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Hur S. Novel Interventional Radiology for the Treatment of Various Lymphatic Leakages: Lymphatic Intervention and Embolization. Vasc Specialist Int 2023; 39:42. [PMID: 38155105 PMCID: PMC10754830 DOI: 10.5758/vsi.230082] [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: 08/22/2023] [Revised: 11/16/2023] [Accepted: 11/27/2023] [Indexed: 12/30/2023] Open
Abstract
Little progress has been made in modern lymphatic medicine since Dr. Kinmonth first described pedal lymphangiography in the 1950s. The clinical need for an effective treatment modality for managing lymphatic leakage greatly increased only after intranodal lymphangiography, which enabled the depiction of the exact location of the leakage. This review introduces five hypotheses that have been proposed while addressing various clinical scenarios involving lymphatic leakage: (1) various embolization techniques can be used to prevent lymphatic leakage; (2) lymph node embolization can treat postoperative pelvic lymphoceles that are refractory to sclerotherapy; (3) the technical success rate of thoracic duct cannulation can be improved by using retrograde thoracic duct access as a bail-out method; (4) non-traumatic chylothorax can be managed by understanding the underlying pathophysiology; and (5) chylous ascites can be managed by understanding the underlying pathophysiology. Five retrospective observational studies, one randomized prospective clinical trial, and two case reports (letters to the editor) were published after the hypotheses were validated. We provide a new systematic approach to lymphatic intervention by describing the process of the current comprehensive research.
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Affiliation(s)
- Saebeom Hur
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
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2
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Pieper CC. Back to the Future II-A Comprehensive Update on the Rapidly Evolving Field of Lymphatic Imaging and Interventions. Invest Radiol 2023; 58:610-640. [PMID: 37058335 DOI: 10.1097/rli.0000000000000966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
ABSTRACT Lymphatic imaging and interventional therapies of disorders affecting the lymphatic vascular system have evolved rapidly in recent years. Although x-ray lymphangiography had been all but replaced by the advent of cross-sectional imaging and the scientific focus shifted to lymph node imaging (eg, for detection of metastatic disease), interest in lymph vessel imaging was rekindled by the introduction of lymphatic interventional treatments in the late 1990s. Although x-ray lymphangiography is still the mainstay imaging technique to guide interventional procedures, several other, often less invasive, techniques have been developed more recently to evaluate the lymphatic vascular system and associated pathologies. Especially the introduction of magnetic resonance, and even more recently computed tomography, lymphangiography with water-soluble iodinated contrast agent has furthered our understanding of complex pathophysiological backgrounds of lymphatic diseases. This has led to an improvement of treatment approaches, especially of nontraumatic disorders caused by lymphatic flow abnormalities including plastic bronchitis, protein-losing enteropathy, and nontraumatic chylolymphatic leakages. The therapeutic armamentarium has also constantly grown and diversified in recent years with the introduction of more complex catheter-based and interstitial embolization techniques, lymph vessel stenting, lymphovenous anastomoses, as well as (targeted) medical treatment options. The aim of this article is to review the relevant spectrum of lymphatic disorders with currently available radiological imaging and interventional techniques, as well as the application of these methods in specific, individual clinical situations.
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Affiliation(s)
- Claus C Pieper
- From the Division for Minimally Invasive Lymphatic Therapy, Department of Diagnostic and Interventional Radiology, University Hospital Bonn; and Center for Rare Congenital Lymphatic Diseases, Center of Rare Diseases Bonn, Bonn, Germany
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3
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Moussa AM, Aly AK, Maybody M, Camacho JC, Ridouani F, Gonzalez-Aguirre AJ, Santos E. A comparison of lymphatic embolization and sclerotherapy in the management of iatrogenic abdominopelvic lymphoceles following oncological surgery. Diagn Interv Radiol 2023; 29:542-547. [PMID: 37171042 PMCID: PMC10679622 DOI: 10.4274/dir.2023.232135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 04/10/2023] [Indexed: 05/13/2023]
Abstract
PURPOSE To compare the safety and efficacy of sclerotherapy and lymphatic embolization (LE) in the treatment of symptomatic iatrogenic lymphoceles following the placement of a percutaneous drainage catheter. METHODS This is a retrospective study of 46 patients who underwent sclerotherapy (17 patients) or LE (29 patients) for the management of symptomatic iatrogenic lymphoceles following percutaneous drain placement between January 2017 and December 2021. The demographic characteristics, time between surgery and lymphatic intervention, clinical presentation, number of procedures, drain output pre- and post-intervention, time from intervention to drain removal, and adverse events were collected and compared for both groups. The clinical success rate, defined as the successful removal of the drain after one procedure, was calculated. Adverse events were reported according to the Society of Interventional Radiology classification. A statistical analysis was conducted using SPSS, and the P value for statistical significance was set at 0.05. The Mann-Whitney U test was used to compare differences in the scale variables, and Fisher's exact test was used to compare the categorical and ordinal variables between both groups. RESULTS A total of 46 patients with 49 lymphoceles met the inclusion criteria of the study. Of these patients, 17 patients (19 lymphoceles) underwent sclerotherapy, and 29 patients (30 lymphoceles) underwent LE as their initial procedures. The clinical success after one procedure was significantly higher (83% vs. 47%, P = 0.011), and the median time between the first intervention and drain removal was significantly shorter in the LE group (median duration of 6 vs. 13 days, P = 0.018) compared with the sclerotherapy group. No statistically significant difference in adverse events was noted between both groups (0.26 vs. 0.10, P = 0.11). CONCLUSION This study found that LE had a higher clinical success rate after the first procedure and a shorter time to drain removal compared with sclerotherapy. There was no difference in the rate of adverse events between both groups. Although LE is a safe and promising technique, a prospective study is needed to further compare the efficacy of both treatment modalities.
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Affiliation(s)
- Amgad M. Moussa
- Department of Radiology, Division of Interventional Radiology,Memorial Sloan Kettering Cancer Center, New York, United States
| | - Ahmed K. Aly
- Department of Radiology, Division of Interventional Radiology,Memorial Sloan Kettering Cancer Center, New York, United States
| | - Majid Maybody
- Department of Radiology, Division of Interventional Radiology,Memorial Sloan Kettering Cancer Center, New York, United States
| | - Juan C. Camacho
- Department of Radiology, Division of Interventional Radiology, Florida Atlantic University, Florida, United States
| | - Fourat Ridouani
- Department of Radiology, Division of Interventional Radiology,Memorial Sloan Kettering Cancer Center, New York, United States
| | - Adrian J. Gonzalez-Aguirre
- Department of Radiology, Division of Interventional Radiology,Memorial Sloan Kettering Cancer Center, New York, United States
| | - Ernesto Santos
- Department of Radiology, Division of Interventional Radiology,Memorial Sloan Kettering Cancer Center, New York, United States
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Benjamin J, O'Leary C, Hur S, Gurevich A, Klein WM, Itkin M. Imaging and Interventions for Lymphatic and Lymphatic-related Disorders. Radiology 2023; 307:e220231. [PMID: 36943078 DOI: 10.1148/radiol.220231] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
The lymphatic system is critical in fluid balance homeostasis. Yet, until recently, lymphatic imaging has been outside of mainstream medicine due to a lack of robust imaging and interventional options. However, during the last 20 years, both clinical lymphatic imaging and interventions have shown dramatic advancement. The key to imaging advancement has been the interstitial delivery of contrast agents through lymphatic-rich tissues. These techniques include intranodal lymphangiography and dynamic contrast-enhanced MR lymphangiography. These methods provide the ability to image and recognize lymphatic anatomy and pathologic conditions. Percutaneous thoracic duct catheterization and embolization became the first widely accepted interventional technique for the management of chyle leaks. Advances in interstitial lymphatic embolization, as well as liver and mesenteric lymphatic interventions, have broadened the scope of possible lymphatic interventions. Also, recent techniques of lymphatic decompression allow for the treatment of a variety of lymphatic disorders. Finally, immunologic studies of central lymphatic fluid reveal the potential of lymphatic interventions on immunity. These advances herald an exciting new chapter for lymphatic imaging and interventions in the coming years.
