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Gada PB, Sachdev RR, Ansari WA, Jadhav AA. Scourge of tuberculosis: A rare case of simultaneous chylothorax and chylous ascites. Lung India 2023; 40:271-274. [PMID: 37148027 PMCID: PMC10298829 DOI: 10.4103/lungindia.lungindia_494_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 01/30/2023] [Accepted: 02/16/2023] [Indexed: 05/07/2023] Open
Abstract
Tuberculosis (TB) is a rare cause of chylothorax and chylous ascites. This is a case of simultaneous TB-chylothorax and chylous ascites in a 20-year-old patient who had been diagnosed with disseminated Multi-Drug Resistant (MDR) Tuberculosis two years ago. Abdominal distention with horseshoe-shaped dullness was found on examination. Abdominal ultrasound revealed gross ascites and bilateral gross pleural effusion. Pleural fluid analysis was positive for chylomicrons and revealed elevated Protein, Albumin, ADA, and Triglyceride. GeneXpert was negative and no growth was seen on culture. Lymphoscintigraphy showed a normal ascent of radio tracer along bilateral lower limb. Lymphangiogram and thoracic ductogram showed multiple dilated lymphatic ducts in the bilateral internal iliac region with obstruction of lymphatic flow in the iliac group of nodes. Low-fat diet was given. No interventional radiological approach or surgical correction could be done for the patient. He died after one and half years with progressive swelling and emaciation.
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Affiliation(s)
- Parth B. Gada
- Department of General Surgery, Grant Medical College and Sir J.J. Group of Hospitals, Mumbai, India
| | | | - Waqar A. Ansari
- Department of General Surgery, Grant Medical College and Sir J.J. Group of Hospitals, Mumbai, India
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2
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Torres OJM, Valleta NH, Moraes-Junior JMA, Falcão MV, Quariguasi JML, Faria IM. LIPIODOL LYMPHANGIOGRAPHY AND EMBOLIZATION OF CHYLOUS ASCITES AFTER PANCREATODUODENECTOMY. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2022; 35:e1677. [PMID: 36102487 PMCID: PMC9462857 DOI: 10.1590/0102-672020220002e1677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 06/02/2022] [Indexed: 11/22/2022]
Affiliation(s)
- Orlando Jorge Martins Torres
- Hospital São Domingos, Department of Gastrointestinal Surgery – São Luiz (MA), Brazil,Universidade Federal do Maranhão, Department of Gastrointestinal and Transplant Surgery – São Luiz (MA), Brazil
| | | | - José Maria Assunção Moraes-Junior
- Hospital São Domingos, Department of Gastrointestinal Surgery – São Luiz (MA), Brazil,Universidade Federal do Maranhão, Department of Gastrointestinal and Transplant Surgery – São Luiz (MA), Brazil
| | - Milena Vasconcelos Falcão
- Universidade Federal do Maranhão, Department of Gastrointestinal and Transplant Surgery – São Luiz (MA), Brazil
| | | | - Igor Murad Faria
- Hospital São Domingos, Department of Interventional Radiology – São Luiz (MA), Brazil
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Ashoor A, Lissidini G, Datta U, Bertoldi L, Veronesi P, Tan MLH. Chyle Leak After Axillary Node Clearance in Breast Cancer Surgery-A Rare Complication and a Proposed Management Strategy from the British and Italian Experience. Ann Surg Oncol 2022; 29:7992-7999. [PMID: 35849297 DOI: 10.1245/s10434-022-12094-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 06/17/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Chyle leak after axillary surgery is a rare complication that lacks consensus and management guidelines. This study aimed to present the experiences of two centers in chyle leak management after axillary node clearance for breast cancer. Furthermore the authors provide a review of its pathophysiology and clinical diagnostic methods. They compare approaches for management of the axilla with those for other locations. METHODS A multicentre case series descriptive analysis of chyle leak after breast cancer axillary node clearance between 1 January 2013 and 31 May 2020 was performed. RESULTS The center in the United Kingdom and the center in Italy performed 655 and 4969 axillary node clearances, respectively. Four patients experienced chyle leaks. All the leaks had left-sided surgery (3 patients had level 3 clearances with mastectomy and implant-based breast reconstructions; 1 patient had level 2 clearance with therapeutic mammoplasty). All the leaks appeared within 3 days after surgery. Leak duration was between 11 and 29 days. The maximum daily output was 600 mL. All the leaks were treated conservatively with nutritional team support together with close drainage monitoring. The management strategy included a low-fat diet, a high-protein diet, total parenteral nutrition, and medium chain triglyceride supplements, as well as other elements. No negative effects on oncoplastic and reconstructive breast surgery wound-healing and no delays in adjuvant treatment were observed. CONCLUSION The incidence of chyle leak after breast cancer axillary node clearance was 0.07%. Early diagnosis and close monitoring together with conservative management involving nutritional team support can result in successful treatment of chyle leak without negative sequalae of breast cancer oncologic treatment.
