Therapeutic effectiveness of diagnostic lymphangiography for refractory postoperative chylothorax and chylous ascites: correlation with radiologic findings and preceding medical treatment. AJR Am J Roentgenol. 2013;201:659-666. [PMID: 23971461 DOI: 10.2214/AJR.12.10008]

A case of refractory chylothorax due to an unenclosed esophageal hiatus after subtotal esophagectomy treated with lipiodol lymphangiography

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.

Treatment of Refractory Ascites with Lymphaticovenous Anastomosis Considering Lymphatic Territories

Lymphatic ascites is an infrequent complication observed in patients who have undergone lymphadenectomy as part of their surgical treatment for gynecological cancer. Previous research has suggested that intranodal lymphangiography can effectively manage lymphatic leakage. However, its efficacy diminishes for ascites with substantial fluid accumulation. This case report presents a patient who underwent lymphaticovenous anastomosis (LVA) for ascites that was unresponsive to lymphangiography and sclerotherapy. A 70-year-old woman required weekly ascites punctures after surgical treatment of ovarian cancer. Lymphoscintigraphy revealed lymphatic leakage originating from the right pelvic lymphatic vessel. Intranodal lymphangiography was performed from the inferior lateral inguinal region, followed by embolization with 33% NBCA. Despite these measures, recurrence of ascites and lower limb lymphedema were observed. LVA was conducted at 149 days after the primary operation. Before the LVA, indocyanine green was injected into the lateral and medial ankles, first and fourth toe web spaces, and lower abdomen. The indocyanine green lymphography revealed several linear patterns extending from the dorsum of the foot and the lower abdomen to the inguinal lymph node. Among these, the lymphatic vessels leading to the inferior lateral inguinal lymph node were chosen for the LVA. Eight anastomoses were executed at the right thigh, right lower leg, and right lower abdomen. The patient was discharged at 1 day postoperatively. A computed tomography examination conducted at 20 days post-LVA revealed no accumulation of ascites. To improve the success rate of LVA for ascites, a treatment strategy based on lymphatic territories is required.

Pediatric Chylothorax Treated With Lymphangiography and Thoracic Duct Embolization: A Case Report

A chylothorax, the accumulation of lymphatic fluid in the pleural space, may occur for a variety of reasons. It is commonly seen in adults post-thoracic surgery. We present the case of a seven-month-old girl with a right-sided chylothorax in the setting of non-accidental trauma. Treatment options for a chylothorax include surgical ligation of the thoracic duct or, as in this case, a minimally invasive procedure performed by interventional radiology known as lymphangiography with thoracic duct embolization. This case highlights interventional radiologists' ability to treat complex lymphatic pathologies effectively with minimally invasive techniques.

Feasibility and safety of direct percutaneous embolization of lymphopseudoaneurysm for postoperative lymphatic leakage

The treatment strategy for refractory postoperative lymphatic leakage is controversial. While the utility of direct percutaneous embolization of lymphopseudoaneurysm has been investigated, only a few reports on this topic exist. The aim of this study was to evaluate the technical and clinical feasibility and safety of direct percutaneous embolization of lymphopseudoaneurysm for refractory postoperative lymphatic leakage. This case series included six consecutive patients who underwent direct percutaneous embolization of lymphopseudoaneurysm for refractory postoperative lymphatic leakage. Technical success (successful percutaneous approach and injection of NBCA glue to the lymphopseudoaneurysm), clinical success (unnecessity of percutaneous drainage tube of the lymphatic leakage), treatment duration (the duration from the treatment to the achievement of clinical success) and procedure-related complications were mainly evaluated. Direct percutaneous embolization of the lymphopseudoaneurysm using NBCA glue was successfully performed in all cases. Clinical success was achieved in five of the six cases (83%). The mean treatment period was 9 days for the cases with clinical success. No major complications occurred postoperatively. In conclusion, direct percutaneous embolization of lymphopseudoaneurysm may become a feasible and safe treatment option for cases of refractory postoperative lymphatic leakage.

Chylothorax in Infants and Children After Congenital Heart Surgery: Approach and Review

Chylothorax in infants after surgery for congenital heart disease is associated with significant morbidity and mortality. Numerous management modalities applied alone or in various combinations have been utilized but definitive guidelines have not yet been established. We present two infants who developed refractory chylothorax after congenital heart surgery. We also reviewed evidence for the use of available treatment modalities. In our experience, the use of lymphangiography followed by pleurodesis by povidone-iodine was safe and our impression was that it may have played a decisive role in controlling the lymph leak.

Novel Interventional Radiology for the Treatment of Various Lymphatic Leakages: Lymphatic Intervention and Embolization

Little progress has been made in modern lymphatic medicine since Dr. Kinmonth first described pedal lymphangiography in the 1950s. The clinical need for an effective treatment modality for managing lymphatic leakage greatly increased only after intranodal lymphangiography, which enabled the depiction of the exact location of the leakage. This review introduces five hypotheses that have been proposed while addressing various clinical scenarios involving lymphatic leakage: (1) various embolization techniques can be used to prevent lymphatic leakage; (2) lymph node embolization can treat postoperative pelvic lymphoceles that are refractory to sclerotherapy; (3) the technical success rate of thoracic duct cannulation can be improved by using retrograde thoracic duct access as a bail-out method; (4) non-traumatic chylothorax can be managed by understanding the underlying pathophysiology; and (5) chylous ascites can be managed by understanding the underlying pathophysiology. Five retrospective observational studies, one randomized prospective clinical trial, and two case reports (letters to the editor) were published after the hypotheses were validated. We provide a new systematic approach to lymphatic intervention by describing the process of the current comprehensive research.

Therapeutic lymphangiography with ethiodized oil for the management of lymphoceles and chylous ascites

PURPOSE

The purpose of this study was to analyze the safety, technical success and clinical outcome of percutaneous intranodal ethiodized oil (Lipiodol®) based lymphangiography (L-LAG) for the management of refractory pelvic lymphoceles or chylous ascites using high doses of ethiodized oil.

