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Mori Y, Yamashita H, Sato S, Shindo H, Tachibana S, Fukuda T, Okamura M, Yamaoka A, Takahashi H, Yoshimoto K. Usefulness of preoperative ice cream consumption and novel postoperative drainage management in patients undergoing left-sided neck dissection for thyroid cancer: a nonrandomized prospective study. Surg Today 2024; 54:642-650. [PMID: 38052742 PMCID: PMC11102873 DOI: 10.1007/s00595-023-02771-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 10/10/2023] [Indexed: 12/07/2023]
Abstract
PURPOSE This study investigated the effects of ice cream consumption on chyle leakage after left lateral neck dissection in patients with thyroid cancer. METHODS A total of 491 patients with thyroid cancer underwent left lateral neck dissection with identification of the thoracic duct following ice cream consumption. Before closing the wound, the anesthesiologist increased the intrathoracic pressure to observe chyle leakage. If chyle leakage occurred postoperatively, the drain was removed using the drain negative pressure release test. RESULTS Postoperative chyle leakage was observed in 18 of the 491 patients who underwent left lateral neck dissection. We treated 17 patients conservatively and 1 patient surgically. Drains were removed within five days in all patients. After the drain negative pressure release test had been performed in eight patients, the drainage volume significantly decreased from an average of 175 ml to 31 ml per day. The average number of days until the removal of the drainage tube was 3.2 days. No perioperative complications were associated with ice cream consumption. CONCLUSIONS In left lateral neck dissection for thyroid cancer, performing surgery following ice cream consumption does not completely prevent chyle leakage; however, early drain removal is possible because there is only mild leakage.
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Affiliation(s)
- Yusuke Mori
- Department of Surgery, Yamashita Thyroid Hospital, 1-8 Simo-Gofukumachi, Hakata-Ku, Fukuoka City, Fukuoka, 812-0034, Japan.
| | - Hiroyuki Yamashita
- Department of Surgery, Yamashita Thyroid Hospital, 1-8 Simo-Gofukumachi, Hakata-Ku, Fukuoka City, Fukuoka, 812-0034, Japan.
| | - Shinya Sato
- Department of Surgery, Yamashita Thyroid Hospital, 1-8 Simo-Gofukumachi, Hakata-Ku, Fukuoka City, Fukuoka, 812-0034, Japan
| | - Hisakazu Shindo
- Department of Surgery, Yamashita Thyroid Hospital, 1-8 Simo-Gofukumachi, Hakata-Ku, Fukuoka City, Fukuoka, 812-0034, Japan
| | - Seigo Tachibana
- Department of Endocrinology, Yamashita Thyroid Hospital, Fukuoka City, Japan
| | - Takashi Fukuda
- Department of Endocrinology, Yamashita Thyroid Hospital, Fukuoka City, Japan
| | - Misa Okamura
- Department of Anesthesiology, Yamashita Thyroid Hospital, Fukuoka City, Japan
| | - Atushi Yamaoka
- Department of Anesthesiology, Yamashita Thyroid Hospital, Fukuoka City, Japan
| | - Hiroshi Takahashi
- Department of Surgery, Yamashita Thyroid Hospital, 1-8 Simo-Gofukumachi, Hakata-Ku, Fukuoka City, Fukuoka, 812-0034, Japan
| | - Koichi Yoshimoto
- Department of Surgery, Yamashita Thyroid Hospital, 1-8 Simo-Gofukumachi, Hakata-Ku, Fukuoka City, Fukuoka, 812-0034, Japan
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Lee EW, Shim DJ, Kim D, Baek SH. Retrograde Distal Thoracic Duct Leak Embolization via Access Through Lymphocele After Thyroidectomy and Neck Dissection. Korean J Radiol 2024; 25:501-503. [PMID: 38685739 PMCID: PMC11058421 DOI: 10.3348/kjr.2024.0247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 03/17/2024] [Accepted: 03/18/2024] [Indexed: 05/02/2024] Open
Affiliation(s)
- Edward Wolfgang Lee
- Division of Interventional Radiology and Liver Transplant Surgery, Department of Radiology and Surgery, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Dong Jae Shim
- Department of Radiology, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Doyoung Kim
- Department of Radiology, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seung Hwan Baek
- Department of Radiology, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Li J, Zhang WQ. Chylothorax following surgery for thoracic-duct cysts due to variations of the thoracic duct: A rare case report. Asian J Surg 2024; 47:2486-2487. [PMID: 38281835 DOI: 10.1016/j.asjsur.2024.01.092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 01/19/2024] [Indexed: 01/30/2024] Open
Affiliation(s)
- Jun Li
- First Clinical Medical College, The Guangdong Medical University, Zhanjiang, China
| | - Wan-Qing Zhang
- Department of Cardiothoracic Surgery, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China.