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Affiliation(s)
- Arwa Ashoor
- Breast Surgery Department, City Hospital Birmingham, Sandwell and West Birmingham NHS Trust, Birmingham, UK.
| | - Germana Lissidini
- Division of Breast Surgery, IEO, European Institute of Oncology, IRCCS, 20141, Milan, Italy
| | - Uttaran Datta
- Breast Surgery Department, City Hospital Birmingham, Sandwell and West Birmingham NHS Trust, Birmingham, UK
| | - Lorenzo Bertoldi
- Division of Breast Surgery, IEO, European Institute of Oncology, IRCCS, 20141, Milan, Italy
| | - Paolo Veronesi
- Division of Breast Surgery, IEO, European Institute of Oncology, IRCCS, 20141, Milan, Italy.,Department of Oncology and Hemato-Oncology, University of Milan, 20133, Milan, Italy
| | - Melissa Ley-Hui Tan
- Breast Surgery Department, City Hospital Birmingham, Sandwell and West Birmingham NHS Trust, Birmingham, UK
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Ashoor A, Lissidini G, Datta U, Bertoldi L, Veronesi P, Tan MLH. ASO Author Reflections: Chyle Leak after Axillary Node Clearance in Breast Cancer Surgery, a Successful Management Approach from Leading Centres. Ann Surg Oncol 2022; 29:8000. [PMID: 35810225 DOI: 10.1245/s10434-022-12122-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 06/23/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Arwa Ashoor
- Breast Surgery Department, City Hospital Birmingham, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK.
| | - Germana Lissidini
- Breast Surgery Department, European Institute of Oncology, Milan, Italy
| | - Uttaran Datta
- Breast Surgery Department, City Hospital Birmingham, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Lorenzo Bertoldi
- Breast Surgery Department, European Institute of Oncology, Milan, Italy
| | - Paolo Veronesi
- Breast Surgery Department, European Institute of Oncology, Milan, Italy.,Department of Oncology and Hemato-Oncology, Faculty of Medicine, University of Milan, Milan, Italy
| | - Melissa Ley-Hui Tan
- Breast Surgery Department, City Hospital Birmingham, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
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5
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Sommer CM, Pieper CC, Offensperger F, Pan F, Killguss HJ, Köninger J, Loos M, Hackert T, Wortmann M, Do TD, Maleux G, Richter GM, Kauczor HU, Kim J, Hur S. Radiological management of postoperative lymphorrhea. Langenbecks Arch Surg 2021; 406:945-969. [PMID: 33844077 DOI: 10.1007/s00423-021-02094-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 01/17/2021] [Indexed: 12/21/2022]
Abstract
PURPOSE Postoperative lymphorrhea can occur after different surgical procedures and may prolong the hospital stay due to the need for specific treatment. In this work, the therapeutic significance of the radiological management of postoperative lymphorrhea was assessed and illustrated. METHOD A standardized search of the literature was performed in PubMed applying the Medical Subject Headings (MeSH) term "lymphangiography." For the review, the inclusion criterion was "studies with original data on Lipiodol-based Conventional Lymphangiography (CL) with subsequent Percutaneous Lymphatic Intervention (PLI)." Different exclusion criteria were defined (e.g., studies with <15 patients). The collected data comprised of clinical background and indications, procedural aspects and types of PLI, and outcomes. In the form of a pictorial essay, each author illustrated a clinical case with CL and/or PLI. RESULTS Seven studies (corresponding to evidence level 4 [Oxford Centre for Evidence-Based Medicine]) accounting for 196 patients were included in the synthesis and analysis of data. Preceding surgery resulting in postoperative lymphorrhea included different surgical procedures such as extended oncologic surgery or vascular surgery. Central (e.g., chylothorax) and peripheral (e.g., lymphocele) types of postoperative lymphorrhea with a drainage volume