities. Discussion : The diagnosis of Chylothorax on this patient was established based on pleural fluid analysis and evidenced by lymphangiography examination by the presence of a leak in the thoracic lymphatic duct. Various modalities to diagnose this condition have been carried out with inconclusive results. Non-pharmacological, pharmacological and radiological interventions with embolization through lymphangiography are proven to be able to stop leaks and reduce symptoms in this patient. Conclusion : Chyle leak to the pleural space may compress the lung and cause respiratory distress. Combinaton of thoracocentesis, embolization of the leakage, dietary intake modification and administration of ocreotide may help prevent further chylous fluid accumulation.

A case of a thoracic duct cyst extending from the mediastinum to the cisterna chyli resected using bilateral thoracoscopic surgery in the prone position

BackgroundThoracic duct cysts are extremely rare mediastinal tumors. We report a case of a thoracic duct cyst extending from the caudal aspect of the left main bronchus to the left renal artery that was safely and completely resected via bilateral thoracoscopic surgery in the prone position.Case presentationA 77-year-old male was referred to our hospital for follow-up computed tomography (CT) of prostate cancer, which revealed a mediastinal tumor and fatty low-density along the posterior mediastinum of the para-aortic artery with a slightly high-density component. Magnetic resonance imaging revealed a T2-weighted image with high intensity. The preoperative radiological diagnosis was lipoma or well-differentiated liposarcoma. CT in the prone position suggested that the tumor could be resected from the thoracic cavity to the caudal side, and bilateral thoracoscopic surgery was performed in the prone position. Based on the surgical findings, the tumor was diagnosed as a thoracic duct cyst rather than a lipoma. Dissection around the thoracic duct cyst was performed using a vessel-sealing system to prevent leakage of the chyle, and reliable clipping was performed to resect the cisterna chyli. Histopathological examination revealed smooth muscle structures around the cyst, suggestive of a thoracic duct cyst. The diagnosis of a thoracic duct cyst was made based on a high triglyceride level of 1310 mg/dL on examination of the milky-white cyst fluid. The patient's postoperative course was uneventful, and he was discharged 4 days postoperatively. A CT scan performed 13 months after surgery showed no recurrence.ConclusionsA rare thoracic duct cyst extending from the mediastinum to the cisterna chyli was safely and completely resected using bilateral thoracoscopic surgery, with the patient in the prone position.

Lymphatic Defects in Zebrafish sox18 Mutants Are Exacerbated by Perturbed VEGFC Signaling, While Masked by Elevated sox7 Expression.

Mutations in the transcription factor-coding gene SOX18, the growth factor-coding gene VEGFC and its receptor-coding gene VEGFR3/FLT4 cause primary lymphedema in humans. In mammals, SOX18, together with COUP-TFII/NR2F2, activates the expression of Prox1, a master regulator in lymphatic identity and development. Knockdown studies have also suggested an involvement of Sox18, Coup-tfII/Nr2f2, and Prox1 in zebrafish lymphatic development. Mutants in the corresponding genes initially failed to recapitulate the lymphatic defects observed in morphants. In this paper, we describe a novel zebrafish sox18 mutant allele, sa12315, which behaves as a null. The formation of the lymphatic thoracic duct is affected in sox18 homozygous mutants, but defects are milder in both zygotic and maternal-zygotic sox18 mutants than in sox18 morphants. Remarkably, in sox18 mutants, the expression of the closely related sox7 gene is elevated where lymphatic precursors arise. Sox7 could thus mask the absence of a functional Sox18 protein and account for the mild lymphatic phenotype in sox18 mutants, as shown in mice. Partial knockdown of vegfc exacerbates lymphatic defects in sox18 mutants, making them visible in heterozygotes. Our data thus reinforce the genetic interaction between Sox18 and Vegfc in lymphatic development, previously suggested by knockdown studies, and highlight the ability of Sox7 to compensate for Sox18 lymphatic dysfunction.

Clinical characteristics of chylothorax: results from the International Collaborative Effusion database.