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Affiliation(s)
- Jamaal Benjamin
- From the Department of Radiology, Division of Interventional Radiology, Perelman School of Medicine, Philadelphia, Pa (J.B., C.O., A.G., M.I.); Center for Lymphatic Disorders, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104 (J.B., C.O., A.G., M.I.); Department of Radiology, Seoul National University, Seoul, Republic of Korea (S.H.); Department of Medical Imaging, Radboudumc, Nijmegen, the Netherlands (W.M.K.); and Department of Radiology, Division of Interventional Radiology University of Texas Southwestern Medical Center, Dallas, TX (J.B.)
| | - Cathal O'Leary
- From the Department of Radiology, Division of Interventional Radiology, Perelman School of Medicine, Philadelphia, Pa (J.B., C.O., A.G., M.I.); Center for Lymphatic Disorders, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104 (J.B., C.O., A.G., M.I.); Department of Radiology, Seoul National University, Seoul, Republic of Korea (S.H.); Department of Medical Imaging, Radboudumc, Nijmegen, the Netherlands (W.M.K.); and Department of Radiology, Division of Interventional Radiology University of Texas Southwestern Medical Center, Dallas, TX (J.B.)
| | - Saebeom Hur
- From the Department of Radiology, Division of Interventional Radiology, Perelman School of Medicine, Philadelphia, Pa (J.B., C.O., A.G., M.I.); Center for Lymphatic Disorders, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104 (J.B., C.O., A.G., M.I.); Department of Radiology, Seoul National University, Seoul, Republic of Korea (S.H.); Department of Medical Imaging, Radboudumc, Nijmegen, the Netherlands (W.M.K.); and Department of Radiology, Division of Interventional Radiology University of Texas Southwestern Medical Center, Dallas, TX (J.B.)
| | - Alexey Gurevich
- From the Department of Radiology, Division of Interventional Radiology, Perelman School of Medicine, Philadelphia, Pa (J.B., C.O., A.G., M.I.); Center for Lymphatic Disorders, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104 (J.B., C.O., A.G., M.I.); Department of Radiology, Seoul National University, Seoul, Republic of Korea (S.H.); Department of Medical Imaging, Radboudumc, Nijmegen, the Netherlands (W.M.K.); and Department of Radiology, Division of Interventional Radiology University of Texas Southwestern Medical Center, Dallas, TX (J.B.)
| | - Willemijn M Klein
- From the Department of Radiology, Division of Interventional Radiology, Perelman School of Medicine, Philadelphia, Pa (J.B., C.O., A.G., M.I.); Center for Lymphatic Disorders, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104 (J.B., C.O., A.G., M.I.); Department of Radiology, Seoul National University, Seoul, Republic of Korea (S.H.); Department of Medical Imaging, Radboudumc, Nijmegen, the Netherlands (W.M.K.); and Department of Radiology, Division of Interventional Radiology University of Texas Southwestern Medical Center, Dallas, TX (J.B.)
| | - Maxim Itkin
- From the Department of Radiology, Division of Interventional Radiology, Perelman School of Medicine, Philadelphia, Pa (J.B., C.O., A.G., M.I.); Center for Lymphatic Disorders, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104 (J.B., C.O., A.G., M.I.); Department of Radiology, Seoul National University, Seoul, Republic of Korea (S.H.); Department of Medical Imaging, Radboudumc, Nijmegen, the Netherlands (W.M.K.); and Department of Radiology, Division of Interventional Radiology University of Texas Southwestern Medical Center, Dallas, TX (J.B.)
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5
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Pan F, Do TD, Schmitt N, Vollherbst DF, Möhlenbruch M, Tinoush P, Brobeil A, Koch V, Richter GM, Pereira PL, Kauczor HU, Sommer CM. Standardizing lymphangiography and lymphatic interventions: a preclinical in vivo approach with detailed procedural steps. CVIR Endovasc 2023; 6:21. [PMID: 36995443 PMCID: PMC10063775 DOI: 10.1186/s42155-023-00364-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 03/13/2023] [Indexed: 03/31/2023] Open
Abstract
PURPOSE To present a preclinical in vivo approach for standardization and training of lymphangiography and lymphatic interventions using a pictorial review. MATERIALS AND METHODS Different lipiodol- and gadolinium-based lymphangiography and lymphatic interventions were performed in twelve (12) landrace pigs with a mean bodyweight of 34 ± 2 kg using various imaging and guiding modalities, similar to the procedures used in humans. The techniques used were explicitly introduced and illustrated. The potential applications of each technique in preclinical training were also discussed. RESULTS By applying visual, ultrasonography, fluoroscopy, CT, cone-beam CT, and/or MRI examination or guidance, a total of eleven techniques were successfully implemented in twelve pigs. The presented techniques include inguinal postoperative lymphatic leakage (PLL) establishment, interstitial dye test, five types of lymphangiography [incl. lipiodol-based translymphatic lymphangiography (TL), lipiodol-based percutaneous intranodal lymphangiography (INL), lipiodol-based laparotomic INL, lipiodol-based interstitial lymphangiography, and interstitial magnetic resonance lymphangiography (MRL)], and four types of percutaneous interventions in the treatment of PLL [incl. thoracic duct embolization (TDE), intranodal embolization (INE), afferent lymphatic vessel sclerotherapy (ALVS), and afferent lymphatic vessel embolization (ALVE)]. CONCLUSION This study provides a valuable resource for inexperienced interventional radiologists to undergo the preclinical training in lymphangiography and lymphatic interventions using healthy pig models.
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Affiliation(s)
- Feng Pan
- Clinic of Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Thuy D Do
- Clinic of Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Niclas Schmitt
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Dominik F Vollherbst
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Markus Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Parham Tinoush
- Clinic of Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Alexander Brobeil
- General Pathology and Pathological Anatomy, Heidelberg University Hospital, Im Neuenheimer Feld 224, 69120, Heidelberg, Germany
- Pathological Institute, NCT Tissue Bank, Heidelberg University Hospital, Im Neuenheimer Feld 224, 69120, Heidelberg, Germany
| | - Vitali Koch
- Institute for Diagnostic and Interventional Radiology, Frankfurt University Hospital, Theodor-Stern-Kai 7, 60590, Frankfurt Am Main, Germany
| | - Götz M Richter
- Clinic of Diagnostic and Interventional Radiology, Klinikum Stuttgart, Stuttgart, Germany
| | - Philippe L Pereira
- Clinic for Radiology, Minimally-Invasive Therapies and Nuclearmedicine, SLK-Kliniken GmbH, Heilbronn, Germany
| | - Hans U Kauczor
- Clinic of Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Christof M Sommer
- Clinic of Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany.
- Clinic of Neuroradiology, Stuttgart Clinics, Katharinenhospital, Kriegsbergstrasse 60, 70174, Stuttgart, Germany.
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Hur S, Kim J, Ratnam L, Itkin M. Lymphatic Intervention, the Frontline of Modern Lymphatic Medicine: Part II. Classification and Treatment of the Lymphatic Disorders. Korean J Radiol 2023; 24:109-132. [PMID: 36725353 PMCID: PMC9892215 DOI: 10.3348/kjr.2022.0689] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 11/03/2022] [Accepted: 11/14/2022] [Indexed: 01/28/2023] Open
Abstract
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.
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Affiliation(s)
- Saebeom Hur
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jinoo Kim
- Department of Radiology, Ajou University Hospital, Suwon, Korea.
| | - Lakshmi Ratnam
- Department of Radiology, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Maxim Itkin
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Seyferth ER, Itkin M, Nadolski GJ. Intranodal Glue Embolization for Postoperative Lymphatic Leaks in the Groin and Pelvis: Comparison with Sclerotherapy. J Vasc Interv Radiol 2022; 34:600-606. [PMID: 36563935 DOI: 10.1016/j.jvir.2022.12.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 12/10/2022] [Accepted: 12/13/2022] [Indexed: 12/25/2022] Open
Abstract
PURPOSE To compare the effectiveness of and adverse events related to intranodal glue embolization (IGE) with those of intracavitary sclerotherapy for the treatment of postoperative groin and pelvic lymphatic leaks. MATERIALS AND METHODS From November 2015 to July 2021, IGE for postoperative pelvic or groin lymphocele or lymphorrhea was performed in 33 patients. From January 2010 to July 2021, 28 patients with postoperative pelvic or groin lymphocele were treated with sclerosis alone. Clinical success was defined as resolution of drainage within 3 weeks of the last intervention performed without recurrence. Patients presenting >1 year after surgery or with <30 days of follow-up were excluded. Patients with lymphorrhea treated with IGE were not statistically compared with those in the sclerosis group because they were not eligible for sclerosis. RESULTS Clinical success was similar between the groups (lymphocele IGE, 15/18, 83.3%, vs sclerosis, 15/23, 65.2% [P = .29]; lymphorrhea IGE, 8/9, 88.9%). The mean number of interventions performed to successfully treat a lymphocele was significantly higher in the sclerosis group (2.5 for sclerosis vs 1.3 for IGE; P = .003; lymphorrhea IGE, 1.0). The mean time to resolution was significantly longer for sclerosis than for IGE (27 vs 7 days; P = .002; 4 days for lymphorrhea IGE). There were no sclerosis-related adverse events and 2 IGE-related adverse events: (a) 1 case of mild lymphedema and (b) 1 case of nontarget embolization resulting in deep vein thrombosis. CONCLUSIONS For treatment of postoperative pelvic and groin lymphoceles, IGE results in faster resolution with fewer interventions compared with sclerosis. IGE is also an effective treatment for postoperative groin lymphorrhea.