MATERIALS AND METHODS

Thirty-four patients presenting with symptomatic, refractory postoperative pelvic lymphocele or chylous ascites referred for theranostic, inguinal, intranodal L-LAG treatment between May 2018 and November 2021 were retrospectively included. There were 21 men and 13 women, with a mean age of 62.7 ± 16.2 (standard deviation) years (age range: 9-86 years), who underwent a total of 49 L-LAG for the management of lymphoceles (n = 14), chylous ascites (n = 18) or a combination of lymphocele and chylous ascites (n = 2). Clinical and radiological pre-interventional, procedural and follow-up data up to January 2022 were collected from patients' electronic medical records and imaging files.

RESULTS

Technical success was obtained in 48 out of 49 L-LAG (98%). No complications related to L-LAG were noted. After one or more L-LAG, clinical success was obtained in 30 patients (88%) with a mean of 1.4 interventions per patient and mean intranodal injected volume of 29 mL of ethiodized oil per session. The remaining four patients (12%), with one or more failed L-LAG, underwent additional surgical intervention to definitively treat the postoperative lymphatic leakage.

CONCLUSION

L-LAG using high doses of ethiodized oil is a minimally invasive, safe and effective treatment of postoperative pelvic lymphocele or chylous ascites. Multiple sessions may be needed to obtain a meaningful clinical result.

Lymphangiography and lymphatic embolisation for the treatment of chyle leaks after neck surgery: assessment of lymphangiography findings and embolisation techniques

OBJECTIVE

To assess lymphangiography findings and outcome of lymphatic embolisation to manage chyle leak after neck surgery.

METHODS

Consecutive cases of lymphangiography performed between April 2018 and May 2022 for management of chyle leaks related to neck surgery were retrospectively reviewed. Lymphangiography findings, techniques, and outcomes were analysed.

RESULTS

Eight patients (mean age: 46.5 years) were included. Six patients had undergone radical neck dissection for thyroid cancer, and two had undergone lymph node excision. Clinical presentations were: chyle drainage through Jackson Pratt catheters in five patients, lymphorrhea through surgical wounds in two, and enlarging lymphocele in one. Lymphangiography techniques included: inguinal lymphangiography in four patients, retrograde lymphangiography in three, and transcervical lymphangiography in one. Lymphangiography revealed leaks in the terminal thoracic duct in two patients, bronchomediastinal trunk in two, jugular trunk in three, and superficial neck channels in one. Embolisation techniques included: non-selective embolisation of terminal thoracic duct (n = 2), selective embolisation of the jugular trunk (n = 3), selective embolisation of the bronchomediastinal trunk (n = 2), and intranodal glue embolisation of superficial neck channels (n = 1). One patient underwent a repeat procedure. Chyle leak resolved in all patients over a mean of 4.6 days. No complication was encountered.

CONCLUSION

Lymphatic embolisation seems to be effective and safe in managing chyle leaks after neck surgery. Lymphangiography allowed for the categorisation of chyle leaks according to their location. Post-embolisation patency of the thoracic duct may be preserved in chyle leaks that do not directly involve the thoracic duct.

ADVANCES IN KNOWLEDGE

Lymphatic embolisation is safe and effective in managing chyle leaks after neck surgery. On lymphangiography, the location of contrast media extravasation may not be consistent. The technique for embolisation should be based on the location of the leak. Post-embolisation patency of the thoracic duct may be preserved in chyle leaks that do not directly involve the thoracic duct.

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.

Successful treatment of thoracic duct injury from blunt trauma

Chylothorax is a rare condition after blunt trauma. We present a 32-year-olds man with a thoracic duct injury resulting in the right chylothorax after a motor vehicle collision. After the failure of conservative management, the patient underwent lymphangiography and successfully embolized the thoracic duct. This report emphasizes the importance of identifying thoracic duct injury in setting blunt trauma and management of this injury.

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.

Lymphatic Intervention, the Frontline of Modern Lymphatic Medicine: Part II. Classification and Treatment of the Lymphatic Disorders

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.

Lymphatic Intervention, the Frontline of Modern Lymphatic Medicine: Part I. History, Anatomy, Physiology, and Diagnostic Imaging of the Lymphatic System

Recent advances in lymphatic imaging have provided novel insights into the lymphatic system. Interventional radiology has played a significant role in the development of lymphatic imaging techniques and modalities. Radiologists should be familiar with the basic physiology and anatomy of the lymphatic system to understand the imaging features of lymphatic disorders, which reflect their pathophysiology. This study comprehensively reviews the physiological and anatomical aspects of the human lymphatic system as well as the latest lymphatic imaging techniques.

Multidisciplinary Management of Chylothorax

Chylothorax, the accumulation of chyle in the pleural space, is usually caused by the disruption of the thoracic duct or its tributaries. Etiologies are broadly divided into traumatic, including postsurgical, and nontraumatic, most commonly in the setting of malignancy. The management of chylothorax largely depends on the cause and includes dietary modification and drainage of the pleural space. A definitive intervention, whether surgical or a percutaneous lymphatic intervention, should be considered in patients with a persistently high volume of chylous output and in those with a prolonged leak, before complications such as malnutrition ensue. No methodologically robust clinical trials guiding management are currently available. In this article, we review the current literature and propose a stepwise, evidence-based multidisciplinary approach to the management of patients with both traumatic and nontraumatic chylothorax.

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.

Postoperative chylous ascites after total gastrectomy successfully treated using peritoneovenous (Denver) shunt: a case report

Background

Chylous ascites (CA) is a rare complication of gastrectomy for gastric cancer. While most cases of postoperative CA improve with medication or nutritional support, some are refractory to conservative treatment. A peritoneovenous shunt (PVS) may help patients who are poor candidates for surgery. However, PVS placement for postoperative CA after gastroenterological surgery has been rarely reported. Herein, we present a case of postoperative CA following total gastrectomy with para-aortic lymphadenectomy, treated successfully by PVS placement.

