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Kaneda K, Miwa T, Okumura T, Numata Y, Fukasawa M, Watanabe T, Hashimoto I, Naruto N, Fujii T. A case of refractory chylothorax due to an unenclosed esophageal hiatus after subtotal esophagectomy treated with lipiodol lymphangiography. Surg Case Rep 2024; 10:216. [PMID: 39256249 PMCID: PMC11387574 DOI: 10.1186/s40792-024-02019-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Accepted: 09/03/2024] [Indexed: 09/12/2024] Open
Abstract
BACKGROUND Chylothorax, a rare but serious complication following esophagectomy, can lead to dehydration, malnutrition, and even mortality. Surgical intervention is considered when conservative treatment is ineffective; however, in some refractory cases, the cause of chylothorax remains unclear. We report a case of refractory chylothorax caused by abdominal chyle leakage into the pleural space via an unenclosed esophageal hiatus. CASE PRESENTATION A 66-year-old man was diagnosed with advanced esophageal squamous cell carcinoma. The patient underwent robot-assisted thoracoscopic subtotal esophagectomy in the prone position with retrosternal gastric tube reconstruction following neoadjuvant chemotherapy. The thoracic duct was ligated and resected because of tumor invasion. Chylothorax and chylous ascites were observed 2 weeks after surgery but did not improve despite conservative management with medications and drainage. Lymphoscintigraphy through the inguinal lymph node showed tracer accumulation in the fluid in both the abdominal and pleural spaces. Lipiodol lymphangiography revealed abdominal lymphoid leakage, but no leakage was detected from the thoracic duct or mediastinum. We considered that the chylothorax was caused by chylous ascites flowing into the pleural space via an unenclosed esophageal hiatus, and we performed surgical intervention. Laparotomy revealed abdominal chyle leakage and a fistula at the esophageal hiatus with the inflow of ascites into the thoracic cavity. Lipiodol lymphangiography was additionally performed for treating abdominal lymphorrhea after surgery, and resulted in the improvement of the chylothorax and ascites. The patient was discharged with no recurrence of chylothorax or chylous ascites. CONCLUSIONS Refractory chylothorax can occur due to chylous ascites flowing into the pleural space via an unenclosed esophageal hiatus. When the site of chylothorax leakage is unclear, the possibility of inflowing chylous ascites via the unenclosed esophageal hiatus should be explored. Esophageal hiatus closure and lipiodol lymphangiography could be effective in treating refractory chylothorax of unknown cause after esophagectomy.
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Affiliation(s)
- Koji Kaneda
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Takeshi Miwa
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Tomoyuki Okumura
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Yoshihisa Numata
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Mina Fukasawa
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Toru Watanabe
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Isaya Hashimoto
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Norihito Naruto
- Department of Radiology, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Tsutomu Fujii
- Department of Surgery and Science, Faculty of Medicine, Academic Assembly, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan.
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Ishii N, Harimoto N, Seki T, Muranushi R, Hagiwara K, Hoshino K, Tsukagoshi M, Watanabe A, Igarashi T, Shibuya K, Araki K, Shirabe K. The impact of lymphangiograpy on chyle leakage treatment duration after pancreatic surgery. Surg Today 2024; 54:651-657. [PMID: 38062229 DOI: 10.1007/s00595-023-02777-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/10/2023] [Indexed: 05/21/2024]
Abstract
PURPOSE Chyle leakage (CL) is a common complication in pancreatic surgery. Lymphangiography is a therapeutic option for CL in cases of conservative treatment failure. This study investigated the effect of lymphangiography on the healing time of CL. METHODS We retrospectively evaluated 283 patients who underwent pancreatic resection between January 2016 and June 2022. The risk factors for CL and the treatment period were evaluated according to whether or not lymphangiography was performed. RESULTS Of the 29 patients (10.2%) that had CL, lymphangiography was performed in 6. Malignant disease, the number of harvested lymph nodes, and drain fluid volume on postoperative day 2 were identified as independent risk factors for CL. Lymphangiography was associated with the cumulative healing rate of CL, and patients who underwent lymphangiography had a significantly shorter treatment period. No lymphangiography-related adverse events were observed. CONCLUSION Lymphangiography is a feasible and safe treatment option for CL. The CL treatment period after pancreatic surgery was significantly shorter in patients who underwent lymphangiography than in those who did not. Our results suggest that lymphangiography may contribute to early improvement of persistent CL.