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Affiliation(s)
- Elisabeth R Seyferth
- Department of Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Maxim Itkin
- Department of Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gregory J Nadolski
- Department of Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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8
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Kashiwagi E, Ono Y, Yano H, Kosai S, Nagai K, Tanaka K, Higashihara H, Tomiyama N. Percutaneous sclerotherapy with OK-432 for lymphocele after pelvic or para-aortic lymphadenectomy: preliminary results. CVIR Endovasc 2022; 5:55. [PMID: 36264442 PMCID: PMC9584008 DOI: 10.1186/s42155-022-00332-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 10/14/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Lymphoceles can result from disruption of lymphatic vessels after surgical procedures in areas with extensive lymphatic networks. Percutaneous catheter drainage with sclerotherapy can be performed for the treatment of lymphoceles. OK-432 has been used to treat benign cysts, such as lymphangioma and ranula. Therefore, we aimed to report the efficacy and safety of sclerotherapy using OK-432 for postoperative lymphoceles. This study retrospectively analyzed 16 patients who underwent sclerotherapy using OK-432 for postoperative pelvic and para-aortic lymphoceles between April 1, 2012, and March 31, 2020. All the patients underwent percutaneous drainage before sclerotherapy. The indications for sclerotherapy were persistent drainage tube output of greater than 50 mL per day and recurrent lymphoceles after percutaneous drainage. If less than 20 mL per day was drained after sclerotherapy, the tube was removed. When the drainage tube output did not decrease to less than 20 mL per day after the first sclerotherapy, the second sclerotherapy was performed 1 week later. Technical success was defined as the completion of drainage and sclerotherapy procedures. Clinical success was defined as the resolution of the patient's symptoms resulting from lymphoceles without surgical intervention. This study also evaluated the complications of sclerotherapy and their progress after sclerotherapy. RESULTS The mean initial lymphocele size and drainage duration after sclerotherapy were 616 mL and 7.1 days, respectively. The technical success rate and clinical success rate were 100% and 93%, respectively. Thirteen patients were treated by one-session sclerotherapy and three patients were treated by two-session sclerotherapy. Minor complications (fever) were observed in eight patients (50%). A major complication (small bowel fistula) was observed in one patient (7%). No recurrence of lymphoceles was observed during the mean follow-up period of 17 months. CONCLUSION Sclerotherapy with OK-432 is an effective therapeutic method for postoperative lymphoceles. Although most complications are minor, a small bowel fistula was observed in one patient.
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Affiliation(s)
- Eiji Kashiwagi
- grid.136593.b0000 0004 0373 3971Department of Diagnostic and Interventional Radiology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, Japan
| | - Yusuke Ono
- grid.136593.b0000 0004 0373 3971Department of Diagnostic and Interventional Radiology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, Japan
| | - Hiroki Yano
- grid.136593.b0000 0004 0373 3971Department of Diagnostic and Interventional Radiology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, Japan
| | - Shinya Kosai
- grid.136593.b0000 0004 0373 3971Department of Diagnostic and Interventional Radiology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, Japan
| | - Keisuke Nagai
- grid.136593.b0000 0004 0373 3971Department of Diagnostic and Interventional Radiology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, Japan
| | - Kaishu Tanaka
- grid.136593.b0000 0004 0373 3971Department of Diagnostic and Interventional Radiology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, Japan
| | - Hiroki Higashihara
- grid.136593.b0000 0004 0373 3971Department of Diagnostic and Interventional Radiology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, Japan
| | - Noriyuki Tomiyama
- grid.136593.b0000 0004 0373 3971Department of Diagnostic and Interventional Radiology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, Japan
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Souza KPD, Gilberto GM, Mariotti GC, Falsarella PM, Galastri FL, Korkes F, Garcia RG. Transafferent nodal embolization for lymphocele treatment: case report. EINSTEIN-SAO PAULO 2022; 20:eRC6889. [PMID: 35976354 PMCID: PMC9377309 DOI: 10.31744/einstein_journal/2022rc6889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 11/02/2021] [Indexed: 11/05/2022] Open
Abstract
Lymphoceles are collections of lymphatic fluid, mainly caused by major surgical approaches. Most lymphoceles are asymptomatic and limited, but some cases may require a medical management. Among the different techniques, transafferent nodal embolization has emerged as a minimally invasive option, with low morbidity and high resolubility, although it is not widespread in the Brazilian scenario. In this study, we report a case of lymphocele drained percutaneously, with maintenance of high output and requiring transafferent nodal embolization.
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10
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Lymphatic Interventions in the Cancer Patient. Curr Oncol Rep 2022; 24:1351-1361. [PMID: 35639331 DOI: 10.1007/s11912-022-01293-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW The incidence of lymphatic leakage (iatrogenic and non-iatrogenic) is growing in cancer population due to the increased complexity of the surgical procedures and improved overall survival in cancer patients. The purpose of this article is to review the contemporary approach in the field of percutaneous lymphatic embolization in cancer patients with lymphatic leaks. RECENT FINDINGS Since the advent of intranodal lymphangiography in 2011 alongside with the MR and CT lymphangiography, the accuracy of diagnosis of the lymphatic diseases has significantly improved significantly. These advancements have triggered a revival of minimally invasive lymphatic interventions. Lymphatic embolization is expanding from the classic indication, thoracic duct embolization, to other lymphatic disorders (chylous ascites, lymphoceles, liver lymphorrhea, protein-losing enteropathy). The growth of lymphatic research and the standardization of the lymphatic interventions require a multidisciplinary and collaborative approach between physicians and researchers.
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Ozawa M, Yamamoto M, Yamada K, Sugawara T, Zako R, Suzuki A, Hitomi S, Hara T, Yamamoto K, Kondo H, Oba H. Intranodal Embolization for Groin Lymphocele. INTERVENTIONAL RADIOLOGY 2021; 6:117-121. [PMID: 35912276 PMCID: PMC9327352 DOI: 10.22575/interventionalradiology.2020-0034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 06/28/2021] [Indexed: 10/24/2022]
Affiliation(s)
- Mizuki Ozawa
- Department of Radiology, Teikyo University School of Medicine
| | | | - Kentaro Yamada
- Department of Radiology, Teikyo University School of Medicine
| | | | - Ryusei Zako
- Department of Radiology, Teikyo University School of Medicine
| | - Akiyoshi Suzuki
- Department of Radiology, Teikyo University School of Medicine
| | - Suguru Hitomi
- Department of Radiology, Teikyo University School of Medicine
| | - Takuya Hara
- Department of Radiology, Teikyo University School of Medicine
| | - Kotaro Yamamoto
- Department of Radiology, Teikyo University School of Medicine
| | - Hiroshi Kondo
- Department of Radiology, Teikyo University School of Medicine
| | - Hiroshi Oba
- Department of Radiology, Teikyo University School of Medicine
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12
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Moussa AM, Camacho JC, Maybody M, Gonzalez-Aguirre AJ, Ridouani F, Kim D, Laudone VP, Santos E. Percutaneous Lymphatic Embolization as Primary Management of Pelvic and Retroperitoneal Iatrogenic Lymphoceles. J Vasc Interv Radiol 2021; 32:1529-1535. [PMID: 34363941 PMCID: PMC9150443 DOI: 10.1016/j.jvir.2021.07.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 07/23/2021] [Accepted: 07/27/2021] [Indexed: 10/20/2022] Open
Abstract
PURPOSE To evaluate the efficacy of lymphatic embolization (LE) in decreasing catheter output and dwell time in iatrogenic lymphoceles after percutaneous catheter drainage. MATERIALS AND METHODS Retrospective review of patients who underwent intranodal lymphangiography (INL) with or without LE for management of iatrogenic lymphoceles between January 2017 and November 2020 was performed. Twenty consecutive patients (16 men and 4 women; median age, 60.5 years) underwent a total of 22 INLs and 18 LEs for 15 pelvic and 5 retroperitoneal lymphoceles. Lymphatic leaks were identified in 19/22 (86.4%) of the INLs. Three patients underwent INL only because a leak was not identified or was identified into an asymptomatic lymphocele. One patient underwent repeat INL and LE after persistent high catheter output, and 1 patient underwent repeat INL with LE after the initial INL did not identify a leak. Catheter output was assessed until catheter removal, and changes in output before and after the procedure were reported. The patients were followed up for 2-30 months, and procedural complications were reported. RESULTS The median catheter output before the procedure was 210 mL/day (50-1,200 mL/day), which decreased to a median of 20 mL/day (0-520 mL/day) 3 days after the procedure, with a median output decrease of 160 mL (0-900 mL). The median time between INL with LE and catheter removal was 6 days, with no recurrence requiring redrainage. Four patients experienced minor complications of low-grade fever (n = 2) and lower limb edema (n = 2). CONCLUSIONS Lymphangiogram and LE are safe and effective methods for the management of lymphoceles.
