Refractory chylothorax in hepatic cirrhosis: successful treatment by transjugular intrahepatic portosystemic shunt

Hepatic lymphatic vascular system in health and disease

In recent years, significant advances have been made in the study of lymphatic vessels with the identification of their specific markers and the development of research tools that have accelerated our understanding of their role in tissue homeostasis and disease pathogenesis in many organs. Compared to other organs, the lymphatic system in the liver is understudied despite its obvious importance for hepatic physiology and pathophysiology. In this review, we describe fundamental aspects of the hepatic lymphatic system and its role in a range of liver-related pathological conditions such as portal hypertension, ascites formation, malignant tumours, liver transplantation, congenital liver diseases, non-alcoholic fatty liver disease, and hepatic encephalopathy. The article concludes with a discussion regarding the modulation of lymphangiogenesis as a potential therapeutic strategy for liver diseases.

Strategic Approach to Massive Chylous Leakage after Neck Dissection

(1) Background: A high volume of chylous leakage (>1 L/day) is a potentially lethal complication after neck dissection. However, a strategic treatment for when the leakage progresses from high to massive (>4 L/day) is lacking. (2) Methods: The PubMed database was searched for articles on neck dissection-associated chylous leakage. Nine articles that included 14 cases with >1 L/day chylous leakage (CL) were analyzed. (3) Results: Of the nine patients with 1-4 L/day CL, three were successfully managed with conservative treatment, two with thoracic ductal ligation, three with ductal embolization, and one with local repair with a strap muscle flap. Of the remaining five cases with >4 L/day chylous leakage, three were successfully treated with the pectoralis major myocutaneous flap (PMMF) and one was successfully treated with thoracic ductal ligation and one case died. (4) Conclusions: In this review, when leakage was >4 L/day, the aforementioned interventions were ineffective, but applying the PMMF could rescue the intractable complication. We propose a strategic treatment for high (1-4 L/day) and massive (>4 L/day) chylous leakage.

Transjugular intrahepatic portosystemic shunt in cirrhosis: An exhaustive critical update

More than five decades after it was originally conceptualized as rescue therapy for patients with intractable variceal bleeding, the transjugular intrahepatic portosystemic shunt (TIPS) procedure continues to remain a focus of intense clinical and biomedical research. By the impressive reduction in portal pressure achieved by this intervention, coupled with its minimally invasive nature, TIPS has gained increasing acceptance in the treatment of complications of portal hypertension. The early years of TIPS were plagued by poor long-term patency of the stents and increased incidence of hepatic encephalopathy. Moreover, the diversion of portal flow after placement of TIPS often resulted in derangement of hepatic functions, which was occasionally severe. While the incidence of shunt dysfunction has markedly reduced with the advent of covered stents, hepatic encephalopathy and instances of early liver failure continue to remain a significant issue after TIPS. It has emerged over the years that careful selection of patients and diligent post-procedural care is of paramount importance to optimize the outcome after TIPS. The past twenty years have seen multiple studies redefining the role of TIPS in the management of variceal bleeding and refractory ascites while exploring its application in other complications of cirrhosis like hepatic hydrothorax, portal hypertensive gastropathy, ectopic varices, hepatorenal and hepatopulmonary syndromes, non-tumoral portal vein thrombosis and chylous ascites. It has also been utilized to good effect before extrahepatic abdominal surgery to reduce perioperative morbidity and mortality. The current article aims to review the updated literature on the status of TIPS in the management of patients with liver cirrhosis.

Transjugular Intrahepatic Portosystemic Shunt for the Treatment of Chylothorax and Chylous Ascites in Cirrhosis: A Case Report and Systematic Review of the Literature

Cirrhosis-related chylothorax and chylous ascites are rare conditions. The pathophysiologic mechanism of cirrhosis-related chylous fluid collections is believed to be excessive lymph flow resulting from portal hypertension. Transjugular intrahepatic portosystemic shunt (TIPS) creation is a well-established method for reducing portal hypertension. The case of a 61-year-old man with cirrhosis-related chylothorax treated successfully with a TIPS is described. A systematic review of the literature revealed nine additional cases of chylothorax or chylous ascites treated successfully with a TIPS. These cases showed that TIPS creation may be effective and safe for the treatment of chylous fluid collections in patients with cirrhosis.

Transjugular intrahepatic portosystemic shunt in refractory chylothorax due to liver cirrhosis

A pleural effusion containing chylomicrons is termed chylothorax and results from leakage of lymph fluid into the pleural cavity. We report on the case of a 59-year-old woman with severe dyspnea due to a large chylothorax. She was known to have liver cirrhosis but no ascites. There was no history of trauma, cardiac function was normal and thorough diagnostic work-up did not reveal any signs of malignancy. In summary, no other etiology of the chylothorax than portal hypertension could be found. Therapy with diuretics as well as parenteral feeding failed to relieve symptoms. After a transjugular intrahepatic portosystemic shunt (TIPS) had successfully been placed, pleural effusion decreased considerably. Eight months later, TIPS revision had to be performed because of stenosis, resulting in remission from chylothorax. This case shows that even in the absence of ascites, chylothorax might be caused by portal hypertension and that TIPS can be an effective treatment option.

Transjugular intrahepatic portosystemic shunt for treatment of cirrhosis-related chylothorax and chylous ascites: single-institution retrospective experience

PURPOSE

To investigate the efficacy and safety of the use of transjugular intrahepatic portosystemic shunt (TIPS) creation to treat cirrhosis-related chylous collections (chylothorax and chylous ascites).

METHODS

We retrospectively reviewed data from four patients treated for refractory cirrhosis-related chylous collections with TIPS at our institution over an 8 year period.