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4
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Zheng X, Yang X, Lei S. Chylous leakage after esophagectomy for esophageal cancer: a systematic review. J Cardiothorac Surg 2024; 19:240. [PMID: 38632619 PMCID: PMC11022397 DOI: 10.1186/s13019-024-02764-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 03/30/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Chylous leakage is a rare complication following esophagectomy; however, it can lead to mortality. We aimed to systematically evaluate the factors that may lead to increased chylous leakage after esophagectomy. METHODS Three databases (PubMed, Embase, and Cochrane Library) were systematically searched for all studies investigating the occurrence of chylous leakage after esophagectomy. RESULTS A total of 32 studies were identified, including 26 randomized controlled trials and 3 cohort and case-control studies, each. The overall incidence of chylous leakage was 4.7% (278/5,971 cases). Analysis of preoperative, intraoperative, and postoperative factors showed that most of the qualitative analysis results did not significantly increase the incidence of chylous leakage. In some quantitative analyses, the chylous leakage rate was significantly lower in the thoracic duct mass ligation group than in the conservative treatment group (relative risk [RR] = 0.33; 95% confidence interval [CI], 0.13-0.83; I2 = 0.0%; P = 0.327). Direct oral feeding significantly reduced chylous leakage compared with jejunostomy (RR = 0.06; 95% CI 0.01-0.33; I2 = 0.0%; P = 0.335). However, preoperative inspiratory muscle training (RR = 1.66; 95% CI, 0.21-12.33; I2 = 55.5%; P = 0.134), preoperative chemoradiotherapy (RR = 0.99; 95% CI, 0.55-1.80; I2 = 0.0%; P = 0.943), and robotic assistance (RR = 1.62; 95% CI, 0.92-2.86; I2 = 0.0%; P = 0.814) did not significantly reduce the incidence of chylous leakage. CONCLUSIONS Ligation of the thoracic duct and direct oral feeding can reduce the incidence of chylous leakage after esophagectomy in patients with esophageal cancer. Other contributing factors remain unclear and require validation in further high-quality studies.
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Affiliation(s)
- Xing Zheng
- Department of Osteoarthrosis, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Xi Yang
- Department of Vascular Surgery, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Sujuan Lei
- Department of Hepatobiliary Surgery, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China.
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Kitashima F, Shimada N, Machii Y, Tanaka M. Successful Percutaneous Thoracic Duct Embolization for Chylothorax After Total Arch Replacement. Tex Heart Inst J 2024; 51:e228077. [PMID: 38623730 DOI: 10.14503/thij-22-8077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
Chylothorax after cardiac surgery is a rare complication associated with severe morbidity and mortality. This report documents successful treatment with percutaneous thoracic duct embolization for chylothorax after total arch replacement. A 69-year-old man underwent replacement of the aortic arch to treat a ruptured aortic aneurysm. After surgery, the left thoracic drain discharged 2,000 to 3,000 mL serosanguineous fluid per day, even though the patient took nothing orally and was administered subcutaneous octreotide therapy. On postoperative day 9, percutaneous thoracic duct embolization was performed, and the drain could be removed. The chylothorax did not recur, and the patient was discharged on postoperative day 17.