Case presentation

A 74-year-old man who underwent total gastrectomy with para-aortic lymph node dissection was hospitalised because of insufficient oral intake and dehydration. His abdomen was markedly distended with severe bilateral lower extremity oedema. On admission, abdominal computed tomography (CT) showed a high volume of ascites and no signs of cancer recurrence. Accordingly, postoperative CA resulting from drainage of fluid on paracentesis was diagnosed. Despite nutritional support, diuretics, and octreotide administration, his abdominal distension and nutritional status did not improve. We could not identify the sites of lymphatic leakage in the three intranodal lymphangiographies followed by CT. Although we considered a surgical treatment in our patient, we decided against it. Because we could not identify lymphatic leakage site during lymphangiography, surgical treatment might have a potential failure of detection and closure of leakage site. Furthermore, the patient’s general condition was poor because of malnutrition resulting from the loss of lymphatic fluid. Consequently, we decided to place PVS. After PVS placement, his abdominal distension improved rapidly, and he was discharged without serious complications. Thirteen months after PVS, patient has no relapse of abdominal distention and nutrition status has improved.

Conclusion

PVS might be a good option to manage refractory postoperative CA, as the leakage point cannot be detected on lymphangiography.

Minimal invasive treatment for post-liver and renal transplant lymphatic leaks

INTRODUCTION

Persistent lymphatic leakage from the surgical drain is a troubling complication occasionally encountered postoperatively. This study investigated lymphatic leaks after renal or liver transplantation, comparing the treatment efficacy of traditional catheter drainage vs. minimally invasive lymphatic interventions. We also discuss access and treatment targets considering the physiology of lymphatic flow.

METHODS

Between September 2018 and September 2020, 13 patients with lymphatic leakage were treated with minimally invasive lymphatic interventions; 11 had received a renal transplant, and two received a liver transplant. The control group included 10 patients with post-renal transplant lymphatic leakage treated with catheter drainage. The treatment efficacy of catheter drainage, lymphatic interventions, and different targets of embolization were compared.

RESULTS

The technical success rate for lymphatic intervention was 100%, and the clinical success rate was 92%, with an 82.9% percent reduction in drain volume on the first day after treatment. The duration to reach clinical success was 5.9 days with lymphatic intervention, and 33.9 days with conservative catheter drainage.

CONCLUSION

Lymphangiography and embolization are minimally invasive and efficient procedures for treating persistent lymphatic leaks after renal or liver transplantation. We suggest prompt diagnosis and embolization at upstream lymphatics to reduce the duration of drain retention, days of hospitalization and associated comorbidities. This article is protected by copyright. All rights reserved.

Retrograde transvenous selective lymphatic duct embolization in post donor nephrectomy chylous ascites

Chylous ascites is a rare, potentially sinister complication in post donor nephrectomy patients which may cause significant morbidity in form of severe malnutrition and an immuno-compromised state. We present two patients with post donor nephrectomy-related chylous leaks who failed conservative treatment. In both cases, lymphangiography was done first to detect the chylous leak site in the left renal fossa, and thereafter transvenous retrograde approach via left subclavian vein with selective lymphatic duct embolization of chylous leak was done with coils and glue successfully. Chylous ascites resolved in both patients after the embolization. Hence retrograde transvenous embolization technique appears to be an effective management option for refractory chylous leaks.

Percutaneous Translymphocele Embolization of Retroperitoneal Lymphatic Leak

Iodized oil-based lymphangiography (LAG) is a well-established diagnostic exam during the workup of postoperative lymphatic leaks. Computed tomography (CT) has been shown to be a useful complement to optimize treatment planning and can easily be performed after conventional LAG. The treatment options for lymphatic leaks include conservative dietary modification, sclerotherapy, embolization, and surgery. We present a case of a 48-year-old man who developed a symptomatic left retroperitoneal lymphatic fluid collection after left nephrectomy, complicated by postoperative retroperitoneal abscess. Retroperitoneal duct leak was confirmed via ultrasound-guided intranodal LAG and post-LAG CT. This leak was successfully managed with N-butyl cyanoacrylate glue embolization of the leaking lymphatics via fluoroscopic-guided catheterization of the leak via percutaneous access through the lymphatic fluid collection.

Postoperative chylothorax following lung cancer surgery with an aberrant course of thoracic duct: a case report

Postoperative chylothorax occurs relatively rarely after pulmonary resections, often caused intraoperatively by injury to the thoracic duct. We describe a case of postoperative chylothorax after lung cancer surgery with an aberrant thoracic duct course. A 66-year-old man showed abnormal findings on chest computed tomography (CT) during health screening and was suspected with primary lung cancer. Then, he underwent a right upper lobectomy with mediastinal lymph-node dissection. The histopathological findings confirmed lung adenocarcinoma. However, the patient developed a postoperative chylothorax and underwent revision surgery. An abnormally running thoracic duct, which was expected to flow into the right venous angle, was found at the cranial side of the right superior mediastinal dissection area and was clipped. Considering the many variations in the route of the thoracic duct, thoracic surgeons should remain alert for postoperative chylothorax when performing lung cancer surgery with mediastinal lymph-node dissection and prepare treatment strategies accordingly.

Embolization of the thoracic duct in patients with iatrogenic chylothorax

Chylothorax is leakage of lymphatic fluid accumulating in the pleural cavity due to the thoracic duct's (TD) trauma or obstructions. It generally occurs as a traumatic complication after general thoracic surgery procedures (0.4%), especially after esophagectomy (4.7-8.6%). Traditionally, surgical intervention is performed if conservative management fails, but reports of high mortality (2.1%) and morbidity (38%) have led to the development of a minimally invasive percutaneous treatment method; TD embolization (TDE). The records of all patients treated for chylothorax with TDE from April 2015 to June 2019 were reviewed. Only patients with iatrogenic chylothorax were included. The outcomes measures are defined as a technical and a clinical success. A technical success, is defined as the ability to perform the embolization procedure, thereby injecting embolizing material Histoacryl with or without coils. A clinical success is defined as a complete cessation of lymphatic leakage into the pleural cavity without surgical intervention and, therefore, a cured patient. Lymphography was performed in all patients, and visualization of cisterna chyli was achieved in 14/17 patients (82.4%). Of the 17 patients included, 15 patients were successfully embolized and cured of chylothorax (88.2%). Successfully embolized patients had a median discharge time of 7 days. Most patients reported postprocedural pain, which was dealt with using conventional pain medication. TDE seems like a safe percutaneous treatment technique with a high clinical success rate in iatrogenic chylothorax patients which can be readily implemented if the clinical experience is available..

