Lymphoscintigraphy with single-photon emission computerized tomography/computed tomography for evaluating lymphatic leakage following pelvic and para-aortic lymphadenectomy

Lymphatic ascites following pelvic and para-aortic lymphadenectomy is a well-known complication. Surgical treatment and interventional radiology are required in a few cases. To determine the appropriate treatment strategy, it is important to preoperatively detect the presence and location of lymphatic leakage. However, the methods have yet to be established. We report a case in which lymphoscintigraphy with single-photon emission computerized tomography/computed tomography (SPECT/CT) was performed to evaluate pelvic lymphorrhea that occurred following total hysterectomy with pelvic and para-aortic lymphadenectomy for stage IIIA uterine sarcoma. Lymphoscintigraphy with SPECT/CT showed leakage of radioisotopes into the pelvic space, and intranodal lymphangiography was performed based on these findings. Following the procedure, the pelvic lymphorrhea improved, and no radioisotope leakage was confirmed by re-evaluation with lymphoscintigraphy with SPECT/CT. Our case indicates that lymphoscintigraphy with SPECT/CT may be useful for detecting the precise site of lymphatic leakage before interventional radiology or surgery.

Back to the Future II-A Comprehensive Update on the Rapidly Evolving Field of Lymphatic Imaging and Interventions

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.

The application of a medium-chain fatty diet and enteral nutrition in post-operative chylous leakage: analysis of 63 patients

Background

Post-operative chylous leakage (CL) is the pathologic leakage of chylomicron fluid after surgery. This retrospective study was performed to evaluate a uniform oral nutrition management strategy on the post-operative CL.

Methods

We retrospectively reviewed patients who developed post-operative CL and received consultation from a clinical nutritionist in seven departments of the Second Affiliated Hospital of Dalian Medical University from May 2020 to April 2022. We designed the oral nutrition intervention program which mainly standardized the type and amount of foods contained in the medium-chain triglyceride (MCT) diet. The influencing factors of curative efficacy were analyzed. Finally, binary logistic regression analysis was conducted to observe the relationship between curative efficacy and potentially predictive variables, including post-operative albumin, post-operative hemoglobin, surgical procedure, and drainage volume at consultation.

Results

Sixty-three patients with post-operative CL were included in this analysis. Of this number, 58 patients were cured successfully without other treatments. Three patients had a significantly prolonged recovery period, and the remaining two cases were treated by reoperation therapy. The leakage volume at the initiation of enteral intervention had no statistically significant difference in seven surgical departments and surgical sites (left, right, median, and bilateral). The length of stay (LOS) of patients with CL after the intervention was not significantly increased in cardiac, hepatobiliary, gastrointestinal, and urological surgeries. Patients with CL had longer LOS than those without CL in gynecology (P=0.044) and thyroid surgery departments (P=0.008). Each unit increase in post-operative hemoglobin would increase the probability of an effective outcome by 8%, which was statistically significant (P = 0.037).

Conclusion

In treating patients with post-operative CL, we recommend the MCT diet and EN as the first option, rather than fasting, parenteral nutrition (PN), or octreotide.

Feasibility study of direct CT lymphangiography in mice: comparison with interstitial CT/MR lymphangiography

OBJECTIVES

To establish a CT lymphangiography method in mice via direct lymph node puncture.

METHODS

We injected healthy mice (n = 8) with 50 µl of water-soluble iodine contrast agent (iomeprol; iodine concentration, 350 mg/mL) subcutaneously into the left-rear foot pad (interstitial injection) and 20 µl of the same contrast agent directly into the popliteal lymph node (direct puncture) 2 days later. Additionally, we performed interstitial MR lymphangiography on eight mice as a control group. We calculated the contrast ratio for each lymph node and visually assessed the depiction of lymph nodes and lymphatic vessels on a three-point scale.

RESULTS

The contrast ratios of 2-min post-injection images of sacral and lumbar-aortic lymph nodes were 20.7 ± 16.6 (average ± standard deviation) and 17.1 ± 12.0 in the direct puncture group, which were significantly higher than those detected in the CT or MR interstitial lymphangiography groups (average, 1.8-3.6; p = 0.008-0.019). The visual assessment scores for sacral lymph nodes, lumbar-aortic lymph nodes, and cisterna chyli were significantly better in the direct puncture group than in the CT interstitial injection group (p = 0.036, 0.009 and 0.001, respectively). The lymphatic vessels between these structures were significantly better scored in direct puncture group than in the CT or MR interstitial lymphangiography groups at 2 min after injection (all p ≤ 0.05).

CONCLUSIONS

In CT lymphangiography in mice, the direct lymph node puncture provides a better delineation of the lymphatic pathways than the CT/MR interstitial injection method.

KEY POINTS

• The contrast ratios of 2-min post-injection images in the direct CT lymphangiography group were significantly higher than those of CT/MR interstitial lymphangiography groups. • The visibility of lymphatic vessels in subjective analysis in the direct CT lymphangiography group was significantly better in the direct puncture group than in the CT/MR interstitial lymphangiography groups. • CT lymphangiography with direct lymph node puncture can provide excellent lymphatic delineation with contrast being maximum at 2 min after injection.

Standardizing lymphangiography and lymphatic interventions: a preclinical in vivo approach with detailed procedural steps

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.

Lymphaticovenular Anastomosis for Lymphorrhea after Expander-based Breast Reconstruction: A Case Report

Refractory axillary lymphorrhea is a postoperative complication of breast cancer with no established standard treatment. Recently, lymphaticovenular anastomosis (LVA) was used to treat not only lymphedema but also lymphorrhea and lymphocele in the inguinal and pelvic regions. However, only a few reports have been published on the treatment of axillary lymphatic leakage with LVA. This report presents a case of successful treatment of refractory axillary lymphorrhea after breast cancer surgery with LVA. A 68-year-old woman underwent nipple-sparing mastectomy for right breast cancer, axillary lymph node dissection, and immediate subpectoral tissue expander placement. Postoperatively, the patient developed refractory lymphorrhea and subsequent seroma around the tissue expander, and underwent postmastectomy radiation therapy and frequent percutaneous aspiration of the seroma. However, lymphatic leakage persisted, and surgical treatment was planned. Preoperative lymphoscintigraphy showed lymphatic outflow from the right axilla to the space around the tissue expander. There was no dermal backflow in the upper extremities. To reduce lymphatic flow into the axilla, LVA was performed at two sites in the right upper arm. The lymphatic vessels used for anastomosis were 0.35 mm and 0.50 mm in diameter, and each was anastomosed to the vein in an end-to-end fashion. The axillary lymphatic leakage stopped shortly after the operation, and there were no postoperative complications. LVA may be a safe and simple option for the treatment of axillary lymphorrhea.

