Direct trans-cervical endolymphatic thoracic duct stent-graft for plastic bronchitis

Plastic bronchitis is a poorly understood and uncommon diagnosis, arising from multiple etiologies. Traditional treatment consists of steroids and vasodilators, with thoracic duct embolization emerging as a new procedural therapy. Herein, abnormal lymphatic vessels were noted on lymphangiography in an adult patient with debilitating plastic bronchitis, but anterograde lymphatic access was not feasible due to the patient's morbid obesity and non-visualization of retroperitoneal lymphatics. After trans-venous thoracic duct access could not be established, direct trans-cervical thoracic duct access was performed. A thoracic duct stent-graft was placed, excluding the abnormal bronchial lymphatics and maintaining physiologic anterograde flow through the central lymphatics. At three-month follow-up, the patient's condition had resolved.

Bilateral chylothorax following anterior cervical spine surgery

Bilateral chylothorax following anterior cervical spine surgery is very rare. This report documents the first case of chylothorax after anterior cervical spine surgery through a right-side surgical approach. Unidentified chyle leakage can easily remain unrecognized and, thus, is difficult to treat. For early diagnosis and treatment, it is very important to consider the possibility of chylothorax following anterior cervical spine surgery, even when using a right-side surgical approach.

Delayed right chylothorax after left blunt chest trauma: a case report

BACKGROUND

Chylothorax is a disease that has various causes such as neoplasm, infection, post-surgery trauma, congenital, and venous thrombosis. In approximately 15% of cases of chylothorax, the exact cause is unknown. We report a case of delayed occurrence of right chylothorax in a patient who had multiple segmental ribs fracture on his left side.

CASE PRESENTATION

A 70-year-old Asian man had a "rollover" accident in which the cultivator he was driving overturned. He presented to our hospital with the main complaint of severe dyspnea. On chest computed tomography, multiple ribs fracture from the first to the eighth rib of the left side of his chest and left-sided hemopneumothorax were presented, but there was no evidence of fracture in the right side of his chest. After closed thoracostomy, an emergency operation for open reduction of fractured ribs was performed. On the fifth postoperative day, tubal feeding was performed. On the next day, a plain chest X-ray image showed pleural effusion of the right side of his chest. After insertion of a small-bore chest tube, 3390 ml of fluid for 24 hours was drained. The body fluid analysis revealed triglycerides levels of 1000 mg/dL, which led to a diagnosis of chylothorax. Although non-oral feeding and total parenteral nutrition were sustained, drain amount was increased on the fifth day. Surgical treatment (thoracoscopic thoracic duct ligation and pleurectomy) was performed in the early phase. The right chest tube was removed on the 14th postoperative day after the effusion completely resolved and he was uneventfully discharged.

CONCLUSIONS

In this case, as our patient was in old age and had multiple traumas, surgical treatment for chylothorax needed to be performed in the early phase.

Effect of Ligation of the Thoracic Duct During Oesophagectomy on the Absorption of D-xylose

OBJECTIVE

To assess if prophylactic thoracic duct ligation during oesophagectomy influences the absorptive function of oesophageal cancer patients.

STUDY DESIGN

Randomized controlled trial.

PLACE AND DURATION OF STUDY

Department of Thoracic Surgery, Tai'an City Central Hospital, Tai'an, from August 2014 to December 2015.

METHODOLOGY

Based on the management of the thoracic duct during oesophagectomy, 60 patients were randomized into two groups. D-xylose absorption test was used to evaluate the absorptive function. The two-independent-samples t-test was employed for statistical analysis with statistical significance at p < 0.05.

RESULTS

The serum D-xylose concentration of ligation-group was significantly lower than that of no-ligation group on the first day after operation, (t=2.82, p=0.0066). However, there was no significant differences between them even before operation (t=1.34, p=0.1849).

CONCLUSION

Ligation of the thoracic duct during oesophagectomy immediately affected the absorption of D-xylose, which may lead to malabsorption in the long run.

TREATMENT OF CHYLOTHORAX - ANESTHESIOLOGICAL OR SURGICAL PROBLEM?