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Affiliation(s)
- Norihiro Ishii
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showamachi, Maebashi, Gunma, 371-8511, Japan
| | - Norifumi Harimoto
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showamachi, Maebashi, Gunma, 371-8511, Japan.
| | - Takamomi Seki
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showamachi, Maebashi, Gunma, 371-8511, Japan
| | - Ryo Muranushi
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showamachi, Maebashi, Gunma, 371-8511, Japan
| | - Kei Hagiwara
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showamachi, Maebashi, Gunma, 371-8511, Japan
| | - Kouki Hoshino
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showamachi, Maebashi, Gunma, 371-8511, Japan
| | - Mariko Tsukagoshi
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showamachi, Maebashi, Gunma, 371-8511, Japan
| | - Akira Watanabe
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showamachi, Maebashi, Gunma, 371-8511, Japan
| | - Takamichi Igarashi
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showamachi, Maebashi, Gunma, 371-8511, Japan
| | - Kei Shibuya
- Department of Diagnostic Radiology and Nuclear Medicine, Graduate School of Medicine, Gunma University, Gunma, Japan
| | - Kenichiro Araki
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showamachi, Maebashi, Gunma, 371-8511, Japan
| | - Ken Shirabe
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgical Science, Graduate School of Medicine, Gunma University, 3-39-22 Showamachi, Maebashi, Gunma, 371-8511, Japan
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Kaminski LC, Wagenpfeil J, Buermann J, Lutz PL, Luetkens JA, Attenberger UI, Strassburg CP, Kalff JC, Schild HH, Pieper CC. Long-Term Clinical Outcome of Abdomino-Thoracic Lymphatic Interventions of Traumatic and Non-Traumatic Lymphatic Leakage in Adults. Biomedicines 2023; 11:2556. [PMID: 37760997 PMCID: PMC10526188 DOI: 10.3390/biomedicines11092556] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 09/02/2023] [Accepted: 09/13/2023] [Indexed: 09/29/2023] Open
Abstract
The aim of this study was to retrospectively evaluate the long-term results of lymphatic interventions in adults with abdomino-thoracic lymphatic pathologies. Management of abdomino-thoracic chylous effusions in adults undergoing X-ray-lymphangiography with or without lymph-vessel embolization (LVE) from 2010-2018 was reviewed. Patients underwent lymphangiography alone when imaging showed normal findings or lymphatic obstruction without leakage or reflux; otherwise, LVE was performed (leakage, reflux, obstruction with leakage or reflux, lymphatic masses). Technical and clinical success, complications, and long-term outcomes were assessed. 78 patients (47 male, median age 56.3 years) were treated for chylous effusions (60.3% traumatic, 39.7% non-traumatic). Lymphangiography showed leakage (48.7%), reflux (14.1%), obstruction (28.2%), lymphatic masses (5.1%), and normal findings (3.8%). Embolization was performed in 49/78 (62.8%) cases. Overall, treatment was clinically successful in 74.4% (mean follow-up of 28 months), with significant differences between LVE and lymphangiography (91.8% vs. 44.8%; p < 0.001), traumatic and non-traumatic etiologies (89.4% vs. 51.6%; p < 0.001), and leakage locations (p = 0.003). The clinical success of LVE did not differ between leakage etiologies or locations. Complications occurred in 5 patients (2/5 needed treatment). Patients survived significantly longer after successful treatment (2679 vs. 927 days; p = 0.044) and without malignancy (3214 vs. 1550 days; p = 0.043). Lymphatic interventions are safe and effective. LVE should be attempted whenever feasible, as success is high (>90%). Successful intervention has a positive effect on patient survival.
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Affiliation(s)
- Lea C. Kaminski
- Department of Diagnostic and Interventional Radiology, University Hospital of Bonn, 53127 Bonn, Germany (H.H.S.)
| | - Julia Wagenpfeil
- Department of Diagnostic and Interventional Radiology, University Hospital of Bonn, 53127 Bonn, Germany (H.H.S.)
| | - Jens Buermann
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital of Bonn, 53127 Bonn, Germany
| | - Philipp L. Lutz
- Department of Internal Medicine I, University Hospital of Bonn, 53127 Bonn, Germany
| | - Julian A. Luetkens
- Department of Diagnostic and Interventional Radiology, University Hospital of Bonn, 53127 Bonn, Germany (H.H.S.)
| | - Ulrike I. Attenberger
- Department of Diagnostic and Interventional Radiology, University Hospital of Bonn, 53127 Bonn, Germany (H.H.S.)
| | | | - Jörg C. Kalff
- Department of General, Visceral, Thoracic and Vascular Surgery, University Hospital of Bonn, 53127 Bonn, Germany
| | - Hans H. Schild
- Department of Diagnostic and Interventional Radiology, University Hospital of Bonn, 53127 Bonn, Germany (H.H.S.)
| | - Claus C. Pieper
- Department of Diagnostic and Interventional Radiology, University Hospital of Bonn, 53127 Bonn, Germany (H.H.S.)
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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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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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Kato F, Tomita M, Shimmura K, Yoshizumi H, Sato T. Chylothorax following transsternal total thymectomy: a case report. J Surg Case Rep 2023; 2023:rjac631. [PMID: 36636650 PMCID: PMC9831646 DOI: 10.1093/jscr/rjac631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 12/19/2022] [Indexed: 01/11/2023] Open
Abstract
Herein, we report a case of chylothorax following total thymectomy. A 46-year-old woman having an anterior mediastinal tumor underwent a thymectomy via median sternotomy. Seven days after surgery, there was no massive pleural effusion. However, on post-operative day 17, a right massive pleural effusion was detected, and it was diagnosed as chylothorax. She was successfully treated with conservative therapy. Chylothorax following thymectomy is a very rare complication.