Successful percutaneous transhepatic lymphangiography and embolization for intractable hepatic lymphorrhea after laparoscopic distal gastrectomy: a case report

BACKGROUND

Hepatic lymphorrhea is a rare and serious complication of surgery for digestive tract cancers and is thought to occur as a result of lymph node dissection of the hepatoduodenal ligament. This complication results in the accumulation of lymphatic fluid, which may in turn lead to nutritional disorders, immune deficiency, and circulation insufficiency. However, there is currently no standard strategy for treating this condition.

CASE PRESENTATION

A 49-year-old woman with alcoholic liver damage underwent laparoscopic distal gastrectomy with lymph node dissection for early gastric cancer. Abundant ascites persisted postoperatively, and the fluid was suspected to indicate hepatic lymphorrhea. The patient was re-admitted on postoperative day 26 due to the onset of a brain infarction caused by dehydration. Various conservative treatments for hepatic lymphorrhea were ineffective. She underwent percutaneous transhepatic lymphangiography and embolization on postoperative day 81, with obvious effect. Computed tomography images demonstrated complete disappearance of ascites.

CONCLUSIONS

Postoperative hepatic lymphorrhea is a rare and serious complication of radical surgery for digestive tract cancers. The current case suggests that percutaneous transhepatic lymphangiography and embolization may be a rational treatment option when conservative treatments fail.

Interventional Management of Acquired Lymphatic Disorders

The lymphatic system is a complex network of tissues, vessels, and channels found throughout the body that assists in fluid balance and immunologic function. When the lymphatic system is disrupted related to idiopathic, iatrogenic, or traumatic disorders, lymphatic leaks can result in substantial morbidity and/or mortality. The diagnosis and management of these leaks is challenging. Modern advances in lymphatic imaging and interventional techniques have made radiology critical in the multidisciplinary management of these disorders. The authors provide a review of conventional and clinically relevant variant lymphatic anatomy and recent advances in diagnostic techniques such as MR lymphangiography. A detailed summary of technical factors related to percutaneous lymphangiography and lymphatic intervention is presented, including transpedal and transnodal lymphangiography. Traditional transabdominal access and retrograde access to the central lymph nodes and thoracic duct embolization techniques are outlined. Newer techniques including transhepatic lymphangiography and thoracic duct stent placement are also detailed. For both diagnostic and interventional radiologists, an understanding of lymphatic anatomy and modern diagnostic and interventional techniques is vital to the appropriate treatment of patients with acquired lymphatic disorders. ^©RSNA, 2022.

Intranodal lipiodol injection for the treatment of chyle leak in children - a preliminary experience

OBJECTIVE

To assess the effectiveness of intranodal lymphangiography using ethiodised oil (Lipiodol; Guerbet Japan, Tokyo, Japan) for the treatment of refractory cases of chylothorax and chylous ascites in the paediatric population.

METHODS

Between 2016 and 2020, eight children having chyle leak resistant to conservative management underwent intranodal lymphangiography using lipiodol injection. After ethical approval by the Institutional Review Board, these patients' data were retrospectively analysed. Technical success was defined by opacification of inguinal and retroperitoneal lymphatics while injection on fluoroscopy. Clinical success was defined as progressively decreasing drain output and eventual cessation of output within a week after the procedure. Long-term follow up was done as feasible.

RESULTS

Technical success was achieved in all the patients. Complete cessation of drain output was noted within 1 week of procedure in all patients indicating clinical success. One patient had recurrence of chylous leakage after an interval of 1 month and intranodal lymphangiography was repeated for that patient. The child had technical as well as clinical success after the repeat procedure. Hence a total of 9 procedures were performed in 8 patients.

CONCLUSION

Intranodal lymphangiography may prove to be a valuable minimally invasive therapeutic tool in cases of refractory chylous leakage in paediatric patients with minimal risk of complications.

ADVANCES IN KNOWLEDGE

Intranodal lymphangiography using lipiodol may prove to be a minimally invasive alternative in paediatric patients with refractory lymphatic leaks.

Changes of thoracic duct flow and morphology in an animal model of elevated central venous pressure

Objective: Investigation of lymph fluid dynamics in thoracic duct during central venous pressure elevation.

Background: Lymphatic flow is affected by elevated central venous pressure (CVP) in congestive heart failure. The changes of thoracic duct (TD) lymph flow have not been studied chronically in the setting of elevated CVP. This study is to investigate fluid dynamics and remodeling of the TD in the elevated CVP animal model.

Methods: A flow probe was implanted on the swine TD (n = 6) and tricuspid regurgitation (TR) was created by cutting tricuspid chordae percutaneously. Six swine were used as control group animals. The TD flow was measured for 2 weeks (baseline) before TR and 4 weeks postop-TR surgery. Arterial pressure and CVP were measured. The pressure and flow in the TD were measured percutaneously. Histological and morphological analyses were performed.

Results: TR resulted in an increase in CVP from 4.2 ± 2.6 to 10.1 ± 4.3 mmHg (p < 0.05). The lymph flow in the TD increased from 0.78 ± 1.06 before TR to 8.8 ± 4.8 ml/min (p < 0.05) 2 days post-TR and remained plateau for 4 weeks, i.e., the TD flow remained approximately 8–11 fold its baseline. Compared to the 8.1 ± 3.2 mmHg control group, the TD average pressures at the lymphovenous junction increased to 14.6 ± 5.7 mmHg in the TR group (p < 0.05). The TD diameter and wall thickness increased from 3.35 ± 0.37 mm and 0.06 ± 0.01 mm in control to 4.32 ± 0.57 mm and 0.26 ± 0.02 mm (p < 0.05) in the TR group, respectively.

Conclusion: The elevated CVP results in a significant increase in TD flow and pressure which causes the TD’s outward remodeling and thickening. Our study implicates that the outward remodeling may result in the TD valve incompetence due to failure coaptation of leaflets.

The Acute Complications After Surgery for Penile Carcinoma and Strategies for Their Management: A Systematic Review of the Literature

OBJECTIVES

To investigate the contemporary rates of 30-day complications after surgery for penile cancer and to discuss the currently used preventative and therapeutic practices aimed at mitigation of these postoperative adverse events.