BACKGROUND

The progress of surgery, the widespread use in the clinic of cardiac surgery and extended lymphadenectomy in thoracic surgery led to a greater incidence of the thoracic lymphatic duct ' trauma. That is why the actuality of treatment of chylothorax and chylorrhea is increased. The aim; improvement of diagnostics, prevention and treatment results ofpatients with chylothorax and chylorrhea.

MATERIALS AND METHODS

37 patients (14 women and 23 men) with chylothorax had been treating with our participation in different hospitals from 2004 to 2014. The age of the patients was from 32 to 71 years. In 34 patients chylothorax occurred after surgery, in 3 patients - during the decompensation of the therapy diseases with the use of central venous catheterization, with an earlier clinic of thrombosis of the large veins of the neck.

RESULTS

Conservative therapy had good clinical effect of 83.8%. 1 patient died due to pneumonia of the single lung on the background of chylothorax developed in the postoperative period after right-sided pneumonectomy. In other cases, chylothorax was eliminated and in the late period had no recurrence.

CONCLUSION

prevention of chylothorax depends on the experience of the operating surgeon. If there is doubt intact thoracic lymphatic duct, it has tightened with the stitching surrounding adipose tissue. Conservative therapy is the method of choice in the treatment of chylothorax. Surgery is indicated for failure of conservative therapy within the first two weeks, or when massive chylorrhea takes place.

[Optimal lymphadenectomy for thoracic esophageal cancer: three-field or modified two-field lymphadenectomy]

Differences in operative procedure and knowledge of esophageal cancer exist among surgeons from different countries and regions. There is controversy in the surgical treatment of esophageal cancer, especially in the extent of lymphadenectomy. Until now, results of the three-field lymphadenectomy and two-field lymphadenectomy are mostly reported by retrospective studies from Japan and China. Three-field lymphadenectomy has been initiated in Fujian Provincial Cancer Hospital since 1990s. After evaluating our database, we found that three-field was superior to two-field lymphadenectomy in terms of long-term survival for patients with upper thoracic esophageal cancer, whereas for those with middle or lower thoracic esophageal cancer, the survival benefit of three-field lymphadenectomy was reduced. Therefore, we propose to perform three-field lymphadenectomy for upper thoracic esophageal cancer. In middle or lower thoracic esophageal cancer, we suggest to perform modified two-field lymphadenectomy in most cases, and three-field lymphadenectomy in selective cases. Video-assisted two-field lymphadenectomy is feasible. Based on the national condition of China, we advise to perform thoracic duct removal only in patients with posterior mediastinal or peri-ductus node metastasis to achieve curative effect.

Congenital Chylothorax of the Newborn: Diagnosis and Treatment in Three Pictures

There is general agreement regarding the evident need for an international, multicenter trial including long-term follow-up to establish the correct criteria for diagnosing and managing congenital chylothorax. In an attempt to identify these criteria, which could then be used to draft a prospective multicenter trial, we propose three flow-charts showing three algorithms that could be used to: 1) obtain a definitive diagnosis of pleural chylous effusion; 2) specifically focus on chyle leakage evolution and etiology of chylothorax; and 3) focus on the management of congenital chylothorax. The aim of the algorithms we propose is to build the basis on which a strongly needed multicenter trial might be structured.

Closure of the thoracic duct from the left-side access: A case report

BACKGROUND

We report a 16-year-old patient with a massive left-sided chylothorax after chemotherapy due to mixed germinal tumor of the testis with massive metastases located in the retroperitoneal space and posterior mediastinum. Chemotherapy resolved the metastases in the mediastinum but evoked a huge pleural effusion in the left pleural cavity, requiring surgical intervention.Left-sided access was used. The 5-mm camera and 3 5-mm working ports were inserted. The parietal pleura was incised and the esophagus located and protected. Behind the esophagus, the thoracic duct and concomitant tissue were clipped with titanium clips, and additionally, thrombin glue was used. Stopping of the lymph leakage was observed during surgery. A local argon pleurodesis was used to finish the procedure. The thoracic tube was removed on the third postoperative day.

CONCLUSION

Left-side access may be a good alternative in the left-sided chylothorax, but the crucial points are location and protection of the esophagus during the procedure, which is also the landmark that allows for locating the thoracic duct.