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Affiliation(s)
- Fumiaki Kato
- Division of Thoracic Surgery, National Hospital Organization Miyakonojo Medical Center, Miyakonojo, Miyazaki, Japan
| | - Masaki Tomita
- Correspondence address. Division of Thoracic Surgery, National Hospital Organization Miyakonojo Medical Center, Iwaiyoshi, Miyakonojo, Miyazaki 885-0014, Japan. Tel: +81-986234111; E-mail:
| | - Kohei Shimmura
- Division of Radiology, National Hospital Organization Miyakonojo Medical Center, Miyakonojo, Miyazaki, Japan
| | - Hideyuki Yoshizumi
- Division of Internal Medicine, National Hospital Organization Miyakonojo Medical Center, Miyakonojo, Miyazaki, Japan
| | - Toshihiko Sato
- Department of General Thoracic, Breast, and Pediatric Surgery, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
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Horner's Syndrome and Lymphocele Following Thyroid Surgery. J Clin Med 2023; 12:jcm12020474. [PMID: 36675400 PMCID: PMC9865845 DOI: 10.3390/jcm12020474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 12/27/2022] [Accepted: 01/02/2023] [Indexed: 01/09/2023] Open
Abstract
Horner’s syndrome (HS), caused by lesions of the 3-neuron oculosympathetic nerve pathway (ONP), includes the triad: blepharoptosis, miosis and anhidrosis (ipsilateral with ONP damage). Thyroid−related HS represents an unusual entity underling thyroid nodules/goiter/cancer−HS (T-HS), and post-thyroidectomy HS (Tx-HS). We aim to overview Tx-HS. This is a narrative review. We revised PubMed published, full-length, English papers from inception to November 2022. Additionally, we introduced data on post-thyroidectomy lymphocele/chylous leakage (Tx-L), and introduced a new pediatric case with both Tx-HS and Tx-L. Tx-HS: the level of statistical evidence varies from isolated case reports, studies analyzing the large panel of post-thyroidectomy complications reporting HS among the rarest side effects (as opposite to hypocalcemia), or different series of patients with HS due to various disorders, including T-HS/Tx-HS. Tx-HS is related to benign or malignant thyroid conditions, regardless the type of surgery. A pre-operatory rate of T-HS of 0.14%; a post-operatory rate of Tx-HS between 0.03% and 5% (mostly, 0.2%) are identified; a possible higher risk on endoscopic rather than open procedure is described. Incomplete HS forms, and pediatric onset are identified, too; the earliest identification is after 2 h since intervention. A progressive remission is expected in most cases within the first 2−6 months to one year. The management is mostly conservative; some used glucocorticoids and neurotrophic agents. One major pitfall is an additional contributor factor like a local compression due to post-operatory collections (hematoma, cysts, fistula, Tx-L) and their correction improves the outcome. The prognostic probably depends on the severity of cervical sympathetic chain (CSC) lesions: indirect, mild injury due to local compressive masses, intra-operatory damage of CSC like ischemia and stretching of CSC by the retractor associate HS recovery, while CSC section is irreversible. Other iatrogenic contributors to HS are: intra-operatory manipulation of parathyroid glands, thyroid microwave/radiofrequency ablation, and high-intensity focused ultrasound, and percutaneous ethanol injection into thyroid nodules. Tx-L, rarely reported (mostly <0.5%, except for a ratio of 8.3% in one study), correlates with extended surgery, especially lateral/central neck dissection, and the presence of congenitally—aberrant lymphatic duct; it is, also, described after endoscopic procedures and chest-breast approach; it starts within days after surgery. Typically low-fat diet (even fasting and parental nutrition) and tube drainage are useful (as part of conservative management); some used octreotide, local sealing solutions like hypertonic glucose, Viscum album extract, n-Butyl-2-cyanoacrylate. Re-intervention is required in severe cases due to the risk of lymphorrhoea and chylothorax. Early identification of Tx-HS and Tx-L improves the outcome. Some iatrogenic complications are inevitable and a multifactorial model of prediction is still required, also taking into consideration standardized operatory procedures, skillful intra-operatory manipulation, and close post-operatory follow-up of the patients, especially during modern era when thyroid surgery registered a massive progress allowing an early discharge of the patients.
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Aguado A. Role of Interventional Radiology in Pediatric Cancer Patients. Curr Oncol Rep 2022; 24:1731-1740. [PMID: 36057070 DOI: 10.1007/s11912-022-01320-1] [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: 07/09/2022] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW Pediatric interventional radiology (IR) is a growing subspecialty. Here, we review the current role of IR in children with cancer, which uses imaging such as ultrasound, fluoroscopy, and computed tomography to perform minimally invasive procedures. These include biopsy, needle localization, central venous access, thermal ablation, transarterial chemoembolization, transarterial radioembolization with yttrium-90, non-tunneled/tunneled drainage catheter placement, and lymphatic interventions. RECENT FINDINGS Although locoregional therapies for the treatment of cancer in adults are common, they are less common in children, perhaps due to the relative rarity of cancer in children, their typically better performance status, and paucity of comorbidities. Preliminary results from small-scale studies for ablation, transarterial chemoembolization, and transarterial radioembolization with yttrium-90 used in the front-line armamentarium of curative therapy are encouraging. Pediatric IR offers an array of minimally invasive procedures intended to diagnose and treat pediatric cancer patients. However, more research is required to determine the efficacy of locoregional therapy in children and to define the clinical scenarios where benefit is likely to be optimized.