DATA SOURCES

A systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed, and studies reporting on the contemporary rates, nature, or management of acute complications following primary penile surgery or inguinal lymph node dissection for penile cancer were abstracted. Medline (PubMed) and EMBASE libraries were used to retrieve the articles published between January 1984 and December 2021 (n = 170 articles). Ultimately, 38 articles were included. The primary outcome of interest was 30-day (acute) postoperative complications, stratified by those associated with treatment of the primary penile lesion and those with inguinal lymph node dissection. Risk of bias assessment was undertaken. Special attention was paid to studies reporting management strategies for these complications.

CONCLUSION

This comprehensive review revealed that the quality of existing studies reporting on complications is poor and the risk of bias is high. Within these studies, the rates of acute complications following primary penile surgery and inguinal lymph node dissection ranged between 0% and 29.4% and 6% and 90%, respectively. More than 50% of these complications were wound related. Over the past two decades, several studies have reported on improved surgical techniques and protocolized postsurgical care pathways. Although the newer techniques have been associated with improved outcomes, the absolute rates of complications have remained high even in the most contemporary series. Therefore, there is an urgent need for health care providers and stakeholders to reach consensus regarding preoperative workup and medical optimization goals, stage appropriate therapies, and postoperative care pathways, as has been done for other malignancies associated with high morbidity.

IMPLICATIONS FOR NURSING PRACTICE

Penile cancer is a disease of the elderly, and surgical management of the primary lesion or the groins is associated with a high rate of complications. Most complications are wound related. Meticulous surgical technique and careful postoperative monitoring with early intervention are keys to mitigating surgery-related morbidity. However, equally important is dissemination and adoption of these principles by all health care workers universally.

Percutaneous embolization of hepatic lymphorrhea post-hepatectomy

Abdominal effusion due to hepatic lymphorrhea post-hepatectomy is an extremely rare and complex complication in clinical practice. No standard treatment method has been established for this condition to date. We report a case of complicated intra-abdominal lymphatic leakage in a patient following hepatectomy to treat hepatocellular carcinoma. The patient underwent percutaneous embolization of the hilar hepatic lymphatic system, combined with intensive medical treatment. Percutaneous embolization represents a safe and effective method that should be considered as a first-line treatment for this complication.

Insufficient hepatic uptake in pediatric patients on lymphoscintigraphy

BACKGROUND

To demonstrate the association between pediatric outcomes and tracer hepatic uptake as a marker of systemic circulation in lymphoscintigraphy.

METHODS

We included 31 initial lymphoscintigraphic studies. We compared the presence or absence of hepatic uptake between deceased and survived patients in both early and delayed images using Fisher's exact test. Kaplan-Meier survival analysis was performed based on imaging results, and these curves were compared using the log-rank test. The primary endpoint was death and the survival period was defined from the day of examination to the day of the last visit or death.

RESULTS

Of 31 patients, six died. Hepatic uptake was significantly different in both early and delayed images (early images, died [with/without visualization] vs. survived [with/without visualization], 0/6 vs. 13/12, P = 0.028; delayed images, died [with/without visualization] vs. survived [with/without visualization], 2/4 vs. 22/3, P = 0.014) between deceased and survived patients. Survival periods were significantly different between the two groups with and without hepatic uptake in early and delayed images (with/without visualization in early imags = 1,177.1 ± 773.8 days/426.7 ± 419.8 days, P = 0.008 and with/without visualization in delayed images = 821.3 ± 738.0 days/467.4 ± 452.4 days, P = 0.003).

CONCLUSIONS

Visualization of hepatic uptake in both early and delayed lymphoscintigraphy is associated with patient outcomes. Hepatic uptake could represent tracer inflow into the systemic circulation, indicating preservation of the connection between the lymphatic system and the systemic circulation. Physicians should evaluate these findings carefully on lymphoscintigraphy.

Preliminary Exploration of Transpedal Lymphangiography With High-Dose Ethiodized Oil Application in the Treatment of Postoperative Chylothorax

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.

Traumatic chylothorax: a dilemma to surgeons and interventionists

Chylothorax is generally seen due to iatrogenic injury to the thoracic duct during thoracic or neck surgery. It can also be encountered secondary to chest trauma either blunt or penetrating. Percutaneous thoracic duct embolisation is an alternative to surgical treatment and is considered an effective and safe minimally invasive treatment option for chylothorax with a success rate of about 80%. We present a case of blunt trauma to the chest with chylothorax, which was successfully managed with transvenous retrograde thoracic duct embolisation.

Radiological management of postoperative lymphorrhea

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.

Lymphaticovenular anastomosis for lymph vessel injury in the pelvis and groin

BACKGROUND

Lymphatic diseases due to lymph vessel injuries in the pelvis and groin require immediate clinical attention when conventional treatments fail. We aimed to clarify the effectiveness of and indications for lymphaticovenular anastomosis (LVA) to treat these lymphatic diseases.

METHODS

We retrospectively evaluated six patients who underwent LVA for lymphatic diseases due to lymph vessel injuries in the pelvis and groin. Specific pathologies included groin lymphorrhea (N = 3), chylous ascites (N = 2), and retroperitoneal lymphocele (N = 1). The maximum lymphatic fluid leakage volume was 150-2600 mL daily. Conventional treatments (compression, drainage, fasting, somatostatin administration, negative pressure wound therapy, or lymph vessel ligation) had failed to control leakage in all cases. We performed lower extremity LVAs after confirming the site of lymph vessel injury using lymphoscintigraphy. We preferentially placed LVAs in thigh sites that showed a linear pattern by indocyanine green lymphography. Postoperative lymphatic fluid leakage volume reduction was evaluated, and leakage cessation was recorded when the drainage volume approached 0 mL.

RESULTS

LVA was performed at an average of 4.3 sites (range, 3-6 sites) in the thigh and 2.7 sites (range, 0-6 sites) in the lower leg. Lymphatic fluid leakage ceased in all cases after a mean of 6 days (range, 1-11 days) postoperatively. No recurrence of symptoms was observed during an average follow-up of 2.9 (range, 0.5-5.5) years.

CONCLUSIONS

LVA demonstrates excellent and rapid effects. We recommend lower extremity LVA for the treatment of lymphatic diseases due to lymph vessel injuries in the pelvis and groin.

Analysis of the fluid biochemistry in patients with prolonged wound drainage after hip hemiarthroplasty

INTRODUCTION

The origin and content of prolonged wound drainage (PWD) after arthroplasty remain uncertain. In this study, we performed the biochemical, biological and advanced proteomic analysis of the drainage fluid collected from PWD patients following hip hemiarthroplasty (HA).