of 100-4000 ml/day underwent CL with subsequent PLI. The intervals between "preceding surgery and CL" and between "CL and PLI" were 2-330 days and 0-5 days, respectively. CL was performed before PLI to visualize the lymphatic pathology (e.g., leakage point or inflow lymph ducts), applying fluoroscopy, radiography, and/or computed tomography (CT). In total, seven different types of PLI were identified: (1) thoracic duct (or thoracic inflow lymph duct) embolization, (2) thoracic duct (or thoracic inflow lymph duct) maceration, (3) leakage point direct embolization, (4) inflow lymph node interstitial embolization, (5) inflow lymph duct (other than thoracic) embolization, (6) inflow lymph duct (other than thoracic) maceration, and (7) transvenous retrograde lymph duct embolization. CL-associated and PLI-associated technical success rates were 97-100% and 89-100%, respectively. The clinical success rate of CL and PLI was 73-95%. CL-associated and PLI-associated major complication rates were 0-3% and 0-5%, respectively. The combined CL- and PLI-associated 30-day mortality rate was 0%, and the overall mortality rate was 3% (corresponding to six patients). In the pictorial essay, the spectrum of CL and/or PLI was illustrated. CONCLUSION The radiological management of postoperative lymphorrhea is feasible, safe, and effective. Standardized radiological treatments embedded in an interdisciplinary concept are a step towards improving outcomes.
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Affiliation(s)
- C M Sommer
- Clinic of Diagnostic and Interventional Radiology, Stuttgart Clinics, Kriegsbergstrasse 60, 70174, Stuttgart, Germany.
- Clinic of Diagnostic and Interventional Radiology, Heidelberg University Hospital, INF 420, 69120, Heidelberg, Germany.
- Clinic of Radiology and Neuroradiology, Sana Kliniken Duisburg, Zu den Rehwiesen 9-11, 47055, Duisburg, Germany.
- Department of Nuclear Medicine, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany.
| | - C C Pieper
- Clinic of Diagnostic and Interventional Radiology, Bonn University Hospital, Venusberg-Campus 1, 53105, Bonn, Germany
| | - F Offensperger
- Clinic of Diagnostic and Interventional Radiology, Stuttgart Clinics, Kriegsbergstrasse 60, 70174, Stuttgart, Germany
| | - F Pan
- Clinic of Diagnostic and Interventional Radiology, Heidelberg University Hospital, INF 420, 69120, Heidelberg, Germany
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - H J Killguss
- Clinic of General, Visceral, Thoracic and Transplantation Surgery, Stuttgart Clinics, Kriegsbergstrasse 60, 70174, Stuttgart, Germany
| | - J Köninger
- Clinic of General, Visceral, Thoracic and Transplantation Surgery, Stuttgart Clinics, Kriegsbergstrasse 60, 70174, Stuttgart, Germany
| | - M Loos
- Clinic of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, INF 420, 69120, Heidelberg, Germany
| | - T Hackert
- Clinic of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, INF 420, 69120, Heidelberg, Germany
| | - M Wortmann
- Clinic of Vascular and Endovascular Surgery, Heidelberg University Hospital, INF 420, 69120, Heidelberg, Germany
| | - T D Do
- Clinic of Diagnostic and Interventional Radiology, Heidelberg University Hospital, INF 420, 69120, Heidelberg, Germany
| | - G Maleux
- Department of Radiology, Leuven University Hospitals, Herestraat 49, 3000, Leuven, UZ, Belgium
| | - G M Richter
- Clinic of Diagnostic and Interventional Radiology, Stuttgart Clinics, Kriegsbergstrasse 60, 70174, Stuttgart, Germany
| | - H U Kauczor
- Clinic of Diagnostic and Interventional Radiology, Heidelberg University Hospital, INF 420, 69120, Heidelberg, Germany
| | - J Kim
- Department of Radiology, School of Medicine, Ajou University Hospital, Ajou University, 164 World Cup-ro, Yeongtong-gu, Suwon, 16499, Republic of Korea
| | - S Hur
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Ihwa-dong, Jongno-gu, Seoul, Republic of Korea