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Affiliation(s)
- Allison Aguado
- Division of Interventional Radiology, Nemours Children's Health, 1600 Rockland Rd., Wilmington, DE, 19803, USA.
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Morisaki T, Morisaki T, Kubo M, Morisaki S, Nakamura Y, Onishi H. Lymph Nodes as Anti-Tumor Immunotherapeutic Tools: Intranodal-Tumor-Specific Antigen-Pulsed Dendritic Cell Vaccine Immunotherapy. Cancers (Basel) 2022; 14:cancers14102438. [PMID: 35626042 PMCID: PMC9140043 DOI: 10.3390/cancers14102438] [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: 02/10/2022] [Revised: 05/06/2022] [Accepted: 05/13/2022] [Indexed: 02/01/2023] Open
Abstract
Simple Summary In the field of cancer therapy, lymph nodes are important not only as targets for metastases resection but also as prudent target organs for cancer immunotherapy. Lymph nodes comprise a complete structure for the accumulation of a large number of T cells and their distribution throughout the body after antigen presentation and activation of dendritic cells. This review highlights current topics on the importance of lymph node structure in antitumor immunotherapy and intranodal-antigen-presenting mature dendritic cell vaccine therapy. We also discuss the rationale behind intranodal injection methods and their applications in neoantigen vaccine therapy, a new cancer immunotherapy. Abstract Hundreds of lymph nodes (LNs) are scattered throughout the body. Although each LN is small, it represents a complete immune organ that contains almost all types of immunocompetent and stromal cells functioning as scaffolds. In this review, we highlight the importance of LNs in cancer immunotherapy. First, we review recent reports on structural and functional properties of LNs as sites for antitumor immunity and discuss their therapeutic utility in tumor immunotherapy. Second, we discuss the rationale and background of ultrasound (US)-guided intranodal injection methods. In addition, we review intranodal administration therapy of tumor-specific-antigen-pulsed matured dendritic cells (DCs), including neoantigen-pulsed vaccines.
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Affiliation(s)
- Takashi Morisaki
- Fukuoka General Cancer Clinic, Fukuoka 812-0018, Japan;
- Correspondence: ; Tel.: +81-922827696; Fax: +81-924056376
| | - Takafumi Morisaki
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan; (T.M.); (M.K.)
| | - Makoto Kubo
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan; (T.M.); (M.K.)
| | - Shinji Morisaki
- Fukuoka General Cancer Clinic, Fukuoka 812-0018, Japan;
- Department of Cancer Therapy and Research, Graduate School of Medical Sciences, Kyushu University; Fukuoka 812-8582, Japan;
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Yusuke Nakamura
- Cancer Precision Medicine Center, Japanese Foundation for Cancer Research, Tokyo 135-8550, Japan;
| | - Hideya Onishi
- Department of Cancer Therapy and Research, Graduate School of Medical Sciences, Kyushu University; Fukuoka 812-8582, Japan;
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Nicol DL. Therapeutic lymphangiography for chylous ascites. BJU Int 2022; 129:559-560. [PMID: 35543402 DOI: 10.1111/bju.15706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/21/2022] [Accepted: 02/02/2022] [Indexed: 11/30/2022]
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Klotz R, Kuner C, Pan F, Feißt M, Hinz U, Ramouz A, Klauss M, Chang DH, Do TD, Probst P, Sommer CM, Kauczor HU, Hackert T, Büchler MW, Loos M. Therapeutic lymphography for persistent chyle leak after pancreatic surgery. HPB (Oxford) 2022; 24:616-623. [PMID: 34702626 DOI: 10.1016/j.hpb.2021.09.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/09/2021] [Accepted: 09/17/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Chyle leak is a common complication following pancreatic surgery. After failure of conservative treatment, lymphography is one of the last therapeutic options. The objective of this study was to evaluate whether lymphography represents an effective treatment for severe chyle leak (International study Group on Pancreatic Surgery, grade C) after pancreatic surgery. METHODS Patients with grade C chyle leak after pancreatic surgery who received transpedal or transnodal therapeutic lymphography between 2010 and 2020 were identified from a prospectively maintained database. Clinical success of the lymphography was evaluated according to percent decrease of drainage output after lymphography (>50% decrease = partial success; >85% decrease = complete success). RESULTS Of the 48 patients undergoing lymphography, 23 had a clinically successful lymphography: 14 (29%) showed partial and 9 (19%) complete success. In 25 cases (52%) lymphography did not lead to a significant reduction of chyle leak. Successful lymphography was associated with earlier drain removal and hospital discharge [complete clinical success: 7.1 days (±4.1); partial clinical success: 12 days (±9.1), clinical failure: 19 days (±19) after lymphography; p = 0.006]. No serious adverse events were observed. CONCLUSION Therapeutic lymphography is a feasible, safe, and effective option for treating grade C chyle leak after pancreatic surgery.