Chylothorax is an uncommon medical condition for which limited data are available regarding the contemporary aetiology, management and outcomes. The goal of this study was to better define these poorly characterised features. The medical records of adult patients diagnosed with chylothorax at 12 centres across Europe, America and South Africa from 2009-2021 were retrospectively reviewed. Descriptive and inferential statistics were performed. 77 patients (median age 69 years, male to female ratio 1.5) were included. Subacute dyspnoea was the most typical presenting symptom (66%). The commonest cause of chylothorax was malignancy (68.8%), with lymphoma accounting for 62% of these cases. Other aetiologies were trauma (13%), inflammatory/miscellaneous conditions (11.7%) and idiopathic cases (6.5%). At the initial thoracentesis, the pleural fluid appeared milky in 73%, was exudative in 89% and exhibited triglyceride concentrations >100 mg·dL-1 in 88%. Lymphangiography/lymphoscintigraphy were rarely ordered (3%), and demonstration of chylomicrons in pleural fluid was never ascertained. 67% of patients required interventional pleural procedures. Dietary measures were infrequently followed (36%). No patient underwent thoracic duct ligation or embolisation. Morbidity included infections (18%), and thrombosis in malignant aetiologies (16%). The 1-year mortality was 47%. Pleural fluid protein >3.5 mg·dL-1 (sub-distribution hazard ratio (SHR) 4.346) or lactate dehydrogenase <500 U·L-1 (SHR 10.21) increased the likelihood of effusion resolution. Pleural fluid protein ≤3.5 mg·dL-1 (HR 4.047), bilateral effusions (HR 2.749) and a history of respiratory disease (HR 2.428) negatively influenced survival. Chylothoraces have a poor prognosis and most require pleural interventions. Despite the standard recommendations, lymphatic imaging is seldom used, nor are dietary restrictions followed.

Case Report of Needle Disruption of the Retroperitoneal Lymph Nodes for Refractory Chylothorax After Double Lung Transplantation

Chylothorax is a rare complication after double lung transplantation. We report a case of a 55-year-old man with idiopathic pulmonary fibrosis. He underwent a double lung transplantation with venoarterial extracorporeal membrane support. The surgery was uncomplicated; however, his postoperative course was complicated with a refractory chylothorax that started postoperative day 4. Medical management could not control the chylothorax, including nil per os, total parenteral nutrition, and octreotide administration. After failed percutaneous embolization via lymphangiography and surgical ligation of the thoracic duct and pleurodesis via video-assisted thoracoscopic surgery, percutaneous needle disruption of the retroperitoneal lymph nodes was performed. After this procedure, the chylothorax resolved quickly. Percutaneous needle disruption of the retroperitoneal lymph node is safe and effective for refractory chylothorax. This technique can be one of the main modalities to manage chylothorax after lung transplantation.

322. FLUORESCENCE LYMPHOGRAPHY USING INDOCYANINE GREEN IN THE PREVENTION OF CHYLE LEAKAGE AFTER MINIMALLY INVASIVE ESOPHAGECTOMY

Abstract Background Chyle leakage is one of the most challenging complications in esophagectomy, with an incidence of 14–21%. The clinical implications for patients are prolonged thoracic drainage and hospital admission, additional reinterventions, unpleasant dietary restrictions, and decreased long-term survival. The anatomy and vulnerability of the thoracic duct render it prone to injury, and mainly side branches and collaterals are often hard to visualize. Fluorescence lymphography using indocyanine green (ICG) can accurately visualize the thoracic duct, which may possibly reduce the incidence of chyle leakage and intra-operative detected chyle leakage can be treated directly. Methods A prospective observational cohort study is performed. Patients aged over 18 years with resectable (cT1-4a, N0–3, M0) esophageal carcinoma undergoing a minimally invasive esophagectomy are included. The primary endpoint of the study is postoperative chyle leakage. Secondary endpoints are overall morbidity and mortality, nature of dietary restrictions, reinterventions, hospital costs, 2 year survival rate and quality of life. Twenty-five milligram of ICG is dissolved in 10 mL of sterile water, obtaining a solution of 2.5 mg ICG per mL. In the McKeown esophagectomy, before the thoracic phase, the surgeon administers a bilateral bolus of 2 mL ultrasound-guided into inguinal lymph nodes. In an Ivor Lewis esophagectomy, 2 mL of reconstituted ICG will be injected into the small bowel mesenteric root just under the peritoneum of the mesentery, at the level where the jejunostomy is placed. Additionally, 50 mL of cream is enterally administered through the just established feeding jejunostomy. Subsequently, the operating area is inspected for chyle leakage with fluorescence lymphography after thoracic duct ligation and just before terminating the procedure. Results We aim to include 50 patients to assess the feasibility of fluorescent lymphography using ICG and enteral cream to prevent chyle leakage after minimally esophagectomy. Inclusion is ongoing, at this time, 31 of 50 patients are included. Results will be expected before the congress. Conclusion It is hypothesized that as a result of this technique the patients will benefit from lower incidence of postoperative chyle leakage, shorter thoracic drainage, reduced hospital admission, reduced dietary restriction, less re-interventions, and improved overall survival.