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Affiliation(s)
- Amgad M Moussa
- Department of Radiology, Division of Interventional Radiology, Memorial Sloan Kettering Cancer Center, New York, New York.
| | - Juan C Camacho
- Department of Radiology, Division of Interventional Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Majid Maybody
- Department of Radiology, Division of Interventional Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Adrian J Gonzalez-Aguirre
- Department of Radiology, Division of Interventional Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Fourat Ridouani
- Department of Radiology, Division of Interventional Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - DaeHee Kim
- Department of Radiology, Division of Interventional Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Vincent P Laudone
- Department of Surgery, Division of Urology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ernesto Santos
- Department of Radiology, Division of Interventional Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
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Vacuum-Assisted Suction Drainage as a Successful Treatment Option for Postoperative Symptomatic Lymphoceles. ROFO-FORTSCHR RONTG 2021; 194:384-390. [PMID: 34649288 DOI: 10.1055/a-1586-3652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
PURPOSE Lymphoceles often occur within several weeks or even months after surgery. Mostly asymptomatic and therefore undiagnosed, they may be self-healing without any treatment. A small percentage of postoperative lymphoceles are symptomatic with significant pain, infection, or compression of vital structures, thus requiring intervention. Many different treatment options are described in the literature, like drainage with or without sclerotherapy, embolization of lymph vessels, and surgical approaches with laparoscopy or laparotomy. Inspired by reports stating that postoperative suction drainage can prevent the formation of lymphoceles, we developed a simple protocol for vacuum-assisted drainage of symptomatic lymphoceles, which proved to be successful and which we would therefore like to present. MATERIALS AND METHOD Between 2008 and 2020, 35 patients with symptomatic postoperative lymphoceles were treated with vacuum-assisted suction drainage (in total 39 lymphoceles). The surgery that caused lymphocele formation had been performed between 8 and 572 days before. All lymphoceles were diagnosed based on biochemical and cytologic findings in aspirated fluid. The clinical and imaging data were collected and retrospectively analyzed. RESULTS In total, 43 suction drainage catheters were inserted under CT guidance. The technical success rate was 100 %. One patient died of severe preexisting pulmonary embolism, sepsis, and poor conditions (non-procedure-related death). In 94.8 % of symptomatic lymphoceles, healing and total disappearance could be achieved. 4 lymphoceles had a relapse or dislocation of the drainage catheter and needed a second drainage procedure. Two lymphoceles needed further surgery. The complication rate of the procedure was 4.6 % (2/43, minor complications). The median indwelling time of a suction drainage catheter was 8-9 days (range: 1-30 days). CONCLUSION The positive effects of negative pressure therapy in local wound therapy have been investigated for a long time. These positive effects also seem to have an impact on suction drainage of symptomatic lymphoceles with a high cure rate. KEY POINTS · Suction drainage of lymphoceles is an easy and successful method to cure symptomatic lymphoceles at various locations.. · We believe this to be due to the induction of cavity collapse and surface adherence.. · In most cases rapid clinical improvement could be obtained.. CITATION FORMAT · Franke M, Saager C, Kröger J et al. Vacuum-Assisted Suction Drainage as a Successful Treatment Option for Postoperative Symptomatic Lymphoceles. Fortschr Röntgenstr 2021; DOI: 10.1055/a-1586-3652.
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14
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Oda Y, Ohyama N, Hashimura M, Maeda S, Hori S, Fujimoto K. Two cases of pelvic lymphocele after prostatectomy and dissection of obturator lymph nodes successfully treated by interventional radiology. IJU Case Rep 2021; 4:322-325. [PMID: 34505003 PMCID: PMC8414875 DOI: 10.1002/iju5.12337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 05/31/2021] [Accepted: 06/11/2021] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Postoperative refractory lymphocele is often difficult to treat. Recently, interventional radiology with N-butyl-cyanoacrylate has been used by urologists and radiologists to treat lymphocele. This modality is an effective treatment with fewer complications. CASE PRESENTATION Case 1. A 70-year-old man, who underwent retropubic radical prostatectomy and bilateral obturator lymph node dissection, developed postoperative lymphocele. Continuous drainage and multiple rounds of sclerotherapy to reduce lymphocele volume ended in failure. Subsequently, lymphangiography with lipiodol and N-butyl-cyanoacrylate was performed, and the lymphocele volume gradually decreased.Case 2. A 75-year-old man underwent retropubic radical prostatectomy and bilateral obturator lymph node dissection. After surgery, the patient developed a high-output lymphocele. The lymphocele volume decreased following lymphangiography with lipiodol. CONCLUSION Interventional radiology using lipiodol and N-butyl-cyanoacrylate could provide a new standard treatment for refractory lymphocele.
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Affiliation(s)
- Yuki Oda
- Department ofUrologyNara Prefecture Seiwa Medical CenterKitakatsuragiJapan
| | - Nobuo Ohyama
- Department ofUrologyNara Prefecture Seiwa Medical CenterKitakatsuragiJapan
| | - Masahiro Hashimura
- Department ofUrologyNara Prefecture Seiwa Medical CenterKitakatsuragiJapan
| | - Shinsaku Maeda
- Department of UrologyNara Medical UniversityKashiharaJapan
| | - Shunta Hori
- Department ofRadiologyNara Prefecture Seiwa Seiwa Medical CenterKitakatsuragiJapan
| | - Kiyohide Fujimoto
- Department ofRadiologyNara Prefecture Seiwa Seiwa Medical CenterKitakatsuragiJapan
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15
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Jones KA, Sadri S, Ahmad N, Weintraub JR, Reis SP. Thoracic Trauma, Nonaortic Injuries. Semin Intervent Radiol 2021; 38:75-83. [PMID: 33883804 DOI: 10.1055/s-0041-1726005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Trauma is one of the leading causes of death worldwide. Approximately two-thirds of trauma patients have thoracic injuries. Nonvascular injury to the chest is most common; however, while vascular injuries to the chest make up a small minority of injuries in thoracic trauma, these injuries are most likely to require intervention by interventional radiology (IR). IR plays a vital role, with much to offer, in the evaluation and management of patients with both vascular and nonvascular thoracic trauma; in many cases, IR treatments obviate the need for these patients to go to the operating room. This article reviews the role of IR in the treatment of vascular an nonvascular traumatic thoracic injuries.
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Affiliation(s)
- Kai A Jones
- Columbia University Vegelos College of Physicians and Surgeons, New York, New York
| | - Shirin Sadri
- Columbia University Vegelos College of Physicians and Surgeons, New York, New York
| | - Noor Ahmad
- Division of Interventional Radiology, Columbia University Irving Medical Center, New York, New York
| | | | - Stephen P Reis
- Division of Interventional Radiology, Columbia University Irving Medical Center, New York, New York
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16
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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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17
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Hur S, Jun H, Jeong YS. Novel interventional radiological management for lymphatic leakages after gynecologic surgery: lymphangiography and embolization. Gland Surg 2021; 10:1260-1267. [PMID: 33842273 DOI: 10.21037/gs-2019-ursoc-10] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Post-operative lymphatic leakage is a common complication of a radical gynecologic surgery involving aggressive lymph node dissection. Its manifestation varies from asymptomatic lymphoceles to life-threatening chylous ascites. In the past, nuclear medicine lymphoscintigraphy was the sole imaging modality for the confirmation of the leakage, of which application is limited due to its poor spatial resolution. While a conservative treatment with percutaneous drainage was the mainstream treatment method, surgical exploration was the last resort for the recalcitrant leakages. Recently, there have been a series of innovations in the field of interventional radiology, including intranodal Lipiodol® lymphangiography, dynamic magnetic resonance (MR) lymphangiography, lymphatic embolization, and mesenteric lymph node lymphangiography. Intranodal Lipiodol® lymphangiography provides very reliable and secure access to the lymphatic system, while requiring only fundamental skills and equipment available to all interventional radiologists. Besides, Lipiodol® is being received a spotlight for its potential therapeutic effects on refractory lymphatic leakage. Dynamic MR lymphangiography plays a vital role in the diagnosis and management of non-traumatic lymphatic diseases, as well as in the post-operative lymphatic leakage with its superior contrast, spatial and temporal resolution. Lymphatic embolization is a technique of using N-BCA glue, a liquid embolic agent, for lymphatic leakages. It can be further described as lymphopseudoaneurysm (LPA) embolization or lymph node embolization, according to which structure is being embolized. Lymphatic embolization opened a new realm of possibilities in the field of interventional lymphology, resulting in the development of treatment approaches for chylous ascites and lymphoceles. Mesenteric lymph node lymphangiography offers the opacification of the upstream mesenteric chylous lymphatic system and can detect lymphatic leakage from the intestinal trunk or the more proximal parts of the mesenteric lymphatic system. With the advent of these latest interventional radiological techniques, more comprehensive approaches to the management of recalcitrant post-operative lymphatic leakages have been enabled.