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Affiliation(s)
- Rosa Klotz
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Charlotte Kuner
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Feng Pan
- Clinic for Diagnostic and Interventional Radiology, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Manuel Feißt
- Institute of Medical Biometry and Informatics, Im Neuenheimer Feld 130.3, 69120, Heidelberg, Germany
| | - Ulf Hinz
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Ali Ramouz
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Miriam Klauss
- Clinic for Diagnostic and Interventional Radiology, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - De-Hua Chang
- Clinic for Diagnostic and Interventional Radiology, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Thuy D Do
- Clinic for Diagnostic and Interventional Radiology, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Pascal Probst
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Christof M Sommer
- Clinic for Diagnostic and Interventional Radiology, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; Clinic of Radiology and Neuroradiology, Sana Kliniken Duisburg, Zu den Rehwiesen 9-11, 47055 Duisburg, Germany
| | - Hans-Ulrich Kauczor
- Clinic for Diagnostic and Interventional Radiology, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany.
| | - Martin Loos
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
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Muzzolini M, Araujo RLC, Kingham TP, Peschaud F, Paye F, Lupinacci RM. Incidence and risk factors for Chyle leak after pancreatic surgery for cancer: A comprehensive systematic review. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:707-717. [PMID: 34887165 PMCID: PMC8995357 DOI: 10.1016/j.ejso.2021.11.136] [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: 08/11/2021] [Revised: 10/25/2021] [Accepted: 11/29/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Chyle leak (CL) is a clinically relevant complication after pancreatectomy. Its incidence and the associated risk factors are ill defined, and various treatments options have been described. There is no consensus, however, regarding optimal management. The present study aims to systematically review the literature on CL after pancreatectomy. METHODS A systematic review from PubMed, Scopus and Embase database was performed. Studies using a clear definition for CL and published from January 2000 to January 2021 were included. The PRISMA guidelines were followed during all stages of this systematic review. The MINORS score was used to assess methodological quality. RESULTS Literature search found 361 reports, 99 of which were duplicates. The titles and abstracts of 262 articles were finally screened. The references from the remaining 181 articles were manually assessed. After the exclusions, 43 articles were thoroughly assessed. A total of 23 articles were ultimately included for this review. The number of patients varied from 54 to 3532. Incidence of post pancreatectomy CL varied from 1.3% to 22.1%. Main risk factors were the extent of the surgery and early oral or enteral feeding. CL dried up spontaneously or after conservative management within 14 days in 53% to 100% of the cases. CONCLUSIONS The extent of surgery is the most common predictor of risk of CL. Conservative treatment has been shown to be effective in most cases and can be considered the treatment of choice. We propose a management algorithm based on the current available evidence.
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Affiliation(s)
- Milena Muzzolini
- AP-HP, Department of Digestive and Oncologic Surgery, Ambroise Paré Hospital, 9 Avenue Charles de Gaulle, 92104, Boulogne-Billancourt, France
| | - Raphael L C Araujo
- Department of Surgery, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - T Peter Kingham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Frédérique Peschaud
- AP-HP, Department of Digestive and Oncologic Surgery, Ambroise Paré Hospital, 9 Avenue Charles de Gaulle, 92104, Boulogne-Billancourt, France; Versailles St-Quentin-en-Yvelines/Paris Saclay University, UFR des Sciences de la Santé Simone Veil, 78180, Montigny-le-Bretonneux, France
| | - François Paye
- Department of Surgery, Saint Antoine Hospital, 184 Rue du Faubourg Saint Antoine, 75012, Paris, France; Sorbonne Université, 75013, 91-105, Bd de l'Hôpital, Paris, France
| | - Renato M Lupinacci
- AP-HP, Department of Digestive and Oncologic Surgery, Ambroise Paré Hospital, 9 Avenue Charles de Gaulle, 92104, Boulogne-Billancourt, France; Versailles St-Quentin-en-Yvelines/Paris Saclay University, UFR des Sciences de la Santé Simone Veil, 78180, Montigny-le-Bretonneux, France.