Evaluation of the Efficacy of the Electrosurgical Bipolar Vessel Sealer (LigaSure) Devices in Sealing Lymphatic Vessels

Various sources of ultrasonic and thermal energy have been developed to facilitate blood vessel ligation. However, their efficacy in sealing lymphatics has not been clearly established to date. We hypothesized that the electrosurgical bipolar vessel sealer (EBVS) produces reliable and durable sealing of large lymphatic vessels in a porcine model. Thoracic ducts from 4 adult pigs were explanted and sealed at multiple levels by using 3 different EBVS devices: LigaSure Atlas, XTD, and V. Fifteen seals (5 per group) were analyzed for sealing time and visual quality. Seal burst strength was measured by using a graduated pressure saline injection system. Twelve intact seals also underwent a histologic analysis. The mean overall burst strength of the seals was 271 78 mm Hg (127 to 360 mm Hg). The burst pressures in the 3 groups were not statistically different. The overall mean time to achieve a seal was 5.12.2 seconds (3 to 10 seconds). Seals were achieved significantly faster in the V group (4.10.6 seconds) compared with the Atlas (6.32.3 seconds) and XTD (6.4 2.6 seconds) groups. Qualitative seal assessment revealed minimal sticking and charring, a favorable degree of seal tissue clarity, and desiccation in the 3 groups. Histologic analysis demonstrated a fusion of lymphovascular channels with a complete obliteration of the lumens. We demonstrated that the use of EBVS results in a fast and effective sealing of large porcine lymphatic vessels. The seals created by all 3 devices burst at markedly supraphysiologic intraluminal pressures. Ongoing randomized human trials may prove the clinical benefits of the routine use of EBVS devices for various tissue dissections.

Clinical outcome of transthoracic esophagectomy with thoracic duct resection: Number of dissected lymph node and distribution of lymph node metastasis around the thoracic duct

The number of dissected lymph nodes (LNs), surgical outcomes, and postoperative recurrence-free survival (RFS) were compared between thoracic duct (TD)-preserved and TD-resected groups. The distribution of metastasis in LNs around TD (TDLN) was reviewed. Transthoracic esophagectomy (TTE) with TD resection for esophageal cancer patients has been one of the standard procedures. Because the adipose tissue surrounding the TD contains LNs, TD resection might be necessary for radical LN dissection. However, few studies have investigated the oncological outcome of TTE with TD resection. Two hundred fifty-six consecutive patients who underwent TTE between 2004 and 2015 were retrospectively reviewed and classified into TD-preserved or TD-resected groups. The number of dissected LNs for each LN station and surgical outcomes were compared. RFS was analyzed in 155 patients who underwent TTE before December 2012. Since 2013, the TDLN number was prospectively examined, independent of the regional LNs (n = 72). Of these, the TDLN number for each location (TDLN-Ut/Mt/Lt) was investigated and the correlation between TDLN metastasis and clinicopathological factors was analyzed. The TD was preserved in 89 patients and resected in 167 patients. Patients with TD resection showed significant advanced stage. There was no significant difference in the incidence of postoperative complications, including pneumonia, anastomotic leakage, and chylothorax. The number of dissected mediastinal LNs was significantly increased in the TD-resected group. The 5-year RFS rate of cStage I patients was 67.3% in the TD-preserved group against 90.3% in the TD-resected group, showing a tendency towards RFS extension that did not quite reach statistical significance (P = 0.055). The mean TDLN-Ut/Mt/Lt numbers were 0.89/0.56/0.44, respectively. Eight of 72 (11%) patients displayed TDLN metastasis. Metastatic TDLNs were observed on the same or cranial level of the primary lesion in 7 of 8 patients. Transthoracic esophagectomy with TD resection could increase the number of dissected mediastinal LNs without increase of postoperative complication. TDLN metastasis was observed in patients with advanced disease. A prospective trial, investigating the survival between TD-preserved and TD-resected groups, should be conducted to clarify if TD should be resected in TTE.

Bilateral Chylothorax after Neck Dissection

Chylous fistula is a well-recognized complication of neck dissection, occurring in 1% to 2% of cases. 1 Cardiopulmonary complications, on the other hand, are rare. Bilateral chylothorax is an extremely rare occurrence following neck dissection. Severe respiratory, metabolic, and immunologic derangements can occur secondary to chylothorax. We report a case of bilateral chylothorax after neck dissection and cervical thoracic duct ligation.