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Affiliation(s)
- Saebeom Hur
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
| | - Hoyong Jun
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
| | - Yoon Soo Jeong
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
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18
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Schneider G, Ourfali S, Rouviere O, Pagnoux G, Colombel M. Lymphatic embolization for the management of symptomatic pelvic lymphocele after radical prostatectomy with lymph node dissection: Report of two cases. IJU Case Rep 2021; 4:5-9. [PMID: 33426486 PMCID: PMC7784736 DOI: 10.1002/iju5.12212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/15/2020] [Accepted: 07/20/2020] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Pelvic lymphocele is the most common complication of pelvic lymph node dissection after radical prostatectomy. Management of symptomatic pelvic lymphocele begins with percutaneous drainage, followed by sclerotherapy or surgical marsupialization and more recently, lymphatic embolization. In this article, we show the feasibility and results of two lymphatic embolization after prostatectomy with lymph node dissection. CASE PRESENTATION We decided to perform lymphatic embolization in two patients with persistent symptomatic pelvic lymphocele, after percutaneous drainage. This was done through inguinal lymph node puncture using Lipiodol and N-butyl cyanoacrylate glue injection. Drainage removal was done on the day after the procedure and clinical recovery was maintained at follow-up visits, 3 and 4 months later, in both patients. Computed tomography at 6 and 10 weeks after embolization showed the disappearance of the lymphocele. CONCLUSION Our two case reports support the promising results of lymphatic embolization in this pathology.
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Affiliation(s)
- Gregoire Schneider
- Urologic Surgery and Transplantation DepartmentHôpital Edouard HerriotHospices Civils de LyonLyonFrance
| | - Said Ourfali
- Urologic Surgery and Transplantation DepartmentHôpital Edouard HerriotHospices Civils de LyonLyonFrance
- Université Lyon 1 Faculté de Médecine Lyon EstUniversité de LyonLyonFrance
| | - Olivier Rouviere
- Department of UroradiologyHôpital Edouard HerriotHospices Civils de LyonLyonFrance
- Université Lyon 1 Faculté de Médecine Lyon EstUniversité de LyonLyonFrance
| | - Gaele Pagnoux
- Department of UroradiologyHôpital Edouard HerriotHospices Civils de LyonLyonFrance
| | - Marc Colombel
- Urologic Surgery and Transplantation DepartmentHôpital Edouard HerriotHospices Civils de LyonLyonFrance
- Université Lyon 1 Faculté de Médecine Lyon EstUniversité de LyonLyonFrance
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19
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Treatment of symptomatic postoperative pelvic lymphoceles: A systematic review. Eur J Radiol 2020; 134:109459. [PMID: 33302026 DOI: 10.1016/j.ejrad.2020.109459] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 11/10/2020] [Accepted: 11/30/2020] [Indexed: 01/22/2023]
Abstract
PURPOSE A broad range of therapeutic options exists for symptomatic postoperative lymphoceles. However, no consensus exists on what is the optimal therapy. In this study, we aimed to compare the efficacy of currently available radiologic interventions in terms of number of successful interventions, number of recurrences, and number of complications. METHODS A systematic review was conducted with a pre-defined search strategy for PubMed, EMBASE, and Cochrane databases from inception until September 2019. Quality assessment was performed using the 'Risk Of Bias In Non-randomized Studies - of Interventions' tool. Statistical heterogeneity was assessed using the I2 and χ2 test and a meta-analysis was considered for studies reporting on multiple interventions. RESULTS 37 eligible studies including 732 lymphoceles were identified. Proportions of successful interventions for percutaneous fine needle aspiration, percutaneous catheter drainage, percutaneous catheter drainage with delayed or instantaneous addition of sclerotherapy, and embolization were as follows: 0.341 (95% confidence interval [CI]: 0.185-0.542), 0.612 (95% CI: 0.490-0.722), 0.890 (95% CI: 0.781-0.948), 0.872 (95% CI: 0.710-0.949), 0.922 (95% CI: 0.731-0.981). Random-effects meta-analysis of seven studies revealed a pooled relative risk for percutaneous catheter drainage with delayed addition of sclerotherapy of 1.57 (95% CI: 1.17-2.10) when compared to percutaneous catheter drainage alone. The risk of bias in this study was severe. CONCLUSIONS This systematic review demonstrates that the success rates of percutaneous catheter drainage with sclerotherapy are more favorable when compared to percutaneous catheter drainage alone in the treatment of postoperative pelvic lymphoceles. Overall, percutaneous catheter drainage with delayed addition of sclerotherapy, and embolization showed the best outcomes.
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20
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Pan F, Loos M, Do TD, Richter GM, Kauczor HU, Hackert T, Sommer CM. The roles of iodized oil-based lymphangiography and post-lymphangiographic computed tomography for specific lymphatic intervention planning in patients with postoperative lymphatic fistula: a literature review and case series. CVIR Endovasc 2020; 3:79. [PMID: 33085018 PMCID: PMC7578215 DOI: 10.1186/s42155-020-00146-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 08/03/2020] [Indexed: 01/30/2023] Open
Abstract
In the management of patients with postoperative lymphatic fistula (LF) in different locations, iodized oil-based lymphangiography (LAG) from trans-pedal or intranodal route is an established diagnostic approach with the potential to plan further interventional treatments. However, specific lymphatic interventions are indicated depending on different locations and morphologies of the LF. After a systematic literature review, four types of interventions can be considered, including direct leakage embolization/sclerotherapy (DLE/DLS), percutaneous afferent lymphatic vessel embolization (ALVE), percutaneous afferent lymphatic vessels disruption/sclerotherapy (ALVD/ALVS), and trans-afferent nodal embolization (TNE). In the iodized oil-based LAG, three potential lymphatic targets including confined leakage, definite afferent LVs, and definite closest afferent LNs should be comprehensively assessed. For optimal prospective treatment planning for LF, iodized oil-based post-lymphangiographic computed tomography (post-LAG CT) is a useful complement to the conventional iodized oil-based LAG, which can be performed easily after LAG. This review article summarized the current evidence of the specific lymphatic interventions in patients with postoperative LF and explored the potential benefits of post-LAG CT in the intervention planning from a case series.
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Affiliation(s)
- F Pan
- Clinic for Diagnostic and Interventional Radiology, University Hospital Heidelberg, INF 110, 69120, Heidelberg, Germany.,Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - M Loos
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - T D Do
- Clinic for Diagnostic and Interventional Radiology, University Hospital Heidelberg, INF 110, 69120, Heidelberg, Germany
| | - G M Richter
- Clinic for Diagnostic and Interventional Radiology, Stuttgart Clinics, Katharinenhospital, Kriegsbergstrasse 60, 70174, Stuttgart, Germany
| | - H U Kauczor
- Clinic for Diagnostic and Interventional Radiology, University Hospital Heidelberg, INF 110, 69120, Heidelberg, Germany
| | - T Hackert
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - C M Sommer
- Clinic for Diagnostic and Interventional Radiology, University Hospital Heidelberg, INF 110, 69120, Heidelberg, Germany. .,Clinic for Diagnostic and Interventional Radiology, Stuttgart Clinics, Katharinenhospital, Kriegsbergstrasse 60, 70174, Stuttgart, Germany.
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21
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Woerner A, Shin DS, Chick JFB, Smith CA, Sarthy JF, Monroe EJ. Endolymphatic exclusion for the treatment of pediatric chylous ascites secondary to neuroblastoma resection: report of two cases. Radiol Case Rep 2020; 15:1044-1049. [PMID: 32461775 PMCID: PMC7240057 DOI: 10.1016/j.radcr.2020.04.060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 04/27/2020] [Accepted: 04/27/2020] [Indexed: 11/24/2022] Open
Abstract
Chylous ascites is a rare, but highly morbid complication of oncologic resection, often associated with retroperitoneal lymphadenectomy. Conservative measures with total parenteral nutrition or lipid-reduced formulas constitute the initial mainstay therapy, but not without risks and failures. This report describes 2 endolymphatic treatment strategies for iatrogenic chylous ascites following neuroblastoma resection. Lymphatic leaks were identified using intranodal lymphangiography, targeted with cone-beam computed tomographic guidance, and embolized with n-butyl cyanoacrylate. There were no adverse outcomes, with complete resolution of chylous ascites and a mean follow-up of 26 months.
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Affiliation(s)
- Andrew Woerner
- Interventional Radiology Section, Department of Radiology, University of Washington, 1959 Northeast Pacific Street, Seattle, WA 98195, USA
| | - David S Shin
- Interventional Radiology Section, Department of Radiology, University of Washington, 1959 Northeast Pacific Street, Seattle, WA 98195, USA
| | - Jeffrey Forris Beecham Chick
- Interventional Radiology Section, Department of Radiology, University of Washington, 1959 Northeast Pacific Street, Seattle, WA 98195, USA.,Division of Vascular and Interventional Radiology, Department of Radiology, Seattle Children's Hospital, 4800 Sand Point Way Northeast, Seattle, WA 98105, USA
| | - Caitlin A Smith
- Department of General Surgery, University of Washington and Seattle Children's Hospital, Seattle, WA, USA
| | - Jay F Sarthy
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.,Cancer and Blood Disorders Center, Seattle Children's Hospital, Seattle, WA, USA
| | - Eric J Monroe
- Interventional Radiology Section, Department of Radiology, University of Washington, 1959 Northeast Pacific Street, Seattle, WA 98195, USA.,Division of Vascular and Interventional Radiology, Department of Radiology, Seattle Children's Hospital, 4800 Sand Point Way Northeast, Seattle, WA 98105, USA
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22
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Abstract
Lipiodol is an iodinated poppy seed oil first synthesized in 1901. Originally developed for therapeutic purposes, it has mainly become a diagnostic contrast medium since the 1920s. At the end of the 20th century, Lipiodol underwent a transition back to a therapeutic agent, as exemplified by its increasing use in lymphangiography and lymphatic interventions. Nowadays, indications for lymphangiography include chylothorax, chylous ascites, chyluria, and peripheral lymphatic fistula or lymphoceles. In these indications, Lipiodol alone has a therapeutic effect with clinical success in 51% to 100% of cases. The 2 main access sites to the lymphatic system for lymphangiography are cannulation of lymphatic vessels in the foot (transpedal) and direct puncture of (mainly inguinal) lymph nodes (transnodal). In case of failure of lymphangiography alone to occlude the leaking lymphatic vessel as well as in indications such as protein-losing enteropathy, postoperative hepatic lymphorrhea, or plastic bronchitis, lymphatic vessels can also be embolized directly by injecting a mixture of Lipiodol and surgical glues (most commonly in thoracic duct embolization). The aim of this article is to review the historical role of Lipiodol and the evolution of its clinical application in lymphangiography over time until the current state-of-the-art lymphatic imaging techniques and interventions.