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Shimakawa T, Naritaka Y, Miyazawa M, Asaka S, Shimazaki A, Yamaguchi K, Yokomizo H, Yoshimatsu K, Shiozawa S, Katsube T. Lymphangiography Was Useful in Postoperative Intractable Chylothorax after Surgery for Esophageal Cancer: A Case Report. J NIPPON MED SCH 2017; 84:268-273. [PMID: 29279556 DOI: 10.1272/jnms.84.268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Postoperative chylothorax after surgery for esophageal cancer is a rare but serious complication. Treatment initially consists of conservative therapy and, if it fails to provide improvement, it is important to perform surgical treatment without delay. We report on a recent case of intractable chylothorax. This report describes a 72-year-old man with Stage III esophageal squamous cell carcinoma. Subtotal esophagectomy, through a right thoracoabdominal approach with two-field lymphadenectomy, and cervical esophagogastric anastomosis via the retrosternal route, were performed. On the 12th postoperative day, a diagnosis of chylothorax was made. Conservative treatment was initiated, but it proved to be ineffective. Therefore, ligation of the thoracic duct via a thoracotomy was performed, but this was not effective, either. Lymphangiography undertaken to identify the site of the leak in the thoracic duct enabled a diagnosis of an extremely rare double thoracic duct and identification of the site of the leak in the thoracic duct, thereby allowing curative direct ligation of the site. This case underscores the remarkable usefulness of lymphangiography in dealing with intractable postoperative chylothorax.
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Affiliation(s)
- Takeshi Shimakawa
- Department of Surgery, Tokyo Women's Medical University Medical Center East
| | - Yoshihiko Naritaka
- Department of Surgery, Tokyo Women's Medical University Medical Center East
| | - Miki Miyazawa
- Department of Surgery, Tokyo Women's Medical University Medical Center East
| | - Shinichi Asaka
- Department of Surgery, Tokyo Women's Medical University Medical Center East
| | - Asako Shimazaki
- Department of Surgery, Tokyo Women's Medical University Medical Center East
| | - Kentaro Yamaguchi
- Department of Surgery, Tokyo Women's Medical University Medical Center East
| | - Hajime Yokomizo
- Department of Surgery, Tokyo Women's Medical University Medical Center East
| | | | - Shunichi Shiozawa
- Department of Surgery, Tokyo Women's Medical University Medical Center East
| | - Takao Katsube
- Department of Surgery, Tokyo Women's Medical University Medical Center East
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Chang YC, Yen YT, Chang MC, Tseng YL. Localization of thoracic duct using heavily T2W MRI for intractable post-esophagectomy chylothorax-a case report. J Thorac Dis 2017; 9:E109-E114. [PMID: 28275492 DOI: 10.21037/jtd.2017.02.37] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Post-esophagectomy chylothorax is a rare yet serious complication. Herein we report the case of a patient with intractable post-esophagectomy chylothorax despite medical treatment with total parenteral nutrition and octreotide, as well as prophylactic and repeated thoracic duct mass ligation. The patient was eventually treated with localization of thoracic duct using T2-weighted magnetic resonance imaging (T2W MRI), followed by video-assisted thoracoscopic thoracic duct ligation.
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Affiliation(s)
- Yi-Chien Chang
- Division of Thoracic Surgery, Tainan Municipal Hospital, Show Chwan Health Care System, Tainan, Taiwan
| | - Yi-Ting Yen
- Division of Thoracic Surgery, Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Ming-Chung Chang
- Department of Nutrition, College of Medicine and Nursing, Hung Kuang University, Taichung, Taiwan
| | - Yau-Lin Tseng
- Division of Thoracic Surgery, Department of Surgery, National Cheng Kung University Hospital, Tainan, Taiwan
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