METHODS

Data of 28 patients who developed PWD after HA were prospectively analyzed. After examining the biochemical content of the drainage fluid collected on postoperative day 6, to find out if the drainage fluid was transudate or exudate, it was compared with the patient's serum values according to the Light criteria. Subsequently, biological and proteomic analyzes of both drainage fluid and serum were performed. The similarities and differences in terms of protein concentrations, protein identities were examined. In the drainage fluid, we analyzed lymph-specific proteins.

RESULTS

16 patients with PWD were male (61.1%), 12 were female (38.9%), and the mean age of all patients was 79.64 ± 8.44 (65-95). Biochemical test results of the drainage fluid / serum were as follows: Total protein: 2.1 / 5.2 g/dl, albumin: 1.3 / 3.1 g/dl, lactate dehydrogenase (LDH): 121/324 U/l, cholesterol: 28/160 mg/dl, triglyceride: 37/122 mg/dl, sodium (Na): 140/ 140mg/dl, potassium (K): 4.1/ 4.1 mg/dl. pH of the drainage fluid was 7.6. According to these biochemical values, drainage fluid was classified as transudate. As a result of protein identification, fibrinogen beta chain, keratin type 1, creatine kinase M-type protein were detected in drainage fluid. Subsequent western analysis revealed that, gliseraldehyde-3-phosphate dehydrogenase (GAPDH) and beta actin antibody were detected in the drainage fluid but not in serum.

CONCLUSION

Despite the similarity in serum and transudative PWD fluid in terms of biochemical content, we found that when we carried out further proteomic analysis, PWD contains lymph-specific proteins. Unlike PWD, these proteins were not determined in serum. PWD fluid can be also called as lymphorrhea. PWD fluid with abundant proteins may also provide an appropriate environment for the growth of microorganisms.

Lymphangiography and Lymphatic Interventions

Compared with the traditional pedal lymphangiography, intranodal lymphangiography and MR lymphangiography have made imaging of the lymphatic system less challenging. Improvements in imaging and availability of newer catheters have allowed embolization of lymphatic system much more feasible that previously envisioned. In this article, we briefly review the anatomy, imaging, and current and future of lymphatic interventions.

Refractory Hepatic Lymphorrhea: Percutaneous Transhepatic Lymphangiography and Embolization with n-Butyl-2-Cyanoacrylate Glue

Hepatic lymphorrhea is a leakage from the liver's lymphatic ducts into the abdominal cavity and an extremely rare complication associated with injury of the hepatoduodenal ligament, which can lead to refractory ascites. Hepatic lymphorrhea is constituted by non-chylous ascites and can be visualized by transhepatic lymphangiography instead of pedal or intranodal lymphangiography. To date, only a few successfully treated cases using interventional procedures have been reported. Although n-butyl-2-cyanoacrylate (NBCA) glue is widely used in various cases of vascular embolization and other lymphatic leak treatments, there have been no reports of its use for post-surgical hepatic lymphorrhea. The NBCA glue embolization described in this case report may be one of the treatment options to control the refractory ascites derived from hepatic lymphorrhea.

Reversed Approach through Lymphocele/Lymphatic Fluid Collection for Glue Embolization of Injured Lymphatic Vessels

A total of 9 glue embolization procedures of injured lymphatic vessels with a reversed approach from the lymphocele/lymphatic fluid collection in 8 patients were retrospectively reviewed. The approach routes were via the indwelling chest tube for pleural effusion (n = 2), the drainage catheter tract for abdominopelvic lymphocele/lymphatic fluid collection/thigh lymphocele (n = 4), and the direct puncture of the lymphatic fluid collection at the operation bed (n = 2). All the procedures were technically successful without complications. The mean daily leakage rate decreased from 465 mL/d before the procedure to 42 mL/d after the procedure, and the drainage catheters could be removed after 8 procedures, achieving a clinical success rate of 88.9% (8 of 9 procedures).

Percutaneous afferent lymphatic vessel sclerotherapy for postoperative lymphatic leakage after previous ineffective therapeutic transpedal lymphangiography

BACKGROUND

To demonstrate the efficacy of percutaneous computed tomography (CT)-guided afferent lymphatic vessel sclerotherapy (ALVS) in the treatment of postoperative lymphatic leakage (LL) after ineffective therapeutic transpedal lymphangiography (TL).

METHODS

A retrospective review in this institute involving 201 patients was conducted from May 2011 to September 2018. Patients diagnosed with postoperative LL undergoing ineffective therapeutical TL before the performance of percutaneous CT-guided ALVS were involved. Technical success and clinical success of TL and ALVS were established. The technical success and efficacy of ALVS in the treatment of postoperative LL after ineffective therapeutic TL were assessed. The clinical success rate of ALVS is also assessed, and the complications are reviewed.

RESULTS

In total, nine patients were involved including three patients (33.3%) presented with chylothorax, three patients (33.3%) presented with inguinal lymphatic fistula/lymphocele, and three patients (33.3%) presented with lymphatic fistula in the thigh; 27 ± 18 days (mean ± standard deviation) after surgery, therapeutic TL was successfully performed and showed definite afferent lymphatic vessel and leakage site in all the patients. Due to clinical failure after TLs, the following ALVS was performed with a mean interval of 12 ± 8 days after TL. The technical success rate was 9/9 (100.0%, 95% confidence interval [CI] 63.1-100.0%). An average of 2.7 ± 1.3 mL 95% ethanol as sclerosant agent was injected during the procedure. The clinical success was observed in 8 of the 9 patients (88.9%, 95% CI 51.8-99.7%) with a time between ALVS and the LL cure of 8 ± 6 days. No complications were reported.

CONCLUSIONS

Our results showed the role of percutaneous CT-guided ALVS as a safe, feasible, and effective salvage treatment for postoperative LL after ineffective TL.

Successful lymphatic embolization using N-butyl-2-cyanoacrylate for postoperative lymphorrhea in a patient with renal pelvic cancer

We present a successful case of percutaneous lymphatic embolization using N-butyl-2-cyanoacrylate (NBCA) for postoperative lymphorrhea in a patient with urothelial carcinoma of renal pelvis. A 75-year-old man with urothelial carcinoma of left renal pelvis with para-aortic lymph nodes metastases. The patient presented severe lymphorrhea after neo-adjuvant chemotherapy followed by laparoscopic total left nephroureterectomy and lymph nodes dissection. Since conservative treatments were ineffective, percutaneous lymphatic embolization using NBCA resulted in healing of the lymphorrhea without recurrence. Percutaneous lymphatic embolization using NBCA followed by intranodal lymphography is a powerful treatment option for intractable postoperative lymphorrhea after lymph nodes dissection.