364. A CASE OF SEVERE REFRACTORY MASSIVE MASTOID ASCITES AFTER THORACIC DUCT LIGATION FOR POSTOPERATIVE MASTOIDECTOMY

Abstract The patient, a male in his 70s, was referred to our hospital after an upper gastrointestinal endoscopy revealed esophageal cancer. After a close examination, he was diagnosed with esophageal squamous cell carcinoma T3, N2, M0, Stage III. After preoperative chemotherapy, he underwent thoracoscopic esophagectomy and gastric tube reconstruction. Intraoperatively, the thoracic duct was injured on the cranial side of the aortic arch and was ligated with a clip. When tube feeding was started postoperatively, a pleural effusion was observed, and the patient was treated with central venous nutrition. The effusion did not improve, so thoracoscopic surgery was performed on the postoperative day 12, and the thoracic duct was ligated just above the diaphragm. Postoperatively, the patient developed ascites in addition to pleural effusion, and continued to totally drain 3000 mL of thoracoabdominal fluid every day. Lymphangiography showed that lymphatic flow was interrupted at the site of thoracic duct ligation, but the site of leakage was unknown. Based on previous reports, octreotide 300 μg and etilefrine 100 mg was administered continuously, and pleural drainage decreased, and ascites drainage increased. Ascites volume exceeded 3000 mL in three days and was treated with a single puncture, but no improvement was observed. Tolvaptan 3.75 mg was started, and ascites decreased gradually. Patient’s general condition improved with nutrition and rehabilitation, and he was discharged on the day 189. We report a very rare case of refractory massive ascites following thoracic duct ligation for postoperative chylothorax, along with a discussion of the relevant literature.

277. SIMPLE METHOD: INGUINAL LYMPHANGIOGRAPHY FOR POSTOPERATIVE CHYLOTHORAX

Abstract Background Chylothorax is a well-known complication of esophageal cancer surgery, with an incidence of approximately 1–3%. The main cause is intraoperative damage to the thoracic duct, which is often discovered after postoperation. If conservative treatment is chosen, lymphangiography with Lipiodol is the diagnostic and embolization procedure for exposed areas. Itkin et al. reported that improvement rate is approximately 70%. Pedal lymphangiography has been used in the past, but we perform lymphangiography from the inguinal lymph node. Method We inject lipiodol under ultrasound guidance. A total of 6–10 mL injected into each bilateral inguinal lymph node. The lipiodol drain upstream from the main lumbar lymphatic trunk and contrasts into the thoracic duct under fluoroscopy. CT scans would be useful in the case that contrasts were unclear. Result If it is possible to inject lipiodol into the inguinal lymph nodes, even the thoracic ducts can be easily detected. With the classical method, an incision must be made between the first and second toes under local anesthesia, and minute lymph ducts must be identified and injected. However, if the inguinal lymph nodes are small, the drug tends to leak easily. Leakage is immediately detectable by fluoroscopy, so large leakage is unusual. If the drug is absorbed slowly, it remains subcutaneously after several months and can be identified as an artifact on abdominal X-rays or CT. Conclusion Lymphangiography from the inguinal lymph node is a relatively safe and simple method of examination, compared to the intervention from the dorsal foot. No skin incision on the dorsal foot is required, only an echo guided puncture is necessary. The examination time is short, and the patient burden is low. The procedure is not particularly difficult, so it can be performed even at small hospitals.