Pediatric chylous ascites treatment with combined ultrasound and fluoroscopy-guided intranodal lymphangiography

Chylous ascites is a form of ascites resulting from the leakage of lymph into the peritoneal cavity, which is particularly rare in children, most common etiology being an iatrogenic injury to lymphatics during surgery. Initial conservative management options include medium-chain triglycerides-based diet, somatostatin analogs, and total parenteral nutrition. If these fail, then interventions such as paracentesis with sclerotherapy, surgical ligation, or peritoneal shunts have been described. This study reports a case of a 7-year-old child with refractory chylous ascites to demonstrate a minimally invasive technique of intranodal lymphangiography with lipiodol as a viable treatment option for chylous ascites in children, particularly in cases of minor and undetectable leaks.

Intranodal Lymphangiography With High-Dose Ethiodized Oil Shows Efficient Results in Patients With Refractory, High-Output Postsurgical Chylothorax: A Retrospective Study

OBJECTIVE. The purpose of this study is to evaluate the safety and efficacy of intranodal lymphangiography (INL) with high-dose ethiodized oil in patients with postoperative refractory chylothorax. MATERIALS AND METHODS. A retrospective review of a cohort of 18 patients with refractory postoperative chylothorax seen between May 2015 and March 2019 was conducted. All patients underwent intranodal lymphangiography with high doses of ethiodized oil (mean, 75 mL; range, 40-140 mL). The following information was gathered from the institutional database: patient demographics, type of surgery, output volumes, interval between surgery and lymphangiography, imaging results, amount of ethiodized oil injected, clinical success, and time to resolution. RESULTS. Of the 18 patients, 11 (61%) had previously undergone thoracic duct ligation, and seven (39%) had not. A lymphatic leak was confirmed by lymphangiography in 12 of 18 patients (67%). A total of five patients underwent a second session of INL, which was successful in three of the patients (60%). Removal of all chest tubes was possible in 15 of 18 patients (83%) after a mean of 12 days (range, 1-25 days). Two patients had an anastomotic leak develop after esophagectomy and died with their chest tubes in situ. One patient underwent thoracic duct ligation after two failed INL procedures. No complications were recorded. CONCLUSION. INL with a high dose of injected ethiodized oil is a safe and effective procedure for the management of postsurgical refractory chylothorax, with chest tube removal in 83% of patients.

Therapeutic Lymphatic Embolization in Pediatric Primary Intestinal Lymphangiectasia

Primary intestinal lymphangiectasia (IL) can cause leakage of lymphatic fluids into the gastrointestinal tract, eventually leading to protein-losing enteropathy. A 15-year-old male patient, whose disease began at the age of 8 years, recently felt worsening general weakness. After diagnosing abnormal lymphatic lesions in the duodenum through endoscopy with biopsy and contrast-enhanced magnetic resonance lymphangiography, glue embolization of the leaking duodenal lymphatic channel was successfully performed. This procedure is typically reserved for adult patients, although as shown in this case, it can be properly performed in children. His serum albumin level was initially 1.5 g/dL, but elevated to 5.0 g/dL after two sessions of lymphatic embolization. Accordingly, we suggest that embolization could potentially be considered a first-line treatment for focal lesions of primary intestinal IL.

Novel interventional radiological management for lymphatic leakages after gynecologic surgery: lymphangiography and embolization

Post-operative lymphatic leakage is a common complication of a radical gynecologic surgery involving aggressive lymph node dissection. Its manifestation varies from asymptomatic lymphoceles to life-threatening chylous ascites. In the past, nuclear medicine lymphoscintigraphy was the sole imaging modality for the confirmation of the leakage, of which application is limited due to its poor spatial resolution. While a conservative treatment with percutaneous drainage was the mainstream treatment method, surgical exploration was the last resort for the recalcitrant leakages. Recently, there have been a series of innovations in the field of interventional radiology, including intranodal Lipiodol^® lymphangiography, dynamic magnetic resonance (MR) lymphangiography, lymphatic embolization, and mesenteric lymph node lymphangiography. Intranodal Lipiodol^® lymphangiography provides very reliable and secure access to the lymphatic system, while requiring only fundamental skills and equipment available to all interventional radiologists. Besides, Lipiodol^® is being received a spotlight for its potential therapeutic effects on refractory lymphatic leakage. Dynamic MR lymphangiography plays a vital role in the diagnosis and management of non-traumatic lymphatic diseases, as well as in the post-operative lymphatic leakage with its superior contrast, spatial and temporal resolution. Lymphatic embolization is a technique of using N-BCA glue, a liquid embolic agent, for lymphatic leakages. It can be further described as lymphopseudoaneurysm (LPA) embolization or lymph node embolization, according to which structure is being embolized. Lymphatic embolization opened a new realm of possibilities in the field of interventional lymphology, resulting in the development of treatment approaches for chylous ascites and lymphoceles. Mesenteric lymph node lymphangiography offers the opacification of the upstream mesenteric chylous lymphatic system and can detect lymphatic leakage from the intestinal trunk or the more proximal parts of the mesenteric lymphatic system. With the advent of these latest interventional radiological techniques, more comprehensive approaches to the management of recalcitrant post-operative lymphatic leakages have been enabled.

Real-time indocyanine green lymphangiography in radical resection of right colon cancer allows the identification of chyle leakage

Chyle leakage can be caused by abdominal surgery and managed successfully without surgical treatment; however, no preventive measures are available. Therefore, we introduce a new method to prevent post-operative chyle leakage.