A medical epopee: recurrent fungal endocarditis, heart transplantation and chylopericardium

Background

Candida prosthetic endocarditis is associated with high mortality rates and valve replacement surgery, together with antifungal treatment, play a major role in eradicating the fungal infection. Valve reoperations in these scenarios may be relatively common due to the high infection relapse rates and, in some cases, heart transplantation may be an imposing therapy for infection resolution and for the heart failure related to the myocardial reoperation injury. Among the many postoperative complications related to heart transplantation, chylopericardium is a rare but challenging example.

Case presentation

We report the case of a 55-year-old man who was admitted to our hospital with a 1-month history of progressive dyspnea and fatigue. His past medical history included four open-heart surgeries for aortic and mitral valve replacement due to recurrent Candida parapsilosis infective endocarditis. Transthoracic echocardiogram showed a markedly reduced left ventricular systolic function and normofunctioning bioprosthetic valves. An inotropic dependency condition led to heart transplantation surgery. In the early postoperative period, a persistent chylous fluid started to drain from the pericardial tube, compatible with the diagnosis of chylopericardium. The lack of clinical response to total parenteral nutrition and intravenous infusion of octreotide imposed the need of interventional radiology with diagnostic lymphography through cisterna chyli puncture and thoracic duct catheterization, confirming the presence of a lymphatic fistula. A successful treatment outcome was achieved with percutaneous thoracic duct embolization using coils and n-butyl-cyanoacrilate glue, possibiliting hospital discharge.

Conclusions

Fungal endocarditis requires combined treatment (surgical and antimicrobial) for eradication. Valve replacement, while necessary, may lead to severe ventricular deterioration and heart transplantation may be the only viable therapeutic solution. Among the several postoperative complications of heart transplantation, chylopericardium is an uncommon and defiant example. Advances in interventional radiology like the percutaneous embolization allow a less invasive and highly efficient approach for this complication.

Nontraumatic Chylothorax: Nonenhanced MR Lymphography

Chylothorax is a rare cause of pleural effusion, secondary to accumulation of lymph in the pleural space. Diagnosis is based on the triglyceride and cholesterol content of pleural fluid obtained with thoracentesis. Because the lymphatic system plays an essential role in fat absorption and immune response, lymphatic leak associated with chylothorax may cause life-threatening malnutrition and immunodeficiency. Chylothorax is usually described as traumatic or nontraumatic. The main cause of chylothorax is traumatic, typically postsurgical, secondary to iatrogenic direct puncture of the thoracic duct during thoracic surgery. Causes of nontraumatic chylothorax include a wide range of differential diagnoses. Lymphoma and thoracic malignancies are the most common causes and are responsible for chylothorax by extrinsic compression or invasion of the thoracic duct. Other rare causes include primary and secondary diffuse lymphatic diseases, responsible for chylothorax by lymphatic vessel wall dysfunction. Imaging the lymphatic system remains a challenge in the days of modern imaging. Nonenhanced MR lymphography is a noninvasive technique based on heavily T2-weighted sequences, thus enabling visualization of the lymphatic circulation. This technique allows diagnosis and differential diagnosis, evaluation of disease severity, and guidance of therapeutic management in nontraumatic chylothorax. Furthermore, it may offer radiologic classification of primary lymphatic diseases on the basis of morphologic features of lymphatic vessels. The authors describe the anatomy and physiology of the thoracic lymphatic system, present the technique of nonenhanced MR lymphography, and discuss pathophysiologic mechanisms and imaging features in different causes of nontraumatic chylothorax. ^©RSNA, 2020.

Extracardiac Complications in Intensive Care Units after Surgical Repair for Congenital Heart Disease: Imaging Review with a Focus on Ultrasound and Radiography

Pediatric patients show various extracardiac complications after cardiovascular surgery, and radiography and ultrasound are routinely performed in the intensive care unit to detect and evaluate these complications. This review presents images of these complications, sonographic approach, and timing of occurrence that are categorized based on their extracardiac locations and include complications pertaining to the central nervous system, mediastinum, thorax and lung parenchyma, diaphragm, liver and biliary system, and kidney along with pleural effusion and iatrogenic complications. This pictorial review will make it easier for medical doctors in intensive care units to identify and manage various extracardiac complications in pediatric patients after cardiovascular surgery.

Treatment of lymphatic leakage after retroperitoneal tumor resection by lymphangiography and embolization: A case report

Lymphatic leakage is an infrequent but relatively serious complication after resection of retroperitoneal tumors. Although different approaches have been attempted in treatment of lymphatic leakage, none of them has been consistently effective. This study report on a female patient, aged 55-years with massive retroperitoneal tumor, with lymphangiography and embolization for resolution of lymphatic leakage after retroperitoneal tumor resection. Computed tomography revealed retroperitoneal cystadenoma. After the right ureteral stent was placed, the retroperitoneal tumor resection was performed, and after operation, the patient presented with lymphatic leakage unresponsive to several treatment measures. From the thirty-seventh postoperative day (POD37), the patient underwent lymphangiography and embolization, which resolved her lymphatic leakage. Lymphangiography is useful for detecting lymphatic leakage occurring after retroperitoneal tumor resection. Furthermore, lymphatic embolization is feasible, effective, and safe for managing leaks demonstrated on lymphangiography.

Chylothorax treated with targeted sclerotherapy by direct puncture of the lymphatic leakage site

We report a novel application of targeted sclerotherapy to eradicate high-output chylothorax. The patient underwent thoracic duct embolization; however, cannulation of the thoracic duct failed, and thoracic duct disruption was performed. Leakage continued; therefore, the leakage site in the mediastinum was punctured directly under fluoroscopic guidance and a drainage catheter was inserted, followed by sclerotherapy using OK-432. Finally, leakage stopped and chylothorax improved. This technique may be useful for refractory chylothorax in patients where thoracic duct embolization fails.