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23
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Majdalany BS, El-Haddad G. Contemporary lymphatic interventions for post-operative lymphatic leaks. Transl Androl Urol 2020; 9:S104-S113. [PMID: 32055491 DOI: 10.21037/tau.2019.08.15] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Post-operative lymphatic injuries are uncommon but increase morbidity and mortality in vulnerable patient populations. Post-surgical lymphatic leaks are most commonly a consequence of radical neck dissection, esophagectomy, and lung cancer resections or retroperitoneal surgeries such as radical nephrectomy and lymphadenectomy. Injury may occur anywhere along the lymphatic chains with most serious leaks occurring along the axial skeleton between the inguinal region and the left venous angle. The resultant clinical manifestations of a lymphatic leak are dependent on the location and severity of the lymphatic injury as well as patient factors. Treatment strategies are tailored toward the causative etiology, symptom severity, and daily leak volume with higher volume leaks warranting a more aggressive approach. Lymphangiography and lymphatic interventions, such as embolization, are increasingly applied for both the diagnosis and as a minimally invasive therapy for lymphatic injuries. Herein, a review of lymphatic anatomy, lymphangiography, and lymphatic interventions for the treatment of post-operative chylothorax, chylous ascites, and lymphocele is presented.
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Affiliation(s)
- Bill S Majdalany
- Division of Interventional Radiology and Image Guided Medicine, Department of Radiology, Emory University Hospital, NE Atlanta, GA, USA
| | - Ghassan El-Haddad
- Department of Diagnostic Imaging and Interventional Radiology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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Cuong NN, Binh NT, Hien PN, Hoang N, Linh LT, Luu DT, Luu VD, Huan PD, Ngoc VTN, Uddin MJ, Nga VT, Chu DT. Interventional Treatment of Lymphatic Leakage Post Appendectomy: Case Report. Open Access Maced J Med Sci 2019; 7:1512-1515. [PMID: 31198465 PMCID: PMC6542381 DOI: 10.3889/oamjms.2019.288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 05/06/2019] [Accepted: 05/07/2019] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND: Postoperative lymphatic complications are not common, and lymphatic leakage complication post appendectomy (LLCPC) is even rarer. However, the number of this operation is high so LLCPC can occur. CASE REPORT: Here, we report a female patient post appendectomy with severe chylous ascites. This patient underwent six operations. A leakage point at the right iliac-fossa, which was embolized successfully after two sessions, was spotted during intranodal lymphangiography. After 6 months, the ascites were significantly reduced while some lymphatic aneurysms still existed in the lumbar-retroperitoneal region. CONCLUSIONS: Basing the knowledge of this clinical case and literature, we have concluded that lymphatic leakage can be diagnosed and embolized by percutaneous intervention.
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Affiliation(s)
- Nguyen Ngoc Cuong
- Radiology Department, Hanoi Medical University Hospital, Hanoi, Vietnam
| | - Nguyen Thai Binh
- Radiology Department, Hanoi Medical University Hospital, Hanoi, Vietnam
| | - Phan Nhan Hien
- Radiology Department, Hanoi Medical University Hospital, Hanoi, Vietnam
| | - Nguyen Hoang
- Department of Surgery B, Hanoi Medical University Hospital, Hanoi, Vietnam
| | - Le Tuan Linh
- Radiology Department, Hanoi Medical University Hospital, Hanoi, Vietnam
| | - Doan Tien Luu
- Radiology Department, Hanoi Medical University Hospital, Hanoi, Vietnam
| | - Vu Dang Luu
- Radiology Department, Bach Mai Hospital, Hanoi, Vietnam
| | - Pham Duc Huan
- Department of Surgery B, Hanoi Medical University Hospital, Hanoi, Vietnam
| | | | - Md Jamal Uddin
- College of Pharmacy, Ewha Womans University, Seoul, South Korea
| | - Vu Thi Nga
- Institute for Research and Development, Duy Tan University, Danang, Vietnam
| | - Dinh-Toi Chu
- Faculty of Biology, Hanoi National University of Education, Hanoi, Vietnam
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Kim SW, Hur S, Kim SY, Cho JY, Kwak C, Kim HS, Ha J, Min SK, Lee M, Kim HC, Jae HJ, Chung JW. The Efficacy of Lymph Node Embolization Using N-Butyl Cyanoacrylate Compared to Ethanol Sclerotherapy in the Management of Symptomatic Lymphorrhea after Pelvic Surgery. J Vasc Interv Radiol 2019; 30:195-202.e1. [PMID: 30717950 DOI: 10.1016/j.jvir.2018.09.038] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 09/06/2018] [Accepted: 09/29/2018] [Indexed: 11/18/2022] Open
Abstract
PURPOSE To compare the efficacy of lymph node (LN) embolization using N-butyl cyanoacrylate versus ethanol sclerotherapy in the management of symptomatic postoperative pelvic lymphorrhea. MATERIALS AND METHODS Thirty-three patients with 40 instances of symptomatic postoperative lymphorrhea were treated with either LN embolization or sclerotherapy at Seoul National University Hospital from January 2009 to July 2017 and were retrospectively included (LN embolization group: 24 lymphoceles of 19 patients, mean age of 59.29 years; sclerotherapy group: 16 lymphoceles of 14 patients, mean age of 60.95 years). The types of operations were hysterectomy and bilateral oophorectomy with pelvic lymph node dissection (n = 9), radical prostatectomy (n = 3), and renal transplantation (n = 2) for the sclerotherapy group and radical prostatectomy (n = 10) and hysterectomy and bilateral oophorectomy with pelvic lymph node dissection (n = 9) for the LN embolization group. The 3 most common indications of treatment were lower extremity edema (n = 11), pain (n = 11), and fever (n = 8). The amount of leak before treatment (initial daily drainage) and clinical outcomes, including the clinical success rate in 3 weeks, treatment period, and complication rate were compared between both groups. RESULTS LN embolization showed a higher 3-week clinical success rate than sclerotherapy in a univariate analysis (83.3% and 43.8%, P = .026). There was no statistically significant difference in the treatment period and the complication rate (7.1 days and 12.3 days, P = .098; 8.3% and 25.0%, P = .184). CONCLUSIONS LN embolization is more effective for treating postoperative pelvic lymphorrhea than sclerotherapy with similar safety.
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Affiliation(s)
- Se Woo Kim
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, Korea
| | - Saebeom Hur
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, Korea.
| | - Sang Youn Kim
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, Korea
| | - Jeong Yeon Cho
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, Korea
| | - Cheol Kwak
- Department of Urology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, Korea
| | - Hee Seung Kim
- Department of Obstetrics and Gynecology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, Korea
| | - Jongwon Ha
- Department of Surgery, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, Korea
| | - Seung-Kee Min
- Department of Surgery, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, Korea
| | - Myungsu Lee
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, Korea
| | - Hyo-Cheol Kim
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, Korea
| | - Hwan Jun Jae
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, Korea
| | - Jin Wook Chung
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, Korea
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Spontaneous Chyluria Treated with Retrograde Embolization via Direct Thoracic Duct Access at the Left Neck. J Vasc Interv Radiol 2019; 30:772-774. [DOI: 10.1016/j.jvir.2018.09.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 09/16/2018] [Accepted: 09/16/2018] [Indexed: 11/23/2022] Open
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Chu HH, Shin JH, Kim JW, Noh SY, Yang WJ, Park S. Lymphangiography and Lymphatic Embolization for the Management of Pelvic Lymphocele After Radical Prostatectomy in Prostatic Cancer. Cardiovasc Intervent Radiol 2019; 42:873-879. [PMID: 30919025 DOI: 10.1007/s00270-019-02209-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 03/18/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE To retrospectively evaluate the short-term outcomes of lymphangiography and lymphatic embolization in the treatment of pelvic lymphocele after radical prostatectomy in patients with prostate cancer. MATERIALS AND METHODS The data of nine, consecutive patients who underwent lymphangiography and lymphatic embolization for pelvic lymphocele after radical prostatectomy with pelvic lymph node dissection (PLND) between January 2016 and May 2018, were retrospectively reviewed. Lymphangiography was performed through inguinal lymph nodes in order to identify the lymphatic leakage. When a leakage was found, lymphatic embolization was performed using a directly punctured fine needle at the closest upstream lymph node or lymphopseudoaneurysm and with N-butyl cyanoacrylate glue. RESULTS Lymphangiography demonstrated extravasation and/or lymphopseudoaneurysm in all of these patients. A total of 13 sessions of lymphangiography and lymphatic embolization were performed. The median number of lymphangiography and lymphatic embolizations required to achieve clinical success was one (range, 1-3). Three patients underwent repeated embolization with successful results. The technical and clinical success rates were 100%, respectively. The median time to resolution was 7 days (range, 2-19 days). There was no recurrence and no procedure-related complications during the follow-up period (mean, 26 weeks; range, 8-77 weeks) in all patients. CONCLUSIONS Lymphangiography and lymphatic embolization are safe and effective for the management of pelvic lymphoceles after radical prostatectomy with PLND.