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Rabinowitz D, Dysart K, Itkin M. Neonatal lymphatic flow disorders: central lymphatic flow disorder and isolated chylothorax, diagnosis and treatment using novel lymphatic imaging and interventions technique. Curr Opin Pediatr 2022; 34:191-196. [PMID: 35102115 DOI: 10.1097/mop.0000000000001109] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Neonatal lymphatic disorders (NLDs) are conditions that are relatively rare and difficult to treat. The recent development of lymphatic imaging, such as Dynamic Contrast-Enhanced MR Lymphangiography and Intranodal Lymphangiography has led to a new, better understanding of the anatomical substrate and pathophysiological mechanisms of the diseases. Consequently, this has allowed the development of new targeted therapeutic interventions as well as prognostication for this population with lymphatic flow disorders. RECENT FINDINGS The underlying causes of all NLD is an obstruction or altered flow of the central lymphatic flow. Two types of NLD have been described: isolated neonatal chylothorax and central lymphatic flow disorder (CLFD). Isolated neonatal chylothorax can be treated successfully with oil-based contrast (lipiodol) embolization. CLFD secondary to obstruction of the thoraco-venous junction can be successfully treated with surgical thoracic duct-venous anastomosis. CLFD caused by elevated central pressure and/or thoracic duct dysplasia can be treated medically, including with new systemic therapies such as mammalian target of rapamycin inhibitors. SUMMARY New diagnostic and interventional tools have recently allowed for classification, prognostication, and targeted interventions for neonatal patients with lymphatic flow disorders. Further research will build on these discoveries.
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Affiliation(s)
- Deborah Rabinowitz
- Division of Interventional Radiology, Department of Medical Imaging, Nemours Children's Hospital, Delaware, Wilmington, Delaware
- Department of Radiology and Pediatrics, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Kevin Dysart
- Division of Neonatal-Perinatal Medicine, Department of Neonatology, Nemours Children's Hospital, Delaware, Wilmington, Delaware
| | - Maxim Itkin
- Center for Lymphatic Imaging, Penn Medicine, Hospital of the University of Pennsylvania
- Department of Radiology and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Pan F, Richter GM, Do TD, Kauczor HU, Klotz R, Hackert T, Loos M, Sommer CM. Treatment of Postoperative Lymphatic Leakage Applying Transpedal Lymphangiography - Experience in 355 Consecutive Patients. ROFO-FORTSCHR RONTG 2022; 194:634-643. [PMID: 35081648 DOI: 10.1055/a-1717-2467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE Report of experience from a single institution in treating postoperative lymphatic leakage (PLL) applying conventional transpedal lymphangiography (TL). MATERIALS AND METHODS 453 patients with the initial diagnosis of PLL receiving TL between 03/1993 and 09/2018 were identified in the database. Only patients with confirmed PLL were included in the study. The technical success, safety, and treatment success of TL were evaluated. Independent predictors of TL treatment failure were examined using univariate and multivariate logistic regression analysis. RESULTS 355 consecutive patients (218 men, 137 women; median age of 62 years) who underwent TL for PLL (e. g., chylothorax) after ineffective conservative treatment were included. The median time between causal surgery and TL was 27 days. The median technical success rate of TL was 88.5 %, with a median volume of Lipiodol of 10.0 ml. No complication of TL was recorded. Three groups were defined according to the different clinical courses: group A (41/355, 11.5 %) - TL with technical failure; group B (258/355, 72.7 %) - "therapeutic" TL alone with technical success; and group C (56/355, 15.8 %) - "diagnostic" TL with simultaneously invasive treatment (incl. surgical revision and percutaneous sclerotherapy). Treatment success rate and median time to treatment success were higher in group C than in group B, but without significant differences (64.3 % vs. 61.6 %, p = 0.710; six vs. five days, p = 0.065). Univariate and multivariate logistic regression analyses for group B confirmed drainage volume (> 500 ml/d) and Lipiodol extravasation as independent predictors of TL clinical failure (odds ratios [ORs] of 2.128 and 2.372 [p = 0.005 and p = 0.003, respectively]). CONCLUSION TL is technically reliable, safe, and effective in treating PLL. When conservative treatment fails, TL can be regarded as the next treatment option. KEY POINTS · TL is technically reliable, safe, and effective for treating PLL.. · When conservative treatment fails, TL can be regarded as the next treatment option.. · Drainage volume > 500 ml/day is an independent predictor of clinical failure after TL.. · Lipiodol extravasation is an independent predictor of clinical failure after TL.. CITATION FORMAT · Pan F, Richter GM, Do TD et al. Treatment of Postoperative Lymphatic Leakage Applying Transpedal Lymphangiography - Experience in 355 Consecutive Patients. Fortschr Röntgenstr 2022; DOI: 10.1055/a-1717-2467.