[Ultrasonically activated coagulating shears and the vessel sealing system in thoracic surgery]

While the recent emergence of energy-based surgical techniques has made surgical procedures less invasive, the safety and proper usage have yet to be investigated. Here we review the experimental and clinical use of ultrasonically activated coagulating shears and a vessel sealing system in thoracic surgery. Both energy devices have been reported to be safe for use with the pulmonary artery and vein, with a burst pressure above 100 mmHg. Although their combined use with a ligature at a central site appeared to be adequate, the long-term durability has yet to be verified. The thoracic duct was reported to be sealed with sufficient burst pressure using these energy devices, which are expected to provide an alternative treatment for chylothorax. There have also been a few reports of their usage with the lung parenchyma, but their clinical adaptation is seemingly limited.

Life-threatening pulmonary lymphedema secondary to thoracic duct ligation

We herein report an extremely rare adult case presenting with life-threatening pulmonary lymphedema secondary to generalized lymphedema. A 47-year-old woman with generalized lymphedema from her feet to below her chest, had undergone surgical ligation of the thoracic duct and bilateral pleurodesis for the treatment of intractable idiopathic chylothorax three years earlier. Chest computed tomography demonstrated bilateral ground-glass opacities, air-space consolidation and interlobular septal wall thickening, presenting as a crazy-paving appearance predominantly on the gravity side. Bronchoalveolar lavage revealed marked lymphocytosis. She was treated with long-term oxygen therapy with noninvasive positive-pressure ventilation, followed by lymphovenous anastomoses of the lower extremities.

Thoracic duct ligation in the rat attenuates lung injuries in acute pancreatitis

In acute pancreatitis (AP), inflammatory cells and products disseminated in abdominal lymph and blood induce systemic inflammation. Interruption of abdominal lymph flow, and thereby reduction of lymphatic dissemination, could alter the course of the disease. Therefore, we investigated whether thoracic duct ligation (TDL) in a rat model of cerulein-induced AP results in reduced lung damage as a marker for reduction of systemic dissemination through the lymphatic system. Thirty-four male rats were assigned to TDL (TDL-rats, n=8), AP (AP-rats, n=8), TDL+AP (TDL+AP-rats, n=9) or sham TDL (Ctr-rats, n=9) groups. TDL and sham TDL were established first. Two days later, AP was induced in AP- and TDL+AP-rats by a series of subcutaneous injections of cerulein. Vehicle was injected in the same manner in Ctr- and TDL-rats as controls. Rats were sacrificed six hours after the end of the serial injections. Histological examination showed that AP-induced damage to the pancreas and ileum were similar in AP- and TDL+AP-rats whereas lung damage was less severe in TDL+AP-rats than in AP-rats. Assays demonstrated that: hepatic and pulmonary myeloperoxidase activities were increased in AP-rats but not in the TDL+AP-rats; more Il-6 was found in AP-rat than TDL+AP-rat lungs; and lung-lavage fluid from AP-rats yielded more angiopoietin-2 than TDL+AP-rats. In conclusion, prior TDL in the rat attenuates lung damage in acute pancreatitis.

Thoracoscopic ligation of thoracic duct for spontaneous chylothorax

Spontaneous chylothorax, without a predisposing factor is an uncommon cause of pleural effusion beyond the neonatal period. We present a case of left sided spontaneous chylothorax in a 20-month-old boy. We report successful management of this difficult problem with thoracoscopic ligation of thoracic duct after a failed trial with conservative management.

[Cisterna chyli ablation in three cats with idiopathic chylothorax]

OBJECTIVE

Presentation of three cats with chronic, idiopathic chylothorax treated with ablation of the cisterna chyli as an additional or a sole surgical treatment.

MATERIAL AND METHODS

Results of clinical and diagnostic examination, therapy and course of disease in three cats as well as the surgical technique of ablation of the cisterna chyli in cats are described.

RESULTS

There were no intraoperative or postoperative complications regarding cisterna chyli ablation. Intraoperative visualization of the cisterna chyli is easily achieved by administering a small portion of a fatty aliment preoperatively or by injection of diluted methylene blue into the lymphatic system intraoperatively. Ablation of the cisterna chyli was performed following an unsuccessful ligation of the thoracic duct, in combination with the ligation of the thoracic duct and subtotal pericardectomy or as a single surgical treatment.