To investigate the role of indocyanine green (ICG) lymphangiography in the reduction of chyle fistula formation after radical resection of right colon cancer.

Five patients with a diagnosis of right colon cancer undergoing laparoscopic radical colectomy with D3 lymph node dissection were examined in this study. At the end of the operation, two points of 2.5 mg ICG were injected subserosally at the proximal end of the anastomosis (1 ml per point). Then the surgical field was screened by using ICG fluorescence to accurately locate the chyle leakage. Chyle leakage was noted and repaired with a Hem-O-Lock. The volume of output of each drain after surgery was measured daily until the patients were discharged.

We were able to observe ICG fluorescence in the lymphatic vessels within 3 minutes of ICG injection. This visualization allowed us to accurately locate and quickly repair chyle leakage within 5 minutes. Clinical observation after surgery and at a 1-month follow-up showed no chyle leakage in all 5 patients.

Indocyanine green lymphangiography can feasibly guide the location and repair of chyle leakage after right colon cancer resection.

Application of ultrasound-guided intranodal lymphangiography and embolisation in cancer patients with postoperative lymphatic leakage

BACKGROUND

Traumatic lymphatic leakage is a rare but potentially life-threatening complication. The purpose of this study was to introduce ultrasound-guided intranodal lymphangiography and embolisation techniques for postoperative lymphatic leakage in patients with cancer.

METHODS

From January 2018 through June 2020, seven cancer patients (three males, four females, aged 59-75 years [mean 67.57 ± 6.11 years]) developed lymphatic leakage after abdominal or pelvic surgery, with drainage volumes ranging from 550 to 1200 mL per day. The procedure and follow-up of ultrasound-guided intranodal lymphangiography and embolisation were recorded. This study retrospectively analysed the technical success rate, operative time, length of hospital stay, clinical efficacy, and complications.

RESULTS

The operation was technically successful in all patients. Angiography revealed leakage, and embolisation was performed in all seven patients (7/7, 100%). The operative time of angiography and embolisation was 41 to 68 min, with an average time of 53.29 ± 10.27 min. The mean length of stay was 3.51 ± 1.13 days. Lymph node embolisation was clinically successful in five patients (5/7, 71.43%), who had a significant reduction in or disappearance of chylous ascites. The other two patients received surgical treatment 2 weeks later due to poor results after embolisation. All patients were followed for 2 weeks. No serious complications or only minor complications were found in all the patients.

CONCLUSIONS

Ultrasound-guided intranodal lymphangiography and embolisation were well tolerated by the patients, who experienced a low incidence of complications. Early intervention is recommended for cancer patients with postoperative lymphatic leakage.

First successful case of percutaneous transabdominal thoracic duct embolization (PTTDE) for chylous ascites resulting from laparoscopic gastric cancer surgery

A 61-year-old woman underwent laparoscopy-assisted distal gastrectomy (LADG) with extragastric lymph node dissection (D2). Two months later, she was readmitted to hospital to be treated for chylous ascites. Oral intake was discontinued and total parenteral nutrition started, but increasing body weight and decreasing serum albumin concentration was not controllable. Percutaneous transabdominal thoracic duct embolization (PTTDE) was performed on the 8th day after the readmission. Five days after PTTDE, oral intake was resumed. Seventeen days after PTTDE, the patient was discharged without recurrence of ascites. She has remained asymptomatic. We describe here the first patient with chylous ascites two months after LADG with D2 dissection for early gastric cancer who was successfully treated by PTTDE.

Individual approach for treatment of primary intestinal lymphangiectasia in children: single-center experience and review of the literature

Background

Intestinal lymphangiectasia is a rare disease. Thus, prospective studies are impossible, and therapy is still controversial. Several medicines are suggested for treatment but there are no existing indications for drug choice and treatment guidelines. We aimed to introduce the action mechanism of each drug and treatment overview in a single-center experience and a review of the literature on second-line therapy for primary intestinal lymphangiectasia.

Method

Children under 18 years old diagnosed with intestinal lymphangiectasia from June 2000 to June 2020 were included and retrospectively reviewed in the study. Capsule endoscopy, MR lymphangiography, or whole-body MRI for investigating the extent of abnormal lymphatic vessels in addition to endoscopy and biopsy were conducted. The individual treatment approaches depended upon the lymphangiectasis locations involved.

Results

Only one patient showed a response to dietary therapy. One patient was successfully cured after two therapeutic lymphatic embolization. Octreotide was tried for two patients who had extensive lymphangiectasis. Lymphangiectasis recurred when octreotide was used for 3 months in one patient, and there was no effect in the other patient. Sirolimus was tried for four patients. Two of them had abnormal lymphatic lesions only in the intestine, and the others had extensive lymphangiectasis. The former group showed clinical improvement after 3–4 months of sirolimus treatment, whereas the latter group showed clinical improvement only after 1 month of sirolimus treatment.

Conclusion

Surgery or embolization is a potential therapeutic option for patients with focal abnormal lymphatic lesions. Octreotide is not an optimal choice for patients with extensive lymphangiectasis. Sirolimus is an effective and safe drug and can be the first drug of choice for patients with extensive lymphangiectasis.

Chylothorax after Lung Cancer Surgery: A Key Factor Influencing Prognosis and Quality of Life

Chylothorax is caused by the accumulation of chylous fluid in the pleural cavity due to the injury of the thoracic duct or its tributaries. Chylothorax following lung cancer surgery, especially pulmonary resection and mediastinal lymph node dissection, is a raw potential postoperative complication as previously reported. Chylothorax might lead to a high mortality rate if not addressed in a timely fashion. This article reviews the anatomy of the thoracic duct, risk factors of postoperative chylothorax, diagnoses and management with chylothorax, and intraoperative prevention of chylothorax. With the development of researches on postoperative chylothorax, more effective treatment and prevention measures need to be proposed to better solve this clinical problem.

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.