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Affiliation(s)
- Hee Ho Chu
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Ji Hoon Shin
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
| | - Jong Woo Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Seung Yeon Noh
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Woo Jin Yang
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Suyoung Park
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
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Giacalone G, Yamamoto T, Hayashi A, Belva F, Gysen M, Hayashi N, Yamamoto N, Koshima I. Lymphatic supermicrosurgery for the treatment of recurrent lymphocele and severe lymphorrhea. Microsurgery 2019; 39:326-331. [DOI: 10.1002/micr.30435] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 01/22/2019] [Accepted: 01/25/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Guido Giacalone
- Department of Lymphatic SurgeryAZ Sint‐Maarten Hospital Mechelen Belgium
| | - Takumi Yamamoto
- Department of Plastic and Reconstructive SurgeryNational Center for Global Health and Medicine (NCGM) Tokyo Japan
| | | | - Florence Belva
- Department of Lymphatic SurgeryAZ Sint‐Maarten Hospital Mechelen Belgium
| | - Mieke Gysen
- Department of Nuclear MedicineH. Hartziekenhuis Mol Belgium
| | - Nobuko Hayashi
- Department of Plastic SurgeryTaiyo‐kai Social Welfare Awachiiki Iryo Center Chiba Japan
| | - Nana Yamamoto
- Department of Plastic and Reconstructive SurgeryNational Center for Global Health and Medicine (NCGM) Tokyo Japan
| | - Isao Koshima
- International Lymphedema CenterHiroshima University Hospital Hiroshima Japan
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Kariya S, Nakatani M, Ono Y, Maruyama T, Ueno Y, Komemushi A, Tanigawa N. Percutaneous Balloon Plasty for Thoracic Duct Occlusion in a Patient with Chylothorax and Chylous Ascites. Cardiovasc Intervent Radiol 2019; 42:779-783. [PMID: 30617452 DOI: 10.1007/s00270-018-02157-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Accepted: 12/21/2018] [Indexed: 10/27/2022]
Abstract
A patient developed abdominal distension, dyspnea, and nausea due to chylothorax and chylous ascites 1 month after bruising her back. Lymphangiography was unable to identify the site of lymph leakage, and lymphatic duct embolization was impractical. However, lymphangiography showed occlusion of the thoracic duct. Thus, balloon plasty was performed to restore the patency of the thoracic duct, and the chylothorax and chylous ascites improved. Although embolization of the thoracic or lymphatic ducts has been reported as a treatment for lymphorrhea, it is impractical if the lymphatic duct responsible for leakage cannot be identified. In such a case, balloon plasty of the occluded thoracic duct to lower the pressure in the peripheral lymphatic ducts was successfully performed.
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Affiliation(s)
- Shuji Kariya
- Department of Radiology, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka, 573-1010, Japan.
| | - Miyuki Nakatani
- Department of Radiology, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Yasuyuki Ono
- Department of Radiology, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Takuji Maruyama
- Department of Radiology, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Yutaka Ueno
- Department of Radiology, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Atsushi Komemushi
- Department of Radiology, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka, 573-1010, Japan
| | - Noboru Tanigawa
- Department of Radiology, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka, 573-1010, Japan
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30
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Smolock AR, Nadolski G, Itkin M. Intranodal Glue Embolization for the Management of Postsurgical Groin Lymphocele and Lymphorrhea. J Vasc Interv Radiol 2018; 29:1462-1465. [PMID: 30217746 DOI: 10.1016/j.jvir.2018.04.020] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 04/17/2018] [Accepted: 04/17/2018] [Indexed: 11/29/2022] Open
Abstract
This report describes intranodal lymphatic embolization for treatment of groin lymphatic leaks following surgery or percutaneous vascular interventions. In 10 consecutive patients with groin lymphatic leak between 2015 and 2017, lymphangiography with embolization was performed by intranodal injection with dilute N-butyl cyanoacrylate (NBCA). Mean volume of dilute NBCA (1:3 with ethiodized oil) injected was 1 mL. Clinical success rate was 80%. Median time to resolution was 7 days. Intranodal lymphatic embolization for treatment of groin lymphatic leaks is a safe and effective treatment alternative to surgery resulting in a rapid time to resolution.
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Affiliation(s)
- Amanda R Smolock
- Division of Interventional Radiology, Department of Radiology, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104.
| | - Gregory Nadolski
- Division of Interventional Radiology, Department of Radiology, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104
| | - Maxim Itkin
- Division of Interventional Radiology, Department of Radiology, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104
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Hill H, Srinivasa RN, Gemmete JJ, Hage A, Bundy J, Chick JFB. Endolymphatic Ethiodized Oil Intranodal Lymphangiography and Cyanoacrylate Glue Embolization for the Treatment of Postoperative Lymphatic Leak After Robot-Assisted Laparoscopic Pelvic Resection. J Endourol Case Rep 2018; 4:66-71. [PMID: 29789814 PMCID: PMC5961458 DOI: 10.1089/cren.2018.0026] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Purpose: To report the approach, technical success, clinical outcomes, complications, and follow-up of ethiodized oil intranodal lymphangiography with cyanoacrylate glue embolization for the treatment of lymphatic leak after robot-assisted laparoscopic pelvic resection. Materials and Methods: Four men with mean age 68.7 ± 14.3 years were treated with ethiodized oil intranodal lymphangiography with cyanoacrylate embolization for postoperative lymphatic leak. Patients underwent either (1) cystoprostatectomy with ileal conduit and bilateral extensive pelvic lymph node dissection for muscle-invasive urothelial carcinoma and presented with postoperative lymphatic ascites (n = 2) or (2) prostatectomy with bilateral standard pelvic lymph node dissection for prostate carcinoma and presented with postoperative pelvic lymphoceles (n = 2). Intranodal lymphangiography and embolization procedural details, technical success, clinical outcomes, and follow-up were recorded. Results: In four patients, a total of six ethiodized oil intranodal lymphangiograms were performed, two procedures being repeated interventions. Inguinal lymph node catheterization and ethiodized oil lymphangiography was technically effective in all procedures. A mean of 5.2 ± 2.0 mL of ethiodized oil was used for lymphatic opacification. Cyanoacrylate was diluted to 24.2% with ethiodized oil and 0.44 mL of cyanoacrylate was instilled during first time interventions. On repeat procedures, cyanoacrylate was diluted to 51.7%, and 0.52 mL was instilled. The primary clinical success rate was 50% (n = 2/4). Clinical success was achieved in all patients after two interventions (n = 4; 100%). No complications were reported at mean follow-up of 134.7 ± 79.2 days (range: 59–248 days). Conclusion: Ethiodized oil intranodal lymphangiography with direct cyanoacrylate glue embolization is a minimally invasive treatment option for lymphatic leak after pelvic resection.
