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Hirano T, Yamamoto M, Kondo H, Oba H. Thoracic duct disruption without lymphangiographic thoracic duct visualization for refractory chylothorax: A case report. Radiol Case Rep 2024; 19:242-245. [PMID: 38028294 PMCID: PMC10630758 DOI: 10.1016/j.radcr.2023.09.097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 09/27/2023] [Indexed: 12/01/2023] Open
Abstract
Percutaneous treatments, including thoracic duct embolization (TDE) and thoracic duct disruption (TDD), are reportedly effective and safe alternatives to surgical thoracic duct ligation for refractory chylothorax. When catheterization of the thoracic duct is impossible, TDD can be performed as long as the thoracic duct can be opacified by lymphangiography. However, no report has described percutaneous treatment when the thoracic duct cannot be visualized. In this case, TDE was not feasible because intranodal lymphangiography failed to opacify the thoracic duct: cannulation was not achieved. Therefore, we aimed to disrupt the thoracic duct by puncturing the retrocrural area where it was anatomically suspected to be located. Chylothorax improved thereafter. In cases without lymphangiographic thoracic duct visualization, TDD by puncturing the retrocrural space might improve refractory chylothorax.
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Affiliation(s)
- Takaki Hirano
- Department of Radiology, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-Ku, Tokyo, 173-8606, Japan
| | - Masayoshi Yamamoto
- Department of Radiology, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-Ku, Tokyo, 173-8606, Japan
| | - Hiroshi Kondo
- Department of Radiology, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-Ku, Tokyo, 173-8606, Japan
| | - Hiroshi Oba
- Department of Radiology, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-Ku, Tokyo, 173-8606, Japan
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Parmeggiani D, Gualtieri G, Terracciano G, Gambardella C, Parisi S, Brusciano L, Ruggiero R, Docimo L. Prolonged iatrogenic thoracic duct chylous fistula in Neck Surgery: conservative management or surgery? A Literature review. Scand J Surg 2021; 110:550-556. [PMID: 33423617 DOI: 10.1177/1457496920987076] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Thoracic duct chylous fistula is a rare complication following neck surgery, especially for malignant disease. Despite its low incidence, it can be a life-threatening postoperative complication increasing the risk of infection, bleeding, hypovolemia, electrolyte imbalance, and malnutrition. Currently, the management of thoracic duct fistula is not standardized yet. It can range from conservative to surgical approaches, and even when surgery indication occurs, there is no unanimous agreement on timing and operative steps, so the surgical approach still remains mostly subjective, in accordance with clinical conditions of the patients and with surgeon's experience. AIMS The aim of the study was to search into Literature a common accepted behaviour in thoracic duct chylous fistula occurring. METHODS A literature review was carried out. Conservative treatments include fasting associated with total parental nutrition or low-fat diet, compressive dressings, and octreotide administration. If conservative treatment fails, in order to avoid dangerous consequences, functional repair of the thoracic duct injury with lymphovenous microanastomosis should be the preferred solution, rather than an approach that obliterates the thoracic duct or lymphatic-chylous pathways, such as thoracic duct embolization, therapeutic lymphangiography, and thoracic duct ligation. CONCLUSIONS In our experience, patients undergone thyroidectomy and neck dissection for thyroid-differentiated cancer, who report an unrecognized thoracic duct chylous fistula after surgery, must be treated via integrated conservative and surgical treatment. A literature review about thoracic duct chylous fistula following neck surgery, focusing on the current management and therapeutic approach, was furthermore carried out, in order to delineate the actual therapeutic options in case of thoracic duct chylous fistula occurrence.
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Affiliation(s)
- D Parmeggiani
- Division of General, Mini-invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli," Naples, Italy
| | - G Gualtieri
- Division of General, Mini-invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli," Naples, Italy
| | - G Terracciano
- Division of General, Mini-invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli," Naples, Italy
| | - C Gambardella
- Division of General, Mini-invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli," Naples, Italy
| | - S Parisi
- Division of General, Mini-invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli," Naples, Italy
| | - L Brusciano
- Division of General, Mini-invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli," Naples, Italy
| | - R Ruggiero
- Division of General, Mini-invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli," Naples, Italy
| | - L Docimo
- Division of General, Mini-invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli," Naples, Italy
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Cholet C, Delalandre C, Monnier-Cholley L, Le Pimpec-Barthes F, El Mouhadi S, Arrivé L. Nontraumatic Chylothorax: Nonenhanced MR Lymphography. Radiographics 2020; 40:1554-1573. [PMID: 33001788 DOI: 10.1148/rg.2020200044] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
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.
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Affiliation(s)
- Clément Cholet
- From the Department of Radiology, Saint-Antoine Hospital (AP-HP), 184 Rue du Faubourg Saint-Antoine, 75012 Paris, France (C.C., C.D., L.M.C., S.E.M., L.A.); Médecine Sorbonne University, Paris, France (C.C., L.A.); and Department of Thoracic and Pulmonary Surgery, Georges Pompidou European Hospital (AP-HP), Paris, France (F.L.P.B.)
| | - Coline Delalandre
- From the Department of Radiology, Saint-Antoine Hospital (AP-HP), 184 Rue du Faubourg Saint-Antoine, 75012 Paris, France (C.C., C.D., L.M.C., S.E.M., L.A.); Médecine Sorbonne University, Paris, France (C.C., L.A.); and Department of Thoracic and Pulmonary Surgery, Georges Pompidou European Hospital (AP-HP), Paris, France (F.L.P.B.)
| | - Laurence Monnier-Cholley
- From the Department of Radiology, Saint-Antoine Hospital (AP-HP), 184 Rue du Faubourg Saint-Antoine, 75012 Paris, France (C.C., C.D., L.M.C., S.E.M., L.A.); Médecine Sorbonne University, Paris, France (C.C., L.A.); and Department of Thoracic and Pulmonary Surgery, Georges Pompidou European Hospital (AP-HP), Paris, France (F.L.P.B.)
| | - Françoise Le Pimpec-Barthes
- From the Department of Radiology, Saint-Antoine Hospital (AP-HP), 184 Rue du Faubourg Saint-Antoine, 75012 Paris, France (C.C., C.D., L.M.C., S.E.M., L.A.); Médecine Sorbonne University, Paris, France (C.C., L.A.); and Department of Thoracic and Pulmonary Surgery, Georges Pompidou European Hospital (AP-HP), Paris, France (F.L.P.B.)
| | - Sanaâ El Mouhadi
- From the Department of Radiology, Saint-Antoine Hospital (AP-HP), 184 Rue du Faubourg Saint-Antoine, 75012 Paris, France (C.C., C.D., L.M.C., S.E.M., L.A.); Médecine Sorbonne University, Paris, France (C.C., L.A.); and Department of Thoracic and Pulmonary Surgery, Georges Pompidou European Hospital (AP-HP), Paris, France (F.L.P.B.)
| | - Lionel Arrivé
- From the Department of Radiology, Saint-Antoine Hospital (AP-HP), 184 Rue du Faubourg Saint-Antoine, 75012 Paris, France (C.C., C.D., L.M.C., S.E.M., L.A.); Médecine Sorbonne University, Paris, France (C.C., L.A.); and Department of Thoracic and Pulmonary Surgery, Georges Pompidou European Hospital (AP-HP), Paris, France (F.L.P.B.)
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