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Affiliation(s)
- Fumihiro Kitashima
- Department of Cardiovascular Surgery, Tokyo West Tokusyukai Hospital, Tokyo, Japan
| | - Naohiro Shimada
- Department of Cardiovascular Surgery, Tokyo West Tokusyukai Hospital, Tokyo, Japan
| | - Yojiro Machii
- Department of Cardiovascular Surgery, Tokyo West Tokusyukai Hospital, Tokyo, Japan
| | - Masashi Tanaka
- Department of Cardiovascular Surgery, Nihon University School of Medicine, Tokyo, Japan
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Mahmoodzadeh H, Farahzadi A, Omranipour R, Harirchi I, Jalaeefar A, Shirkhoda M, Miri SR, Hadjilooei F. Thoracic duct identification with indocyanine green fluorescence to prevent chyle leaks during minimally invasive esophagectomy. Cancer Rep (Hoboken) 2024; 7:e2053. [PMID: 38577849 PMCID: PMC10995935 DOI: 10.1002/cnr2.2053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 02/09/2024] [Accepted: 03/05/2024] [Indexed: 04/06/2024] Open
Abstract
INTRODUCTION Chylothorax (CT) is a rare yet serious complication after esophagectomy. Identification of the thoracic duct (TD) during esophagectomy is challenging due to its anatomical variation. Real-time identification of TD may help to prevent its injury. Near infra-red imaging with Indocyanine green (ICG) is a novel technique that recently has been used to overcome this issue. METHODS Patients who underwent minimally invasive esophagectomy for esophageal cancer were divided into two groups with and without ICG. We injected ICG into bilateral superficial inguinal lymph nodes. Identification of TD and its injuries during the operation was evaluated and compared with the non-ICG group. RESULTS Eighteen patients received ICG, and 18 patients underwent surgery without ICG. Each group had one (5.5%) TD ligation. In the ICG group injury was detected intraoperative, and ligation was done at the site of injury. In all cases, the entire thoracic course of TD was visualized intraoperatively after a mean time of 81.39 min from ICG injection to visualization. The Mean extra time for ICG injection was 11.94 min. In the ICG group, no patient suffered from CT. One patient in the non-ICG group developed CT after surgery that was managed conservatively. According to Fisher's exact test, there was no significant association between CT development and ICG use, possibly due to the small sample size. CONCLUSIONS This study confirms that ICG administration into bilateral superficial inguinal lymph nodes can highlight the TD and reduce its damage during esophagectomy. It can be a standard method for the prevention of postoperative CT.
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Affiliation(s)
- Habibollah Mahmoodzadeh
- Department of General SurgeryTehran University of Medical Sciences, Cancer InstituteTehranIran
| | - Athena Farahzadi
- Department of General SurgeryTehran University of Medical Sciences, Cancer InstituteTehranIran
| | - Ramesh Omranipour
- Department of General SurgeryTehran University of Medical Sciences, Cancer InstituteTehranIran
| | - Iraj Harirchi
- Department of General SurgeryTehran University of Medical Sciences, Cancer InstituteTehranIran
| | - Amirmohsen Jalaeefar
- Department of General SurgeryTehran University of Medical Sciences, Cancer InstituteTehranIran
| | - Mohammad Shirkhoda
- Department of General SurgeryTehran University of Medical Sciences, Cancer InstituteTehranIran
| | - Seyed Rouhollah Miri
- Department of General SurgeryTehran University of Medical Sciences, Cancer InstituteTehranIran
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Jona N, Majdalany BS, Klein AM. Thoracic Duct Occlusion Leading to Intermittent Left Supraclavicular Swelling and Pancreatitis. Laryngoscope 2024; 134:1313-1315. [PMID: 37462348 DOI: 10.1002/lary.30898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 07/04/2023] [Indexed: 02/17/2024]
Abstract
Intermittent left supraclavicular swelling is an uncommon and elusive condition that can lead to extensive diagnostic workups to determine the etiology and treatment. One potential cause is partial, intermittent, or complete thoracic duct occlusion (TDO). We report on a patient who presented with chronic, intermittent left supraclavicular swelling and abdominal pain that was relieved by thoracic duct angioplasty. Thoracic duct occlusion should be included in the differential diagnosis of left supraclavicular swelling. Lymphatic imaging can facilitate the diagnosis and allows for potential percutaneous treatment. Laryngoscope, 134:1313-1315, 2024.