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Affiliation(s)
- Feng Pan
- Clinic of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Germany.,Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Goetz M Richter
- Clinic for Diagnostic and Interventional Radiology, Klinikum Stuttgart Katharinenhospital, Stuttgart, Germany
| | - Thuy Duong Do
- Clinic of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Germany
| | - Hans-Ulrich Kauczor
- Clinic of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Germany
| | - Rosa Klotz
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Germany
| | - Martin Loos
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Germany
| | - Christof M Sommer
- Clinic of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Germany.,Clinic for Diagnostic and Interventional Radiology, Klinikum Stuttgart Katharinenhospital, Stuttgart, Germany.,Department of Nuclear Medicine, University Hospital Heidelberg, Germany.,Clinic of Radiology and Neuroradiology, Sana Clinics Duisburg, Germany
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Lympho-venous anastomosis for the treatment of congenital and acquired lesions of the central lymphatic system: a multidisciplinary treatment approach. EUROPEAN JOURNAL OF PLASTIC SURGERY 2022. [DOI: 10.1007/s00238-021-01926-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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17
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Li L, Wu X, Liu D, Zhang W, Yang L, Pan F. Preliminary Exploration of Transpedal Lymphangiography With High-Dose Ethiodized Oil Application in the Treatment of Postoperative Chylothorax. Front Med (Lausanne) 2021; 8:754781. [PMID: 34977063 PMCID: PMC8714876 DOI: 10.3389/fmed.2021.754781] [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: 08/07/2021] [Accepted: 11/17/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: To preliminarily explore the safety and effectiveness of transpedal lymphangiography (TL) with high-dose ethiodized oil application (>20 ml) in the treatment of high-output postoperative chylothorax.Methods: From 1 July 2020 to 1 July 2021, a total of 7 patients with high-flow postoperative chylothorax (> 1,000 ml/d) were retrospectively reviewed in a single center. Clinical data, including surgery types, technical and treatment success of TL, and adverse events of TL, were collected and analyzed.Results: Seven patients (5 cases of non-small cell lung cancer; 2 cases of esophageal carcinoma) with a median age of 62 years (range: 30–70 years) occurred postoperative chylothorax after tumor resection with mediastinal lymphadenectomy. All patients received conservative treatment including total parenteral nutrition and somatostatin administration for a median of 20 days (range: 15–31 days) that failed to cure the chylothorax, so TL was performed as a salvage. Before TL, the median daily chyle output was 1,500 ml/day (range: 1,100–2,000 ml/day). The technical success rate of TL was 100% (7/7), with the median volume of ethiodized oil of 27.6 ml (range: 21.2–30.0 ml) injected in TL. Ruptured thoracic duct was identified in 5 patients (5/7, 71%) in fluoroscopy and chest CT after TL. The treatment success rate of TL was 86% (6/7). In 6 patients, the thoracic drainage was removed after a median of 7 days (range: 4–13 days) from TL performance. No adverse event of TL was reported.Conclusion: Transpedal lymphangiography with high-dose ethiodized oil application (>20 ml) is a feasible, safe, and effective modality for the treatment of high-flow (> 1,000 ml/day) postoperative chylothorax.
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Affiliation(s)
- Lin Li
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Xin Wu
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Dehan Liu
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Wei Zhang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Lian Yang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Feng Pan
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
- *Correspondence: Feng Pan
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Ahn HY, I H. Non-conservative Management of Chylothorax. J Chest Surg 2021; 54:325-329. [PMID: 34353975 PMCID: PMC8350472 DOI: 10.5090/jcs.21.056] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 07/02/2021] [Indexed: 12/11/2022] Open
Abstract
Chylothorax is caused by lymphatic leakage, which can develop after thoracic surgery and is associated with cancer. Although prospective randomized trials have not been performed, radiological interventions have been performed in several cases with persistent chylothorax, adjunct to 2 weeks of conservative management. The success rate of such interventions is diverse due to anatomical variations, although the results are promising. However, in cases of treatment failure after cycles of interventions, a team approach may be necessary to determine whether surgical management is warranted.
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Affiliation(s)
- Hyo Yeong Ahn
- Department of Thoracic and Cardiovascular Surgery, Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Hoseok I
- Department of Thoracic and Cardiovascular Surgery, Medical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
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Nguyen TK, Luong TH, Nguyen NC, Nguyen HH, Le VK, Trinh HS, Do HD, Le VD, Nguyen NH. Hepatic lymphorrhea following pancreaticoduodenectomy: Preliminary diagnosis and treatment experience from case series of four patients. Ann Med Surg (Lond) 2021; 68:102648. [PMID: 34386232 PMCID: PMC8346360 DOI: 10.1016/j.amsu.2021.102648] [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: 05/23/2021] [Revised: 07/28/2021] [Accepted: 07/29/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction Hepatic lymphorrhea (HL) is an uncommon but potentially life-threatening type of postoperative lymphatic leakage, especially following pancreaticoduodenectomy. Case presentation We herein report a case series of four patients with HL following pancreaticoduodenectomy that presented to the department with a severe clinical picture with the discovery in imaging and intraperitoneal fluid's tests. All our patients presented with a condition of Hepatic lymphorrhea secondary to pancreaticoduodenectomy, which were treated successfully with percutaneous hepatic lymphangiography (HLG). Discussion Hepatic lymphorrhea is an uncommon but potentially life-threatening complication following pancreaticoduodenectomy. Periportal lymphatic vessels, which was often isolated and dissected especially with extended lymphadenectomy, is potentially damaged and caused resistant chylous leakage. Newly techniques are updated and applied in diagnosis and treatment for this difficult-to-treat complication, one of them is percutaneous Hepatic Lymphangiography (HLG). Conclusion HLG with percutaneous access could be effective to identify and terminate the chylous fistula from periportal lymphatic vessels after pancreaticoduodenectomy. Hepatic lymphorrhea is a rare, life-threatening complication of pancreaticoduodenectomy. Periportal lymphatic vessels was a potential location of lymphatic fistula and leakage. This complication can be diagnosed with imaging and intraperitoneal fluid's tests. Hepatic lymphangiography is a minor-invasive therapy to close the lymphatic fistula.