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Affiliation(s)
- Hannah Hill
- Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Health System, Ann Arbor, Michigan
| | - Ravi N Srinivasa
- Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Health System, Ann Arbor, Michigan
| | - Joseph J Gemmete
- Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Health System, Ann Arbor, Michigan
| | - Anthony Hage
- Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Health System, Ann Arbor, Michigan
| | - Jacob Bundy
- Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Health System, Ann Arbor, Michigan
| | - Jeffrey Forris Beecham Chick
- Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Health System, Ann Arbor, Michigan.,Cardiovascular and Interventional Radiology, Inova Alexandria Hospital, Alexandria, Virginia
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Kayama E, Nishimoto K, Kaneko G, Shirotake S, Hayashi T, Kondo H, Okabe T, Nakazawa K, Oyama M. Embolization Using N-butyl Cyanoacrylate for Postoperative Lymphatic Leakage: A Case Report. Clin Genitourin Cancer 2018; 16:e355-e371. [PMID: 29398386 DOI: 10.1016/j.clgc.2017.12.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 12/16/2017] [Indexed: 11/19/2022]
Affiliation(s)
- Emina Kayama
- Department of Uro-Oncology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Koshiro Nishimoto
- Department of Uro-Oncology, Saitama Medical University International Medical Center, Saitama, Japan.
| | - Gou Kaneko
- Department of Uro-Oncology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Suguru Shirotake
- Department of Uro-Oncology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Taiki Hayashi
- Department of Uro-Oncology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Hideyuki Kondo
- Department of Uro-Oncology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Takashi Okabe
- Department of Uro-Oncology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Ken Nakazawa
- Department of Diagnostic Radiology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Masafumi Oyama
- Department of Uro-Oncology, Saitama Medical University International Medical Center, Saitama, Japan
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Itkin M, Nadolski GJ. Modern Techniques of Lymphangiography and Interventions: Current Status and Future Development. Cardiovasc Intervent Radiol 2017; 41:366-376. [PMID: 29256071 DOI: 10.1007/s00270-017-1863-2] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Accepted: 12/14/2017] [Indexed: 12/28/2022]
Abstract
One of the crucial functions of the lymphatic system is maintenance of fluid balance. Nonetheless, due to lack of clinical imaging and interventional techniques, the lymphatic system has been under the radar of the medical community. The recently developed intranodal lymphangiography and dynamic contrast-enhanced MR lymphangiography provide new insight into lymphatic pathology. Thoracic duct embolization has become the method of choice for the treatment of patients with chylous leaks. Interstitial lymphatic embolization further expanded the lymphatic embolization approaches. Liver lymphatic lymphangiography and embolization allow treatment of postsurgical liver lymphorrhea and protein-losing enteropathy. The potential for further growth of lymphatic interventions is vast and includes liver lymphatic procedures and advanced thoracic duct interventions, such as thoracic duct externalization and stenting. These current and future advances will open up a realm of new treatments and diagnostic opportunities.
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Affiliation(s)
- Maxim Itkin
- HUP/CHOP Center for Lymphatic Imaging and Interventions, Penn Medicine, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA.
| | - Gregory J Nadolski
- HUP/CHOP Center for Lymphatic Imaging and Interventions, Penn Medicine, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
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Itkin M. Magnetic Resonance Lymphangiography and Lymphatic Embolization in the Treatment of Pulmonary Complication of Lymphatic Malformation. Semin Intervent Radiol 2017; 34:294-300. [PMID: 28955119 DOI: 10.1055/s-0037-1604301] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Lymphatic malformations (LMs; especially those involving the central conducting lymphatic channels) are characterized by dysplastic and incompetent lymphatic channels in multiple tissues and organs. The major cause of mortality and morbidity in patients with thoracic LM is deterioration of pulmonary function due to chronic chylous effusions and progressive interstitial lung disease. The etiology of these pulmonary processes is unknown, although lymphatic involvement is certain. Understanding of the changes in the lymphatic anatomy in patients with LM has been hindered by difficulty of imaging of the lymphatic system. Recently developed dynamic contrast-enhanced magnetic resonance lymphangiography (DCMRL) allows dynamic MR imaging of the lymphatic system by injecting gadolinium contrast agent in the groin lymph nodes. Using this technique, pathological lymphatic flow from the central lymphatic system and/or retroperitoneal and mediastinal masses into lung parenchyma ("pulmonary lymphatic perfusion syndrome") has been demonstrated in patients with LM. This abnormal lymphatic perfusion overflows pulmonary parenchyma and results in deterioration of pulmonary function due to interstitial process and/or compression effect of chylous effusions. Percutaneous thoracic duct embolization or lymphatic interstitial embolization of the lymphatic masses results in cessation of the pulmonary lymphatic overflow and significant improvement in pulmonary symptoms in these patients.
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Affiliation(s)
- Maxim Itkin
- Center for Lymphatic Imaging and Interventions, Children's Hospital of Philadelphia/Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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35
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Itkin M. Introduction. Tech Vasc Interv Radiol 2016; 19:245-246. [DOI: 10.1053/j.tvir.2016.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Kraitchman D, Kamel I, Weiss C, Georgiades C. Elucidation of Percutaneously Accessible Lymph Nodes in Swine: A Large Animal Model for Interventional Lymphatic Research. J Vasc Interv Radiol 2016; 28:451-456. [PMID: 27866702 DOI: 10.1016/j.jvir.2016.08.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 08/28/2016] [Accepted: 08/29/2016] [Indexed: 12/27/2022] Open
Abstract
PURPOSE To define percutaneously accessible, anatomically reproducible swine lymph nodes using magnetic resonance imaging, ultrasound, and ethiodized oil (Lipiodol; Guerbet, Bloomington, Indiana) lymphangiography. MATERIALS AND METHODS Five adult female swine (Yorkshire, 50-60 kg) were used. Under general anesthesia, T1-weighted and T2-weighted, coronal and axial images of the entire swine were obtained. The animal's extrathoracic, extraperitoneal soft tissues from the neck to the groins were examined with ultrasound. Lymph nodes ≥ 1 cm were marked before the animal was transferred to the angiography suite. Under ultrasound guidance, the nodes were accessed, and lymphangiograms were obtained. The imaging findings between the 3 modalities were correlated, and the lymph node drainage was mapped. RESULTS Four lymph nodes/lymph node groups were identified that were reproducible in all 5 animals, > 1 cm and percutaneously accessible: submandibular node, superficial cervical lymph node group, subiliac node, and superficial inguinal lymph node group. Drainage of these nodes mirrored human anatomy. The abdominopelvic lymphatics formed a retroperitoneal cisterna chyli and drained cephalad via a thoracic duct. CONCLUSIONS The swine exhibits reproducible lymphatic anatomy with at least 4 percutaneously accessible lymph nodes/lymph node groups. Based on these results, the swine may be a suitable large animal model for research into lymphatic interventions.
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Affiliation(s)
- Dara Kraitchman
- Departments of Radiology, Interventional Radiology Center, Sheikh Zayed Tower, Suite 7203, 1800 Orleans Street, Baltimore, MD 21287
| | - Ihab Kamel
- Departments of Radiology, Interventional Radiology Center, Sheikh Zayed Tower, Suite 7203, 1800 Orleans Street, Baltimore, MD 21287
| | - Clifford Weiss
- Departments of Radiology, Interventional Radiology Center, Sheikh Zayed Tower, Suite 7203, 1800 Orleans Street, Baltimore, MD 21287; Surgery, Johns Hopkins University, Interventional Radiology Center, Sheikh Zayed Tower, Suite 7203, 1800 Orleans Street, Baltimore, MD 21287
| | - Christos Georgiades
- Departments of Radiology, Interventional Radiology Center, Sheikh Zayed Tower, Suite 7203, 1800 Orleans Street, Baltimore, MD 21287; Surgery, Johns Hopkins University, Interventional Radiology Center, Sheikh Zayed Tower, Suite 7203, 1800 Orleans Street, Baltimore, MD 21287.
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Abstract
Chylous ascites occurs as a result of lymphatic leakage, which contains high concentration of triglycerides. The leakage is caused by various benign or malignant etiologies ranging from congenital lymphatic abnormality to trauma. Lymphangiography has been shown to be effective in the diagnosis of lymphatic leakage and has also been reported to have therapeutic outcome. The development of intranodal technique for lymphangiography has recently made the procedure more widespread. As an adjunctive procedure, percutaneous embolization may be performed which involves use of embolic agents such as N-butyl cyanoacrylate and coil to occlude the leak. Embolization in the lymphatic system was first made popular by the introduction of thoracic duct embolization by Cope et al and has recently led to the development of various techniques for percutaneous embolization. This article reviews the options and techniques for percutaneous treatment of lymphatic leaks in patients presenting with chylous ascites.
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Affiliation(s)
- Jinoo Kim
- Department of Radiology, School of Medicine, Ajou University Hospital, Ajou University, Suwon-si, Gyeonggi-do, Republic of Korea.
| | - Je Hwan Won
- Department of Radiology, School of Medicine, Ajou University Hospital, Ajou University, Suwon-si, Gyeonggi-do, Republic of Korea
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Hur S, Shin JH, Lee IJ, Min SK, Min SI, Ahn S, Kim J, Kim SY, Kim M, Lee M, Kim HC, Jae HJ, Chung JW, Kim HB. Early Experience in the Management of Postoperative Lymphatic Leakage Using Lipiodol Lymphangiography and Adjunctive Glue Embolization. J Vasc Interv Radiol 2016; 27:1177-1186.e1. [DOI: 10.1016/j.jvir.2016.05.011] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 04/29/2016] [Accepted: 05/10/2016] [Indexed: 01/07/2023] Open
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40
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Itkin M. Lymphatic Intervention Techniques: Look Beyond Thoracic Duct Embolization. J Vasc Interv Radiol 2016; 27:1187-8. [DOI: 10.1016/j.jvir.2016.05.038] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Accepted: 05/27/2016] [Indexed: 12/12/2022] Open
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