A chylothorax in a young woman: The difficulties of medical management

Lymphangioleiomyomatosis is a rare pulmonary disease affecting women of childbearing age. Whilst chylothorax is a well-recognized complication of the condition, management strategies aren't well-defined, have low success rates and are often only available at tertiary or specialist centres. We describe a case of a young woman referred to pleural clinic with a chylous effusion found to be secondary to lymphangioleiomyomatosis. Initial medical management was unsuccessful and recurrent drainages caused significant complications. Remission was ultimately achieved with a combination of mTOR inhibitors and interventional radiology techniques.

Feasibility study of percutaneous thoracic duct embolization with lower-limb intermittent pneumatic compression devices

PURPOSE

To demonstrate intranodal thoracic duct embolization (TDE) for treating chyle leaks following thoracic surgery and the feasibility of applying lower-limb intermittent pneumatic compression devices during TDE.

METHODS

Between December 2017 and October 2020, 12 consecutive TDEs for post-operative chyle leaks were performed in 11 patients using intranodal lymphangiogram (IL) with an intermittent pneumatic compressive device applied to the lower limb. The procedure's duration, technical/clinical success, and complications were retrospectively evaluated.

RESULTS

IL was successful at imaging the thoracic duct in all procedures (100%), and TDE had an intention- to-treat success rate of 92% (11/12). No related complications were observed during follow-up, which took place at a mean of 27 days. The time from the commencement of lymphangiogram until visualization of the thoracic duct was a mean of 21.6 min, and the mean overall procedure time was 87.3 min.

CONCLUSION

This study supports IL-guided TDE as a safe and effective option to treat post-thoracic surgery chyle leaks. We revealed shorter lymphangiogram times compared with previously published studies, and we postulate that the application of intermittent lower-limb pneumatic compressive devices contributed toward this study's results by expediting the return of lymph from the lower limb. This study is the first to illustrate this approach in TDE and advocates for randomized controlled studies to further evaluate the influence of intermittent pneumatic compressive devices on the procedure.

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.

A gelatinous veil inside the abdomen of a pancreatic cancer patient. What lies beneath it?

Chylous ascites following pancreatic surgery results from surgical damage to the cisterna chyli or tributaries, with an incidence in pancreatic surgery of 1.8%-11%. Usually, conservative treatment is effective.

Intranodal lymphangiography with thoracic duct embolization for the treatment of chyle leaks after head and neck cancer surgery

BACKGROUND

Thoracic duct injury is a rare complication of head and neck surgery. Thoracic duct embolization (TDE) has been proposed to manage postoperative chyle leaks.

METHODS

Twelve patients who underwent lymphangiography for a chyle leak after head and neck surgery (M:F = 5:7, mean 55 years) were retrospectively reviewed. Lymphangiographic findings, technical success, complications, and clinical outcomes were analyzed.

RESULTS

Chyle leak was identified and TDE attempted in 11 of 12 patients. Three patients required repeat TDE. Technical success of TDE was 86% (12/14). Clinical success for patients with technically successful TDE was 90% (9/10). Median time until drain removal was 2.1 days in nine patients with clinical success. Two major complications were encountered, chylothorax after initial TDE, requiring additional TDE and in one case surgical TD ligation.

CONCLUSIONS

TDE is a safe treatment for chyle leaks after head and neck surgery with high technical and clinical success rates.

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.

Sentinel lymph node detection differs when comparing lymphoscintigraphy to lymphography using water soluble iodinated contrast medium and digital radiography in dogs

Sentinel lymph node (SLN) mapping by various means has become standard of care in certain types of human cancers and is receiving more attention in veterinary oncology. Current SLN mapping techniques can be costly and often require advanced imaging equipment. The objective of this prospective, method comparison study was to compare an SLN mapping protocol of lymphoscintigraphy to lymphography using water soluble iodinated contrast medium (WIC) and digital radiography for identification of an SLN. Lymphoscintigraphy and lymphography were performed on eight healthy purpose-bred dogs using technetium-99m sulfur colloid and WIC injected into the subcutaneous tissues in a four-quadrant technique around a predefined area of skin on the brachium. Images were obtained using a gamma camera and digital radiography at different time points post-injection. Image sequences were evaluated by one of two American College of Veterinary Radiology board-certified veterinary radiologists. Data obtained were compared between methods using descriptive statistics. An SLN was identified in all dogs with lymphoscintigraphy and seven of eight dogs with lymphography. Agreement between results of the lymphoscintigraphy and lymphography studies was a complete match in three dogs, a partial match in four dogs, and no match in one dog. The SLN detected differed based on the imaging modality used.

Cerebral Embolization of Ethiodized Oil following Intranodal Lymphangiography

Intranodal lymphangiography (IL) has supplanted pedal lymphangiography (PL) as an easier and more practical approach to opacifying lymphatic vessels for interventional radiologists treating refractory chyle leaks. As more interventional radiologists-many of who are not trained in or have not performed PL-incorporate IL into their practice, it is imperative that they be familiar with the risks of lymphangiography, including pulmonary and systemic embolization of oily contrast material. Herein, the authors report a devastating case of cerebral embolization of ethiodized oil following IL and review the literature regarding systemic embolization following lymphangiography.