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Affiliation(s)
- Thanh Khiem Nguyen
- Department of Gastrointestinal and Hepato-pancreato-biliary Surgery, Bach Mai Hospital, Hanoi, Viet Nam
| | - Tuan Hiep Luong
- Department of Surgery, Hanoi Medical University, Hanoi, Viet Nam
| | - Ngoc Cuong Nguyen
- Department of Diagnostic and Interventional Radiology, Hospital of Hanoi Medical University, Hanoi, Viet Nam
| | - Ham Hoi Nguyen
- Department of Gastrointestinal and Hepato-pancreato-biliary Surgery, Bach Mai Hospital, Hanoi, Viet Nam
| | - Van Khang Le
- Department of Diagnostic and Interventional Radiology, Bach Mai Hospital, Hanoi, Viet Nam
| | - Hong Son Trinh
- Department of Oncology, Viet Duc University Hospital, Hanoi, Viet Nam
| | - Hai Dang Do
- Department of Surgery, Hanoi Medical University, Hanoi, Viet Nam
| | - Van Duy Le
- Department of Gastrointestinal and Hepato-pancreato-biliary Surgery, Bach Mai Hospital, Hanoi, Viet Nam
| | - Ngoc Hung Nguyen
- Department of Gastrointestinal and Hepato-pancreato-biliary Surgery, Bach Mai Hospital, Hanoi, Viet Nam
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Successful minimal invasive treatment of chylous ascites following pancreaticoduodenectomy: A case report and review of literature. Ann Med Surg (Lond) 2021; 66:102451. [PMID: 34141422 PMCID: PMC8188255 DOI: 10.1016/j.amsu.2021.102451] [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: 04/28/2021] [Revised: 05/18/2021] [Accepted: 05/23/2021] [Indexed: 11/18/2022] Open
Abstract
Introduction Chylous ascites is an uncommon but potentially life-threatening type of postoperative lymphatic leakage, especially following pancreaticoduodenectomy. Case presentation A 59-year-old man underwent pancreaticoduodenectomy (PD) with extended lymphadenectomy and segmental Superior Mesenteric Vein (SMV) resection for SMV-involved pancreatic ductal adenocarcinoma (PDAC). After 20th postoperative day, patient had a drain output with a milky appearance, and with a triglyceride level was 1.6 mmol/L, and the daily output volume was up to 1500 mL per day. She has been performed Conventional Lymphangiography (CLAG) to identify the broken lymphatic vessels as well as close the leakage. Following two consecutive lymphangiography, the source of chylous leakage was identified from hilar lymphatic system, and injection of Aetoxisclerol 2% into lymphatic vessels to close the leakage was performed. Partial parenteral nutrition with limited fat components or medium-chain triglyceride (MCT) was administered, and the amount of ascites decreased particularly. The drain was removed in 20th day after the second CLAG. He had no symptoms of abdominal distention after drain removal and had been discharged after 37 postoperative days (PODs). Discussion Chylous ascites is an uncommon but potentially life-threatening complication following pancreaticoduodenectomy. Portal lymphatic plexus, which was often isolated and dissected especially with extended lymphadenectomy, is potentially damaged and caused resistant chylous leakage. Newly techniques are updated and applied in diagnosis and treatment for this difficult-to-treat complication, one of them is percutaneous transhepatic Conventional Lymphangiography (CLAG). Conclusion CLAG with percutaneous transhepatic access could be effective to identify and terminate the chylous fistula from portal lymphatic plexus after pancreaticoduodenectomy. Chylous ascites is a potentially life-threatening type of lymphatic leakage, following pancreaticoduodenectomy. Portal lymphatic plexus was a potential location of lymphatic fistula due to the regularity of isolation and dissection in pancreaticoduodenectomy with extended lymphadenectomy. Conventional Lymphangiography (CLAG) is an invasion to identify the broken lymphatic vessels and close the leakage. Percutaneous transhepatic CLAG is a technique to puncture the portal lymphatic vessels, which could not be approached with other methods.
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21
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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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22
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Management options for post-esophagectomy chylothorax. Surg Today 2020; 51:678-685. [PMID: 32944822 DOI: 10.1007/s00595-020-02143-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 08/03/2020] [Indexed: 12/15/2022]
Abstract
Chylothorax, although an uncommon complication of esophagectomy, is associated with high morbidity and mortality if not treated promptly. Consequently, knowledge of the thoracic duct (TD) anatomy is essential to prevent its inadvertent injury during surgery. If the TD is injured, early diagnosis and immediate intervention are of paramount importance; however, there is still no universal consensus about the management of post-operative chylothorax. With increasing advances in the spheres of interventional radiology and minimally invasive surgery, there are now several options for managing TD injury. We review this topic in detail to provide a comprehensive and practical overview to help surgeons manage this challenging complication. In particular, we discuss an appropriate step-up approach to prevent the morbidity associated with open surgery as well as the metabolic, nutritional, and immunological disorders that accompany a prolonged illness.
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