Retrograde transvenous lymphatic embolization for postoperative chylous ascites: A report of three cases and literature review

Percutaneous transabdominal lymphangiography and embolization have been reported as useful approaches for intractable chylothorax or chylous ascites. However, they are often difficult to perform after extensive lymph node dissection because disruption of the antegrade lymphatic flow makes leaks identification difficult. When the leakage point cannot be identified or percutaneous transabdominal lymphangiography and embolization fail, a retrograde transvenous approach to the thoracic duct can be used instead. We report 3 cases of refractory chylous ascites after retroperitoneal operation or extensive lymph node dissection that was addressed by retrograde transvenous lymphatic embolization. In one case, a combination of retrograde transvenous lymphatic embolization, transcatheter sclerotherapy, and transcatheter embolization was used. These findings suggest that retrograde transvenous lymphatic embolization appears to be feasible and efficient for postoperative chylous ascites.

Near infra-red fluorescence-guidance for percutaneous sclerotherapy of thoracic duct leak

Treatment of thoracic duct leaks can be very challenging. Intractable chlye leaks may require image-guided methods to increase the likelihood of treatment success. Near infra-red fluorescence is an easy-to-use nonionizing imaging method that has been described to detect thoracic duct leaks in open surgery or thoracoscopic interventions, yet no application to percutaneous sclerotherapy has been described. The authors suggest near infra-red fluorescence as a feasible and useful tool to guide percutaneous sclerotherapy.

Dynamic contrast-enhanced computed tomography lymphangiography with intranodal injection of water-soluble iodine contrast media in microminipig: imaging protocol and feasibility

OBJECTIVES

To evaluate the optimal imaging protocol and the feasibility of intranodal dynamic contrast-enhanced computed tomography lymphangiography (DCCTL) in microminipigs.

METHODS

The Committee for Animal Research and Welfare provided university approval. Five female microminipigs underwent DCCTL after inguinal lymph node injection of 0.1 mL/kg of iodine contrast media at a rate of 0.3 mL/min with three different iodine concentrations: group 1, 75 mgI/mL; group 2, 150 mgI/mL; and group 3, 300 mgI/mL. The CT values of the venous angle, thoracic duct (TD), cisterna chyli, iliac lymphatic duct, and iliac lymph node were measured; increases in CT values pre- to post-contrast were assessed as the contrast-enhanced index (CEI). Multi-detector row CT (MDCT) and volume rendering images showing the highest CEI were qualitatively evaluated.

RESULTS

The CEI of all lymphatics peaked at 5-10 min. The mean CEI of TD at 10 min of group 2 (193.0 HU) and group 3 (201.5 HU) were significantly higher than that of group 1 (70.7 HU) (p = 0.024). The continuity and overall diagnostic acceptability of all lymphatic system components were better in group 3 (3.6 and 3.0, respectively) than group 1 (2.6 and 1.6) and group 2 (3.0 and 2.6) (p = 0.249 and 0.204).

CONCLUSIONS

The optimal imaging protocol for intranodal DCCTL could be dual-phase imaging at 5 and 10 min after the injection of 300 mgI/mL iodinated contrast media. DCCTL provided good images of lymphatics and is potentially feasible in clinical settings.

KEY POINTS

• Dynamic contrast-enhanced computed tomography lymphangiography with intranodal injection of water-soluble iodine contrast media showed the highest enhancement of all lymphatics at scan delays of 5 and 10 min. • The optimal iodine concentration for intranodal dynamic contrast-enhanced computed tomography lymphangiography might be 300 mgI/mL. • Intranodal dynamic contrast-enhanced computed tomography lymphangiography provided good images of all the lymphatic system components and is potentially feasible in clinical settings.

Transverse versus vertical groin incision for femoral artery approach

BACKGROUND

Access to the femoral vessels is necessary for a wide range of vascular procedures, including treatment of thromboembolic disease, arterial grafts (i.e. bifemoral aortic bypass or infrainguinal bypass), endovascular repair of abdominal aortic aneurysm (EVAR), thoracic endovascular aneurysm repair (TEVAR) and transcatheter aortic valve implantation (TAVI). The surgical technique used to access the femoral artery may be a factor in the occurrence of postoperative complications; this will be the focus of our review. We will compare the transverse surgical technique-a cut made parallel to the groin crease-versus the vertical groin incision surgical technique-classic technique: a surgical cut made across the groin crease-to access the femoral artery, in an attempt to determine which technique has the lower rate of complications, is safer and is more effective.

OBJECTIVES

To evaluate the efficacy and safety of transverse groin incision compared with vertical groin incision for accessing the femoral artery in endovascular surgical procedures and open surgery.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED databases, and the World Health Organization (WHO) International Clinical Trials Registry Platform and ClinicalTrials.gov to 17 February 2020. The review authors searched the IBECS database to 26 March 2020 and reference lists of relevant studies/papers.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-randomized trials (qRCTs) that compare transverse and vertical groin incision, during either endovascular or open surgery procedures.

DATA COLLECTION AND ANALYSIS

Two review authors (MVCRC, FCN) independently selected the studies, assessed risk of bias, extracted data, performed data analysis and graded the certainty of evidence according to GRADE.

MAIN RESULTS

We included one RCT and one qRCT in this review. These two studies had a combined total of 237 participants (283 groins). Infection of the surgical wound was the only outcome that was similar in both studies, and that could therefore be submitted to a combined analysis. Meta-analysis of the two studies showed low-certainty evidence that transverse groin incision resulted in a lower risk of surgical wound infection in the 10- to 28-day period following surgery (risk ratio [RR] 0.25, 95% confidence interval [CI] 0.08 to 0.76; 2 studies; 283 groin incisions). There was low heterogeneity between the studies. We downgraded the certainty of the evidence for surgical wound infection by one level due to serious limitations in the design (there was a high risk of bias in critical domains). The confidence interval for surgical wound infection is relatively wide, further indicating that the certainty of the effect estimate is low. This is likely due to the small number of studies and participants. We observed no evidence of a difference between the two surgical techniques for the other evaluated primary outcome 'lymphatic complications': lymphocele (RR 0.46, 95% CI 0.20 to 1.02; 1 study; 116 groins); and lymphorrhea (RR 2.77, 95% CI 0.92 to 8.34; 1 study; 116 groins). We downgraded the certainty of evidence for lymphatic complications by one level due to serious limitations in the design (there was a high risk of bias in critical domains); and by two further levels because of imprecision (small number of participants and only one study included). High-quality studies are needed to enable a comparison of the two surgical techniques with respect to other outcomes, such as infection of the vascular graft (endoprosthesis/prosthesis), prolonged hospitalization, reoperative surgery, death, neurological deficit (e.g. paresthesia), amputation, graft patency, and postoperative pain.