RESULTS

One patient had chylothorax, and three patients had concomitant chylothorax and chylous ascites. There were no major complications, and the only procedure-related complications occurred in two patients who had mild, treatable hepatic encephalopathy. All patients had improvement as defined by decreased need for thoracentesis or paracentesis, with postprocedure follow-up ranging from 19 to 491 days.

CONCLUSION

TIPS is a safe procedure that is effective in the treatment of cirrhosis-related chylous collections.

Idiopathic chylous ascites treated with total parenteral nutrition and octreotide. A case report and review of the literature

Chylous ascites is the accumulation of lipid-rich lymph in the peritoneal cavity. The usual cause in adults is lymphatic obstruction or leakage caused by malignancy. Non-malignant causes include postoperative trauma, cirrhosis, tuberculosis, pancreatitis and filariasis. A variety of treatment options have been proposed for the management of chylous ascites; however, their effectiveness in idiopathic or primary form is unknown. Here we report a case of chylous acid rapidly resolved with the treatment of fasting, total parenteral nutrition and somatostatin analogue.

Dilated cisternae chyli: a sign of uncompensated cirrhosis at MR imaging

BACKGROUND

In order to retrospectively determine the frequency of dilated cisterna chyli (CC) on MR images in patients with cirrhosis, and to assess its value as a simple diagnostic imaging sign of uncompensated cirrhosis.

METHODS

Study population included 257 patients (149 with pathologically proved cirrhosis and 108 control subjects without the history of chronic liver diseases) who had 1.5 T MR imaging. Cirrhosis patients were divided into compensated and uncompensated groups. Three independent observers qualitatively evaluated the visibility of CC 2 mm or greater in transverse diameter, identified as a tubular structure with fluid signal intensity. CC diameters greater than 6 mm were defined as dilated. Statistical analysis was performed by Student t-test and interobserver agreement via intraclass correlation coefficient.

RESULTS

CCs with diameter 2 mm or more were recorded in 113 of 149 (76%) cirrhotic patients and 15 of 108 (14%) control subjects (P < 0.001). Dilated CCs were significantly more frequent in uncompensated than compensated cirrhotic patients (54% vs 5%, P < 0.001). The sensitivity, specificity, accuracy, and positive predictive value of dilated CC for uncompensated cirrhosis were 54%, 98%, 80%, and 96%, respectively.

CONCLUSIONS

Dilated CC can be used as a simple and specific sign complimentary to other findings of uncompensated cirrhosis.

Cirrhosis related chylous ascites successfully treated with TIPS

We describe a patient with chylous ascites, who was extensively investigated for the cause. No malignant or lymphatic disease could be found, but a liver biopsy revealed liver cirrhosis. The chylous ascites was unsuccessfully treated with a sodium restriction diet, diuretics and a medium chain triglyceride diet. After the placement of a transjugular intrahepatic portosystemic shunt the ascites disappeared.

Transjugular intrahepatic portosystemic shunt creation as treatment for refractory chylous ascites and chylothorax in a patient with cirrhosis

The etiology of chylothorax is usually considered to consist of four major categories: tumors, trauma, idiopathic conditions, and miscellaneous conditions. It appears that chylothorax is a rare and underreported manifestation of cirrhosis resulting from transdiaphragmatic passage of chylous ascites. This condition can be debilitating as a result of respiratory compromise from a large volume of pleural fluid, as well as metabolic derangements, malnutrition, and immunologic impairment from loss of vital lymphatic constituents. Herein the authors present a case of a 46-year-old male patient with cirrhosis and complications of high-volume chylous ascites and chylothorax who was successfully treated with creation of a transjugular intrahepatic portosystemic shunt.

[Surgery for chylothorax]

Chyle is lymph fluid of intestinal origin containing fat digestion products. Chylothorax is produced by leaks from the thoracic duct or from one of its collaterals subsequent to valve incompetence. These leaks may be due to trauma (post-surgical chylothorax, the most frequent) or to spontaneous rupture of a lymph vessel distended by chyle reflux, the thoracic duct itself being pathological. When the thoracic duct is interrupted (obstruction, agenesis), chylothorax may occur from leakage due to reflux within substitution collateral pathways diverting the flow of chyle into the venoux confluents of the neck. Medical treatment is always attempted first: evacuation of chylothorax by drainage and fat-free diet or parenteral nutrition. Recently, treatment with octreotide has been found to be beneficial. Surgery consists in thoracic duct ligation or suture of leaking collaterals. In difficult cases, when the chyle leakage cannot be identified, pleurodesis is the only option.

Hepatic hydrothorax

A hepatic hydrothorax is a pleural effusion that develops in a patient with cirrhosis and portal hypertension in the absence of cardiopulmonary disease. The pleural effusion is derived from ascitic fluid that enters the chest because of the negative pressure within the pleural space via defects in the diaphragm. The peritoneal-to-pleural flow of fluid can be demonstrated by nuclear scanning, even when the ascites is not clinically apparent. The pleural fluid usually has the characteristics of a transudate. However, an occasional patient with hepatic hydrothorax will develop spontaneous bacterial pleuritis manifest by increased pleural fluid neutrophils or a positive bacterial culture and will require antibiotic therapy. Treatment of the hydrothorax is directed at the underlying liver disease but a dyspneic patient can obtain relief from a thoracentesis or paracentesis. When medical therapy fails, liver transplantation is the treatment of choice. Both transjugular intrahepatic portosystemic shunting and thoracoscopic repair of diaphragmatic defects with pleural sclerosis can provide symptomatic relief, but the morbidity and mortality of these procedures are high because of the fragile nature of the patients.