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Affiliation(s)
- Nikitha Jona
- Wake Forest School of Medicine, Winston-Salem, North Carolina, U.S.A
| | - Bill S Majdalany
- Department of Radiology, University of Vermont Medical Center, Burlington, Vermont, U.S.A
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Yang X, Zhang J, Sun P, Liu J, Wang J, Zhu H. Chylopericardium following esophagectomy: a case report and systematic review. J Cardiothorac Surg 2024; 19:50. [PMID: 38310296 PMCID: PMC10838423 DOI: 10.1186/s13019-024-02536-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 01/28/2024] [Indexed: 02/05/2024] Open
Abstract
BACKGROUND Chylopericardium is a rare condition characterized by the accumulation of chyle in the pericardial space. It is most commonly caused by thoracic duct injury. Chylopericardium following esophagectomy is extremely rare but can cause life-threatening complications. This report presents a case of chylopericardium post-esophagectomy, resulting in cardiac tamponade and cardiac arrest. A systematic literature review was also conducted to facilitate the understanding of this rare condition. CASE PRESENTATION A 41-year-old male was admitted to our hospital with intermediate to highly differentiated squamous cell carcinoma of the mid-thoracic esophagus (clinical T4NxM0). He underwent thoracoscopic-laparoscopic esophagectomy with cervical anastomosis. On postoperative day 1, patient had a cardiac arrest secondary to cardiac tamponade, requiring emergency ultrasound-guided drainage. The drained fluid was initially serous but became chylous after the administration of enteral nutritional emulsion. As a result of significant daily pericardial drainage, patient subsequently underwent thoracic duct ligation. The amount of drainage was substantially reduced post-thoracic duct ligation. Over a period of 2 years and 7 months, patient recovered well and tolerated full oral diet. A comprehensive literature review was conducted and 4 reported cases were identified. Among these cases, three patients developed pericardial tamponade secondary to chylopericardium post-esophagectomy. CONCLUSION Chylopericardium is a rare but serious complication post-esophagectomy. Prompt echocardiography and thorough pericardial fluid analysis are crucial for diagnosis. Thoracic duct ligation has been shown to be an effective management approach for this condition.
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Affiliation(s)
- Xinglin Yang
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Jinghong Zhang
- Central Clinical School, Monash University, Melbourne, VIC, 3004, Australia
| | - Pengxia Sun
- Emergency Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Jihai Liu
- Emergency Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Jiangshan Wang
- Emergency Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China.
| | - Huadong Zhu
- Emergency Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China.
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9
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Farrow H, Pickering OJ, Gossage JA, Pucher PH. Impact of thoracic duct resection during radical esophagectomy on oncological and survival outcomes: Systematic review. Eur J Surg Oncol 2024; 50:107271. [PMID: 37979459 DOI: 10.1016/j.ejso.2023.107271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 10/14/2023] [Accepted: 11/08/2023] [Indexed: 11/20/2023]
Abstract
Practice is variable in the inclusion or exclusion of the thoracic duct (TD) as part of the resected specimen and associated lymphadenectomy in radical esophagectomy for esophageal cancer. While some surgeons believe that the removal of TD-associated nodes may improve radicality and survival, others suggest this represents systemic disease and resection may increase morbidity without survival benefit. A systematic review was performed up to March 2023 using the search terms 'esoph∗' AND 'thoracic duct' for relevant articles which compared thoracic duct preservation (TDP) to resection (TDR) in esophagectomy for esophageal cancer. Included studies were required to report relevant oncological outcomes including at least one of overall survival (OS), disease free survival (DFS) and nodal yield. Seven cohort studies were included in data synthesis, including data for 5926 patients. None of the reported studies were randomised controlled trials. All studies originated from Japan or South Korea with almost exclusively squamous cell-type cancer. Nodal yield was higher in TDR groups. TDR was equivalent or inferior to TDP with reference to clinical outcomes (length of stay, morbidity, mortality). A single study reported increased OS in the TDR group while the remaining studies reported no significant difference. Overall study quality was moderate to poor. While an increased nodal yield may be associated with TDR, this may also be associated with higher morbidity, and currently available data does not suggest any survival benefit.