AUTHORS' CONCLUSIONS

In this systematic review, we found low-certainty evidence that performing transverse groin incision to access the femoral artery resulted in fewer surgical wound infections compared with performing vertical groin incision. We observed no evidence of a difference between the two surgical techniques for the other evaluated outcomes (lymphocele and lymphorrhea). Other outcomes were not evaluated in these studies. Limitations of this systematic review are, however, the small sample size, short clinical follow-up period and high risk of bias in critical domains. For this reason, the applicability of the results is limited.

Morphometry and Lymph Dynamics of Swine Thoracic Duct

Background: The goal of this study was to characterize the thoracic duct (TD) both morphologically and hemodynamically. Methods and Results: The lymphatic flow and pressure gradient from the cisterna chyli (CC) to the lymphovenous junction were measured in anesthetized swine (n = 9). After the animals were euthanized, the TD were harvested for histomorphometric analyses in which three samples were perfused with 9% gelatin to obtain the morphometry of the TD valve in both the open and closed configuration. Spectral analyses were performed. An afferent lymphatic vessel of the CC was accessed and cannulated after the animal was euthanized for casting (n = 3) to obtain morphometric data. The in vivo flow rate was 0.7 ± 0.49 mL/minute. Spectral analysis (Fast Fourier Transformation) showed correlation coefficients of 0.858 ± 0.063 and 0.586 ± 0.112 (p < 0.05) for the TD and JVPs, respectively. The average pressure gradient was 8.1 mmHg along the TD. The length of the TD was 35.6 ± 2.2 cm. The maximal width of the CC ranged from 11.4 to 15 mm. The diameter of the TD varied irregularly from 2 to 4.3 mm. The geometry of the TD leaflets was determined to have an area of 1.99 ± 0.53 mm², a leaflet length of 3.26 ± 0.86 mm, a packet depth of 0.66 ± 0.19 mm, and a wall length of 5.46 ± 2.16 mm. The TD media thickness was ∼7 ± 3 μm. The number of valves ranged from 9 to 13 in the full length of the TD. Conclusions: A relatively constant pressure gradient in the swine TD drives lymph flow from the CC to the jugular vein. The TD is a thin-walled vessel with valves that prevent reflux of lymph flow. This study of morphometric and lymphatic dynamics is important for interventionalists to understand the anatomy and physiology of the TD to design new diagnostic, interventional procedures, and devices.

A Canine Model for Lymphangiography and Thoracic Duct Access

OBJECTIVE

To evaluate the technical feasibility of intranodal lymphangiography and thoracic duct (TD) access in a canine model.

MATERIALS AND METHODS

Five male mongrel dogs were studied. The dog was placed in the supine position, and the most prominent lymph node in the groin was accessed using a 26-gauge spinal needle under ultrasonography (US) guidance. If the cisterna chyli (CC) was not opacified by bilateral lymphangiography, the medial iliac lymph nodes were directly punctured and Lipiodol was injected. After opacification, the CC was directly punctured with a 22-gauge needle. A 0.018-in microguidewire was advanced through the CC and TD. A 4-Fr introducer and dilator were then advanced over the wire. The microguidewire was changed to a 0.035-in guidewire, and this was advanced into the left subclavian vein through the terminal valve of the TD. Retrograde TD access was performed using a snare kit.

RESULTS

US-guided lymphangiography (including intranodal injection of Lipiodol [Guerbet]) was successful in all five dogs. However, in three of the five dogs (60%), the medial iliac lymph nodes were not fully opacified due to overt Lipiodol extravasation at the initial injection site. In these dogs, contralateral superficial inguinal intranodal injection was performed. However, two of these three dogs subsequently underwent direct medial iliac lymph node puncture under fluoroscopy guidance to deliver additional Lipiodol into the lymphatic system. Transabdominal CC puncture and cannulation with a 4-Fr introducer was successful in all five dogs. Transvenous retrograde catheterization of the TD (performed using a snare kit) was also successful in all five dogs.

CONCLUSION

A canine model may be appropriate for intranodal lymphangiography and TD access. Most lymphatic intervention techniques can be performed in a canine using the same instruments that are employed in a clinical setting.

Successful treatment of hepatic lymphorrhea by percutaneous transhepatic lymphangiography followed by sclerotherapy using OK-432

Background

Conventional lymphangiography cannot detect leakage sites of hepatic lymphatic vessels. Percutaneous transhepatic lymphangiography can be used to visualize leakage sites, and once the leakage site has been confirmed, effective sclerotherapy can be performed.

Case presentation

A rare case of intractable hepatic lymphorrhea due to injury of the hepatoduodenal ligament following pancreaticoduodenectomy is reported. Drainage of massive ascites from the drainage tube continued after surgery. Percutaneous transhepatic lymphangiography visualized the intrahepatic lymphatic vessels and the leakage site at the hepatic hilum. An 8-Fr drainage catheter was inserted adjacent to the leakage point under fluoroscopic computed tomography guidance. Repeated sclerotherapy using intraperitoneal administration of OK-432 (picibanil) through the catheter was performed, which exposed the leakage site, and control of the ascites was finally achieved.

Conclusions

To the best of our knowledge, this is the first successful case of detection of a leakage site using intrahepatic lymphangiography, followed by sclerotherapy using OK-432.

Ultrasound-guided lymphangiography and interventional embolization of chylous leaks following esophagectomy

Objectives

Postoperative chylothorax is a serious complication after transthoracic esophagectomy, and is associated with major morbidity due to dehydration and malnutrition. For patients with high-output fistula, re-thoracotomy with ligation of the thoracic duct is the treatment of choice. Radiologic interventional management is an innovative procedure that has the potential to replace surgery in the treatment algorithm.

Methods

Four patients with high-output chylous leaks following esophagectomy are presented. Ultrasound-guided lymphangiography with embolization of the thoracic duct and/or disruption of the cisterna chyli was performed to occlude the leakage site. Radiologic interventions and procedure-related outcomes are described in detail.

Results

In all four patients, ultrasound-guided lymphangiography of the groin with injection of Lipiodol was able to detect and visualize the leakage site in the lower mediastinum. In three patients, the leak could be successfully occluded by Lipiodol embolization. In one patient, embolization failed and the disruption technique was successfully performed. No procedure-related complications were observed.

Conclusions

In case of a postoperative chylothorax, radiologic intervention is feasible and safe. The procedure is indicated for high-output chylous fistulas after esophagectomy, and should be applied early after the diagnosis of this postoperative complication.

Interventional Treatment of Lymphatic Leakage Post Appendectomy: Case Report

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.