144. OPTIMIZING MEDIASTINAL ACCESS FOR RADICAL ESOPHAGECTOMY: A BILATERAL CERVICAL AND TRANSHIATAL APPROACH TO RESECT ESOPHAGEAL CANCER

Abstract Background Major medical centers have gradually attempted and promoted esophagectomy via mediastinal approach. However, this operation is challenging and requires a high level of technical proficiency from surgeons because of the limited space and restricted visibility of the mediastinum. The current surgical method limits its application in patients with locally advanced esophageal cancer, which underscores an urgent need for optimization to facilitate its refinement and dissemination. Methods We have implemented the following enhancements to the surgical procedure: 1. The cervical level was chosen for transecting the esophagus, and then the proximal esophageal stump was pulled down and invaginated. 2. Bilateral cervical incisions were made, with a small 0.5 cm incision at the anterior edge of the right sternocleidomastoid muscle. 3. The position of abdominal surgical incisions was adjusted so that all incisions were located on the left side of the abdominal midline. 4. A portion of the left diaphragm was dissected. 5. During the superior mediastinum procedure, gauze was positioned within the expanded superior mediastinum. Results 1. The surgical field was fully exposed, expanding the operative space for upper mediastinal surgery. 2. The difficulty of this surgery was reduced, and it was easier to expose both RLNs and completely remove the mediastinal lymph nodes. 3. The 106recR could be completely removed under endoscopy. 4. The thoracic duct could be fully exposed and freed. 5. During surgery, gauze is placed in the upper mediastinum to aid in hemostasis and improve visibility. 6. Even if the tumor was slightly larger or locally invaded surrounding tissues, it could be completely resected. 7.Complete resection of the esophageal mesorectum was successfully achieved. Conclusion Esophagectomy for esophageal cancer via bilateral cervical and transhiatal approach can achieve radical resection and can be applied to patients with locally advanced esophageal cancer. This surgical method expands the surgical indications, reduces the surgical difficulty for surgeons, and facilitates the promotion and popularization of the mediastinal approach surgery.

175. OPTIMIZING MEDIASTINAL ACCESS FOR RADICAL ESOPHAGECTOMY: A BILATERAL CERVICAL AND TRANSHIATAL APPROACH TO RESECT ESOPHAGEAL CANCER

Abstract Background Major medical centers have gradually attempted and promoted esophagectomy via mediastinal approach. However, this operation is challenging and requires a high level of technical proficiency from surgeons because of the limited space and restricted visibility of the mediastinum. The current surgical method limits its application in patients with locally advanced esophageal cancer, which underscores an urgent need for optimization to facilitate its refinement and dissemination. Methods We have implemented the following enhancements to the surgical procedure: 1. The cervical level was chosen for transecting the esophagus, and then the proximal esophageal stump was pulled down and invaginated. 2. Bilateral cervical incisions were made, with a small 0.5 cm incision at the anterior edge of the right sternocleidomastoid muscle. 3. The position of abdominal surgical incisions was adjusted so that all incisions were located on the left side of the abdominal midline. 4. A portion of the left diaphragm was dissected. 5. During the superior mediastinum procedure, gauze was positioned within the expanded superior mediastinum. Results 1. The surgical field was fully exposed, expanding the operative space for upper mediastinal surgery. 2. The difficulty of this surgery was reduced, and it was easier to expose both RLNs and completely remove the mediastinal lymph nodes. 3. The 106recR could be completely removed under endoscopy. 4. The thoracic duct could be fully exposed and freed. 5. During surgery, gauze is placed in the upper mediastinum to aid in hemostasis and improve visibility. 6. Even if the tumor was slightly larger or locally invaded surrounding tissues, it could be completely resected. 7.Complete resection of the esophageal mesorectum was successfully achieved. Conclusion Esophagectomy for esophageal cancer via bilateral cervical and transhiatal approach can achieve radical resection and can be applied to patients with locally advanced esophageal cancer. This surgical method expands the surgical indications, reduces the surgical difficulty for surgeons, and facilitates the promotion and popularization of the mediastinal approach surgery. Video address: https://www.icloud.com.cn/iclouddrive/085wyZDN6Qqm6Ou06fhOsi-Rw#2023_ISDE_abstract_video