The roles of iodized oil-based lymphangiography and post-lymphangiographic computed tomography for specific lymphatic intervention planning in patients with postoperative lymphatic fistula: a literature review and case series

In the management of patients with postoperative lymphatic fistula (LF) in different locations, iodized oil-based lymphangiography (LAG) from trans-pedal or intranodal route is an established diagnostic approach with the potential to plan further interventional treatments. However, specific lymphatic interventions are indicated depending on different locations and morphologies of the LF. After a systematic literature review, four types of interventions can be considered, including direct leakage embolization/sclerotherapy (DLE/DLS), percutaneous afferent lymphatic vessel embolization (ALVE), percutaneous afferent lymphatic vessels disruption/sclerotherapy (ALVD/ALVS), and trans-afferent nodal embolization (TNE). In the iodized oil-based LAG, three potential lymphatic targets including confined leakage, definite afferent LVs, and definite closest afferent LNs should be comprehensively assessed. For optimal prospective treatment planning for LF, iodized oil-based post-lymphangiographic computed tomography (post-LAG CT) is a useful complement to the conventional iodized oil-based LAG, which can be performed easily after LAG. This review article summarized the current evidence of the specific lymphatic interventions in patients with postoperative LF and explored the potential benefits of post-LAG CT in the intervention planning from a case series.

Intranodal lymphangio-embolisation as treatment for lymphocele after kidney transplantation: A case report

Introduction and objectives:

The rate of symptomatic lymphoceles requiring intervention after renal transplantation is reported to be only 5.6%. Controversies prevail in the current literature regarding the management of symptomatic lymphoceles post renal transplantation, with no established algorithm. The creation of a peritoneal window, frequently performed laparoscopically, is deemed the gold standard for management. We herin report the case of a lymphocele post renal transplant treated minimally invasively with intranodal lymphangio-embolisation, with a review of the current literature of this uncommon procedure.

Methods:

This was a retrospective review of this patient’s electronic medical records.

Results:

We present a 43-year-old male with end-stage kidney disease secondary to chronic glomerulonephritis, having been on hemodialysis for seven years. He underwent a deceased donor dual kidney transplant, complicated postoperatively by renal vein thrombosis in one of the grafts, resulting in early graft nephrectomy as well as a distal ureterovesical leak requiring reimplantation. On re-implantation on postoperative day 16, he was noted to have a persistent high drain ouput with a normal drain fluid creatinine. A right intranodal lymphagiogram was performed, and this demonstrated an active lymph leak around the transplanted kidney. A 33% glue (N-butyl cyanoacrylate)-Lipodiol infusion was then injected at a rate of 0.2 mL/min intranodally under fluoroscopic guidance. The patient underwent another repeat embolisation five days later for a residual lymph leak with satisfactory results. Drain output subsequently decreased, and the drain was removed.

Conclusions:

This case suggests that intranodal lymphangiography and embolisation may not only be a diagnostic tool but can be considered as an effective, minimally invasive and safe method for the treatment of lymphoceles after kidney transplantation.

Isolated thoracic duct injury from blunt force trauma

Isolated thoracic duct injury is an uncommon clinical event and is rare in the setting of trauma. We describe a case of an isolated thoracic duct injury resulting in the development of bilateral chylothorax following a motor vehicle collision in the absence of any other definable injury. We outline the initial patient presentation and diagnosis. After failing a trial of conservative management the patient underwent lymphangiography followed by thoracic duct ligation with pleurodesis. This case highlights the importance of recognizing thoracic duct injury following trauma.

Lymphatic imaging and intervention for chylothorax following thoracic aortic surgery

Reports on lymphatic intervention for chylothorax complicating thoracic aortic surgery are limited. We aimed to evaluate technical and clinical outcomes of lymphangiography and thoracic duct embolization (TDE) for chylothorax complicating thoracic aortic surgery.Nine patients (mean age, 38.9 years) who underwent chylothorax interventions after thoracic aortic surgery (aorta replacement [n = 7] with [n = 2] or without [n = 5] lung resection, and vascular ring repair [n = 2]) were reviewed retrospectively. Magnetic resonance (MR) lymphangiograms were obtained in 5 patients. The median interval between surgery and conventional lymphangiography was 9 days (range, 4-28 days). TDE clinical success was defined as lymphatic leakage resolution with chest tube removal within 2 weeks.MR lymphangiograms revealed contrast leakage from the thoracic duct (n = 4) or no definite leakage (n = 1), which correlated well with conventional lymphangiogram findings. The technical success rate of conventional lymphangiography was 88.9% (8/9); 8 patients showed contrast leakage, while the patient without definite leakage on MR lymphangiography had small inguinal lymph nodes, and thoracic duct visualization by conventional lymphangiography failed. The technical success rates of antegrade and retrograde TDE via pleural access were 75% (6/8) and 100% (3/3), respectively. Clinical outcomes after embolization, as judged by the tube-removal day, were similar between low- (<500 mL/day) and high-output (≥500 mL/day) chylothorax patients. The drainage amount decreased significantly after lymphangiography/TDE, from 710.0 mL/day to 109.7 mL/day (p < .05). The clinical success rate of TDE was 87.8% (7/8).Conventional lymphangiography and TDE yielded high technical success rates and demonstrated encouraging clinical outcomes for chylothorax complicating thoracic aortic surgery.

Interventional Radiology Treatment for Postoperative Chylothorax

Postoperative chylothorax is a rare occurrence after various thoracic surgical procedures, but it poses a substantial risk of morbidity and mortality. Thoracic duct embolization (TDE) is currently deemed the optimal treatment due to its safety and efficacy. This review offers an introduction to interventional options in this setting, detailing the steps of TDE for the edification of those engaged in postoperative care.

Lymphatic Imaging: Current Noninvasive and Invasive Techniques

After nearly disappearing, invasive lymphangiography not only has resurged, but new approaches have been developed to guide lymphatic interventions. At the same time, noninvasive lymphatic imaging is playing a larger role in the evaluation of lymphatic pathologies. Lymphangioscintigraphy, computed tomography lymphangiography, and magnetic resonance lymphangiography are increasingly being used as alternatives to invasive diagnostic lymphangiography. The purpose of this article is to review current invasive and noninvasive lymphatic imaging techniques.