The Visibility of the Terminal Thoracic Duct Into the Venous System Using MR Thoracic Ductography with Balanced Turbo Field Echo Sequence

RATIONALE AND OBJECTIVES

Magnetic resonance thoracic ductography (MRTD) with balanced turbo field echo (bTFE) can visualize both the thoracic duct and its surrounding vessels. This study aimed to investigate the visibility of the terminal thoracic duct into the venous system in the subclavian region using MRTD with bTFE.

MATERIALS AND METHODS

MRTD was performed with bTFE as a preoperative workup comprising respiratory gating on a 1.5-T magnetic resonance system for patients with esophageal cancer. The portion and the number of terminal thoracic ducts into the venous system and preterminal branching in the left subclavian region were assessed using MRTD in 132 patients. The confidence level of the visibility using MRTD was also evaluated.

RESULTS

The most frequent terminal portion of the thoracic duct was the jugulovenous angle (92 patients, 69.7%), followed by the subclavian vein (27 patients, 20.5%) and the internal jugular vein (8 patients, 6.1%). Four patients also exhibited double entry of the thoracic duct into the venous system. The preterminal branching was single in 96 patients (72.7%) and multiple in 36 patients (27.3%). The confidence level of the visibility of the thoracic duct using MRTD was absolutely certain in 112 patients (84.8%) and was somewhat certain in 20 patients (15.2%).

CONCLUSIONS

MRTD with bTFE is a robust imaging modality to visualize the terminal portion of the thoracic duct into the venous system in the subclavian region.

Lymphangiography and Post-lymphangiographic Multidetector CT for Preclinical Lymphatic Interventions in a Rabbit Model

PURPOSE

To describe the feasibility of lymphangiography and the visibility of the lymphatic system using post-lymphangiographic multidetector CT (MDCT) for preclinical lymphatic interventions in a rabbit model.

MATERIALS AND METHODS

Lymphangiography via the popliteal lymph node or vessel after surgical exposure was performed, using six healthy female Japanese White rabbits. Lipiodol was manually injected for lymphangiography. Post-lymphangiographic MDCT examinations were performed in all rabbits. The dataset images were subjected to image processing analysis utilizing the three-dimensional maximum intensity projection technique. Three reviewers evaluated the degree of depiction of the lymphatic system using a four-point visual score (1, poor; 2, fair; 3, good; 4, excellent). The distance between the body surface and cisterna chyli was measured on post-lymphangiographic MDCT axial image.

RESULTS

Lymphangiography was successfully performed in all rabbits. The popliteal lymph node was detectable in 90%. The visualization of lymphatic system via the popliteal node was achieved in 89%. Mean visual scores of > 3.0 were realized by the right femoral lymphatic vessel, left femoral lymphatic vessel, left iliac lymphatic vessel, left lumbar lymphatic trunks and cisterna chyli, whereas mean visual scores of < 3.0 were yielded by the right iliac lymphatic vessel, right lumbar lymphatic trunks and thoracic duct. The distance between the body surface and cisterna chyli on post-lymphangiographic MDCT axial images was 4.33 ± 0.14 cm.

CONCLUSION

Lymphangiography is feasible, and the visibility of the lymphatic system on post-lymphangiographic MDCT in a rabbit model provides enough information for interventional radiologists to perform preclinical lymphatic interventions.

The anatomy and physiology of the terminal thoracic duct and ostial valve in health and disease: potential implications for intervention

The thoracic duct (TD) transports lymph drained from the body to the venous system in the neck via the lymphovenous junction. There has been increased interest in the TD lymph (including gut lymph) because of its putative role in the promotion of systemic inflammation and organ dysfunction during acute and critical illness. Minimally invasive TD cannulation has recently been described as a potential method to access TD lymph for investigation. However, marked anatomical variability exists in the terminal segment and the physiology regarding the ostial valve and terminal TD is poorly understood. A systematic review was conducted using three databases from 1909 until May 2017. Human and animal studies were included and data from surgical, radiological and cadaveric studies were retrieved. Sixty-three articles from the last 108 years were included in the analysis. The terminal TD exists as a single duct in its terminal course in 72% of cases and 13% have multiple terminations: double (8.5%), triple (1.8%) and quadruple (2.2%). The ostial valve functions to regulate flow in relation to the respiratory cycle. The patency of this valve found at the lymphovenous junction opening, is determined by venous wall tension. During inspiration, central venous pressure (CVP) falls and the valve cusps collapse to allow antegrade flow of lymph into the vein. During early expiration when CVP and venous wall tension rises, the ostial valve leaflets cover the opening of the lymphovenous junction preventing antegrade lymph flow. During chronic disease states associated with an elevated mean CVP (e.g. in heart failure or cirrhosis), there is a limitation of flow across the lymphovenous junction. Although lymph production is increased in both heart failure and cirrhosis, TD lymph outflow across the lymphovenous junction is unable to compensate for this increase. In conclusion the terminal TD shows marked anatomical variability and TD lymph flow is controlled at the ostial valve, which responds to changes in CVP. This information is relevant to techniques for cannulating the TD, with the aid of minimally invasive methods and high resolution ultrasonography, to enable longitudinal physiology and lymph composition studies in awake patients with both acute and chronic disease.

Magnetic resonance thoracic ductography assessment of serial changes in the thoracic duct after the intake of a fatty meal

The thoracic duct, a terminal lymph vessel, is thought to dilate after the intake of a fatty meal. However, this physiological change has not been well explored in vivo. Therefore, the present study aimed to assess serial changes in the thoracic duct after the intake of a fatty meal using magnetic resonance thoracic ductography (MRTD). Eight healthy volunteers were subjected to one MRTD scan before a fatty meal and eight serial MRTD scans every hour thereafter. The cross-sectional areas of the thoracic duct were estimated using MRTD measurements of the diameters of the thoracic duct at the upper edge of the aortic arch, the tracheal bifurcation, the mid-point between the tracheal bifurcation and the left part of the diaphragm and the left part of the diaphragm. The change-rates in these areas were calculated before and after the fatty meal intake, and the maximal change-rate and timing of its achievement were determined for each subject. The summed change-rates in the four portions of the thoracic duct ranged from -40.1 to 81.3%, with maximal change-rates for each subject ranging from 22.8 to 81.3% (mean, 50.4%). Although individual variations were observed, most subjects (88.9%) exhibited a maximal change-rate at 4-6 h after meal intake, with subsequent decreases at 7-8 h. In conclusion, MRTD revealed a tendency toward thoracic duct enlargement at 4-6 h after the intake of a fatty meal, followed by contraction.