CLINICAL RELEVANCE

Cisterna chyli ablation can be performed without complications in cats. This technique should be considered in cases of previously failed surgical therapy or as an adjunct therapy used with other surgical options to decrease the risk of recurrence.

Chyluria after ligation of the thoracic duct: a rare complication after thoracoscopic-assisted esophagectomy for esophageal cancer

Chyluria is leakage of lymphatic fluid into the urine, following trauma to or obstruction of the lymphatic system. We herein report a rare case of chyluria after esophagectomy for esophageal cancer. A 69-year-old male complaining of epigastric pain and reflux symptoms was diagnosed with advanced esophageal cancer and regional lymph node metastases. After receiving neoadjuvant chemotherapy to control the regional lymph node metastases, the patient underwent transthoracic excision of the esophagus assisted by thoracoscopy, with excision of the azygos vein and thoracic duct, esophagostomy and tube gastrostomy. On postoperative day 22, the urine appeared ivory white in color, and urine tests showed a high triglyceride level, thus confirming the diagnosis of chyluria. The chyluria decreased temporarily after switching the patient from enteral nutrition (EN) to parental nutrition, but it emerged again after the resumption of EN. Lymphangiography at that stage showed the flow of lipiodol into the pelvis of the left kidney. Resolution of the chyluria was noted after lymphangiography. He underwent esophageal reconstruction with a gastric tube through an anterior mediastinal route, and was discharged 36 days after the second operation. He was thereafter followed up at the outpatient clinic with radiotherapy.

Idiopathic chylothorax in dogs and cats: nonsurgical and surgical management

Idiopathic chylothorax is a debilitating disease that can lead to respiratory and metabolic compromise and fibrosing pleuritis. Several treatment options are available once a diagnosis has been made. Although large-scale studies on the outcome of treatment for idiopathic chylothorax are lacking, long-term resolution of clinical signs is possible. Pathophysiology, diagnosis, and thoracic duct imaging are discussed in a companion article. This article provides an overview of nonsurgical and surgical management techniques for idiopathic chylothorax in dogs and cats.

Primary idiopathic chylopericardium: a rare case with a synopsis of the literature

Primary idiopathic chylopericardium is a rare clinical entity characterised by the collection of chyle within the pericardial cavity without a definitive cause. This case report describes the history, physical examination, evaluation, diagnosis and treatment of a 19-year-old boy with primary idiopathic chylopericardium. Radiological findings and biochemical analysis of the pericardial fluid following pericardiocentesis sustained this diagnosis. Initial conservative management failed, and the patient was surgically treated subsequently. He recovered well postoperatively and remained asymptomatic thereafter. Primary idiopathic chylopericardium is a rare pathology with very few cases reported till date, and the symptoms are commonly due to cardiac compression. Computed tomography of the chest and bipedal lymphoscintigraphy are considered the standard methods for accurate diagnosis, and in cases of failed medical treatment, open and thoracoscopic thoracic duct ligation with pericardiectomy have been described as the best surgical options.

Successful treatment of plastic bronchitis with low fat diet and subsequent thoracic duct ligation in child with fontan physiology

Plastic bronchitis is a rare condition characterized by the formation and expectoration of long, branching bronchial casts that develop in the tracheobronchial tree and cause airway obstruction. Plastic bronchitis has become increasingly recognized as a feared complication of the Fontan operation with a mortality of up to 50%. We report an 11 year old boy who developed severe plastic bronchitis following Fontan repair and the successful long-term control of cast formation utilizing a low-fat diet and subsequent thoracic duct ligation.

Chyloptysis after ligation of the thoracic duct

Chyloptysis is a very rare clinical finding. We describe a 44-year-old man who presented with cough and milky-white sputum. Fiberoptic bronchoscopy revealed white sputum, which originated from the right B(6) bronchus. The finding of elevated triglyceride levels in his sputum led to the diagnosis of chyloptysis. He had a surgical history of ligation of the thoracic duct for idiopathic chylopericarditis 7 years-previously. He also suffered from postoperative bilateral empyema. Since then, his pleural cavity has been adhered bilaterally. It is thought that his abnormal postoperative lymphatic flow caused the chyloptysis.