Resolution of refractory chylothorax with a combination of talc pleurodesis and CPAP

Chylothorax is an uncommon cause of pleural effusion. Recurrent chylous effusions are often resistant to conservative treatment and many need surgical intervention. We report a 69‐year‐old woman with refractory idiopathic chylothorax resistant to medium‐chain triglyceride diet and intermittent thoracentesis. Lymphangiography and lymphoscintigraphy failed to identify the site of leakage. We initiated continuous positive airway pressure (CPAP) 12 h before and 48 hours after talc pleurodesis. Chest drain was removed at day 3 and she was discharged at day 5. To our knowledge, this is the first case of successful resolution of idiopathic refractory chylothorax with CPAP ventilation used in tandem with talc pleurodesis.

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.

A Single-Center Experience With Percutaneous Interventional Management of Refractory Chylous Ascites

Purpose:

Management of chylous ascites is poorly understood with no management guidelines. We retrospectively reviewed patients treated for chylous ascites at our institution to evaluate efficacy and safety of lipiodol lymphangiography and embolization.

Materials and Methods:

Seven patients underwent percutaneous interventional management of chylous ascites (average age 52.5 years, 3 female, 6 post-surgical, 1 pancreatitis) from 2012. All patients underwent lipiodol inguinal lymph node injection. Adjunctive glue embolization was performed if a leak was identified. Data were collected on the cause of chylous ascites, conservative management strategies, procedural details, and success.

Results:

All patients had chylous ascites refractory to conservative management. Preprocedure lymphoscintigraphy identified a retroperitoneal leak in 6 patients. Seven patients underwent 12 lymphangiogram procedures; 8 were performed at our institution. Lymphangiography identified a leak in 5 patients (71%). Success was achieved in 2 patients (28%) treated at our institution after glue embolization following cannulation of the leaking lymphatic channels and 1 patient (14%) after lymphangiography alone for an overall success rate of 43% (3/7). Two patients (29%) were successfully treated after one procedure. Two patients (29%) unsuccessfully treated at our institution were referred to a specialized center in the United States. No 30 day post procedural complications.

Conclusions:

In our experience, lymphangiography and embolization was a safe, relatively effective and minimally invasive method for treating medically refractory chylous ascites. Complex cases required referral to a specialized institution with resources unavailable at our tertiary care center.

Lymphangiography with or without Embolization for the Treatment of Postoperative Chylous Ascites

BACKGROUND

Lymphatic interventions have recently been increasingly used for treating lymphatic leak of the abdomen and pelvis. This retrospective case study series and systematic review evaluated the efficacy and safety of lymphatic interventions for the treatment of postoperative lymphatic leak of the abdomen and pelvis.

METHODS

A total of 15 consecutive patients with postoperative lymphatic leak of the abdomen and pelvis treated with lymphatic interventions (i.e., diagnostic intranodal or pedal lymphangiography [LAG], i.e., potentially therapeutic or diagnostic LAG with intention to treat through embolization) at our institution were reviewed. The data of 72 patients from 13 relevant articles identified through a literature search of the MEDLINE/PubMed, EMBASE, and Cochrane databases were extracted.

RESULTS

The data of 87 patients (mean age, 59 [range, 24-84] years) were pooled. The technical success rate of LAG (intranodal approach, 78.2% [68/87]; pedal approach, 21.8% [19/87]) was 97.7% (85/87; 95% confidence interval [CI], 91.5-99.9%). Of the 85 patients in whom technical success of LAG was achieved, data on clinical success were available for 47 patients (55.3%). The clinical success rate of LAG was 68.1% (32/47; 95% CI, 53.8-79.7%). Of the 85 patients in whom technical success of LAG was achieved, 38 (44.7%) underwent embolization. The technical success rate of embolization was 97.4% (37/38; 95% CI, 85.3-99.9%). The clinical success rate of embolization was 70.3% (26/37; 95% CI, 54.1-82.6%). Major complications did not occur. The overall primary and secondary clinical success rates were 65.5% (57/87; 95% CI, 55.0-74.7%) and 78.2% (68/87; 95% CI, 68.3-85.6%), respectively.

CONCLUSIONS

Lymphatic interventions are safe and relatively effective adjunct to conservative therapy, with the primary and secondary clinical success rate of 65.5% and 78.2%, for postoperative lymphatic leak of the abdomen and pelvis.

Thoracic Duct Embolization in Post-neck Dissection Chylous Leakage: A Case Series of Six Patients and Review of the Literature

Chylous leak is a serious complication of neck dissection. Patients are often managed conservatively, and failure of conservative management necessitates surgical management, which adds to their morbidity. We present a case series demonstrating the value of thoracic duct embolization (TDE) in management of patients with chylous leaks following neck dissection who have failed conservative management and to review the literature on this specific application of TDE. Between 2011 and 2019, six patients underwent a total of seven TDE procedures. Lymphatic leak was identified, and clinical success was achieved in all patients, with one patient requiring repeat TDE. No minor or major complications were reported. In conclusion, TDE is a safe and effective tool in management of chylous leaks following neck dissection.

Conventional Lymphangiography (CL) in the Management of Postoperative Lymphatic Leakage (PLL): A Systematic Review

BACKGROUND

 Postoperative lymphatic leakage (PLL) is usually managed by conservative and/or surgical treatments but these procedures can be challenging to perform and potentially clinically ineffective. Therefore, conventional lymphangiography (CL) has emerged as an important alternative. The aim of this review is to present the available outcome data on CL in the management of PLL.

METHOD

 A systematic literature search (PubMed) using the MeSH term "lymphangiography" was performed and the search was restricted to literature published between January 2007 and August 2019. Identification, screening, and assessment for eligibility and inclusion were conducted in accordance with PRISMA.

RESULTS

 From the initially obtained 1006 articles (identification), 28 articles with a total of 201 patients were finally included (inclusion). The methodological quality of all included articles corresponds to level 4 (Oxford Centre for Evidence-based Medicine - Levels of Evidence, March 2009). PLL occurs after oncological and non-oncological surgery in the form of chylothorax, chylous ascites, and cervical, thoracic, abdominal and peripheral lymph fistula and/or lymphocele. The technical success rate of CL is 75-100 %. Access for CL is transpedal (176 patients) or intranodal (25 patients). Lipiodol is used as the contrast material in all articles, with a maximum amount of 20 ml for transpedal CL and 30 ml for intranodal CL. The X-ray imaging modalities used for CL are fluoroscopy, radiography and/or CT. Two articles report CL-associated major complications and CL-associated morbidity and mortality. The PLL cure rate is 51-70 % for transpedal CL (time to PLL cure: 2-29 days) and 33-100 % for intranodal CL (time to PLL cure: 2-< 30 days). Bailout procedures in the case of clinically ineffective CL include a range of treatments.

CONCLUSION

 CL is feasible, safe, and effective in the management of PLL. Lipiodol as the contrast material is essential in CL because the highly viscous iodinated poppy-seed oil has not only diagnostic but therapeutic effects. Guidelines and randomized controlled trials are further steps towards defining the ultimate value of CL.

KEY POINTS

  · PLL is a difficult-to-treat and potentially life-threatening surgical complication.. · CL has emerged as an alternative to conservative/surgical treatment of PLL.. · CL is feasible, safe, and effective in the management of PLL. · Lipiodol-based CL can be regarded as a therapeutic procedure.. · Guidelines and randomized controlled trials are further important steps..

CITATION FORMAT

· Sommer CM, Pieper CC, Itkin M et al. Conventional Lymphangiography (CL) in the Management of Postoperative Lymphatic Leakage (PLL): A Systematic Review. Fortschr Röntgenstr 2020; 192: 1025 - 1035.

Back to the Future: Lipiodol in Lymphography-From Diagnostics to Theranostics

Lipiodol is an iodinated poppy seed oil first synthesized in 1901. Originally developed for therapeutic purposes, it has mainly become a diagnostic contrast medium since the 1920s. At the end of the 20th century, Lipiodol underwent a transition back to a therapeutic agent, as exemplified by its increasing use in lymphangiography and lymphatic interventions. Nowadays, indications for lymphangiography include chylothorax, chylous ascites, chyluria, and peripheral lymphatic fistula or lymphoceles. In these indications, Lipiodol alone has a therapeutic effect with clinical success in 51% to 100% of cases. The 2 main access sites to the lymphatic system for lymphangiography are cannulation of lymphatic vessels in the foot (transpedal) and direct puncture of (mainly inguinal) lymph nodes (transnodal). In case of failure of lymphangiography alone to occlude the leaking lymphatic vessel as well as in indications such as protein-losing enteropathy, postoperative hepatic lymphorrhea, or plastic bronchitis, lymphatic vessels can also be embolized directly by injecting a mixture of Lipiodol and surgical glues (most commonly in thoracic duct embolization). The aim of this article is to review the historical role of Lipiodol and the evolution of its clinical application in lymphangiography over time until the current state-of-the-art lymphatic imaging techniques and interventions.

Contemporary lymphatic interventions for post-operative lymphatic leaks

Post-operative lymphatic injuries are uncommon but increase morbidity and mortality in vulnerable patient populations. Post-surgical lymphatic leaks are most commonly a consequence of radical neck dissection, esophagectomy, and lung cancer resections or retroperitoneal surgeries such as radical nephrectomy and lymphadenectomy. Injury may occur anywhere along the lymphatic chains with most serious leaks occurring along the axial skeleton between the inguinal region and the left venous angle. The resultant clinical manifestations of a lymphatic leak are dependent on the location and severity of the lymphatic injury as well as patient factors. Treatment strategies are tailored toward the causative etiology, symptom severity, and daily leak volume with higher volume leaks warranting a more aggressive approach. Lymphangiography and lymphatic interventions, such as embolization, are increasingly applied for both the diagnosis and as a minimally invasive therapy for lymphatic injuries. Herein, a review of lymphatic anatomy, lymphangiography, and lymphatic interventions for the treatment of post-operative chylothorax, chylous ascites, and lymphocele is presented.

Complete resolution of chylopericardium after chemotherapy for chronic lymphocytic leukemia

Nontraumatic chylous pleural effusions (chylothorax) and pericardial effusions (chylopericardium) are rare. They can, however, accompany intrathoracic malignancies and, most commonly, lymphomas. An association of chronic lymphocytic leukemia (cll) with chylopericardium has rarely been reported. A 68-year-old woman with cll, previously treated with single-agent fludarabine in the community, developed pleuritic chest pain and a new pericardial effusion. Computed tomography (ct) imaging of her chest revealed a large pericardial effusion with progressive lymphadenopathy. Pericardiocentesis identified a chylous effusion, and complete evacuation was achieved by catheter drainage. The cll was not treated. An asymptomatic pericardial effusion subsequently recurred. Pericardiocentesis was not repeated. Lymph node biopsy and flow cytometry revealed no evidence of large-cell lymphoma transformation. The patient was treated with 6 cycles of chlorambucil and obinutuzumab. Imaging of her chest by ct between cycles 2 and 3 revealed a marked resolution of the intrathoracic lymphadenopathy, with complete disappearance of the pericardial effusion. Repeat imaging at 5 months and again at 3 years after completion of chemotherapy demonstrated no recurrence of either the lymphadenopathy or the pericardial effusion. The mechanism of production and the treatment of chylous effusions are poorly defined. In this case, resolution of the pericardial effusion with effective chemotherapy is postulated to have alleviated obstruction of anterograde lymphatic flow facilitating drainage into the systemic venous system and allowing for spontaneous complete resolution of the pericardial effusion without surgical intervention.