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Affiliation(s)
- Harry Farrow
- Department of General Surgery, Queen Alexandra Hospital, University Hospital Portsmouth NHS Trust, Portsmouth, UK
| | - Oliver J Pickering
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - James A Gossage
- Department of Surgery, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
| | - Philip H Pucher
- Department of General Surgery, Queen Alexandra Hospital, University Hospital Portsmouth NHS Trust, Portsmouth, UK; Division of Surgery, Imperial College London, London, UK; Department of Pharmacology and Biosciences, University of Portsmouth, Portsmouth, UK.
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10
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Owusu-Brackett N, Chakedis JM, Dedhia P, Gilliam C, Agrawal A, Kang SY, Old M, Miller BS, Phay JE. Efficacy and safety of near-infrared fluorescence identification of the thoracic duct during left lateral neck dissection. Surgery 2024; 175:134-138. [PMID: 38057229 DOI: 10.1016/j.surg.2023.08.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 07/20/2023] [Accepted: 08/17/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND Thoracic duct leaks occur in up to 5% of left lateral neck dissections. No one imaging modality is routinely used to identify the thoracic duct intraoperatively. The goal of our study was to evaluate the efficacy and safety of indocyanine green lymphangiography for intraoperative identification of the thoracic duct compared to traditional methods using ambient and evaluate the optimal timing of indocyanine green administration. METHODS We enrolled all patients who underwent left lateral neck dissection at our institution from 2018 to 2022 in this prospective clinical trial. After indocyanine green injection into the dorsum of the foot, we performed intraoperative imaging was performed with a near-infrared fluorescence camera. We reported the data using descriptive statistics. RESULTS Of the 42 patients we enrolled, 14 had prior neck surgery, and 3 had prior external beam radiation. We visualized the thoracic duct with ambient light in 48% of patients and with near-infrared fluorescence visualization in 64%. In 17% of patients, we could identify the thoracic duct only using near-infrared fluorescence visualization, which occurred within 3 minutes of injection, and were required to re-dose 5 patients. We visualized the thoracic duct with near-infrared fluorescence in all patients with prior neck radiation and 77% of patients with prior neck surgery. One adverse reaction occurred (hypotension), and 5 intraoperative thoracic duct injuries occurred that were ligated. There with no chylous fistulas postoperatively. CONCLUSION This trial demonstrates that near-infrared fluorescence identification of the thoracic duct is feasible and safe with indocyanine green lymphangiography, even in patients with prior neck surgery or radiation.
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Affiliation(s)
- Nicci Owusu-Brackett
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital, Columbus, OH
| | - Jeffery M Chakedis
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital, Columbus, OH; Department of General Surgery, The Permanente Medical Group, Walnut Creek, CA
| | - Priya Dedhia
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital, Columbus, OH
| | - Christopher Gilliam
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Amit Agrawal
- Department of Otolaryngology-Head and Neck Surgery, Division of Head and Neck Oncology, Ohio State University, James Cancer Centre and Solove Research Institute, Columbus, OH
| | - Stephan Y Kang
- Department of Otolaryngology-Head and Neck Surgery, Division of Head and Neck Oncology, Ohio State University, James Cancer Centre and Solove Research Institute, Columbus, OH
| | - Matthew Old
- Department of Otolaryngology-Head and Neck Surgery, Division of Head and Neck Oncology, Ohio State University, James Cancer Centre and Solove Research Institute, Columbus, OH
| | - Barbra S Miller
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital, Columbus, OH
| | - John E Phay
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital, Columbus, OH.
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Ahn S, Lee H, Kang JK, Kim IS, Moon Y, Choi JS, Won YD, Jeong SC, Choi SY. Intractable chylous leak after radical esophagectomy treated with radiotherapy. J Cardiothorac Surg 2023; 18:325. [PMID: 37964362 PMCID: PMC10647089 DOI: 10.1186/s13019-023-02419-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 11/03/2023] [Indexed: 11/16/2023] Open
Abstract
Postoperative chylous leak after esophagectomy is a rare but potentially life-threatening complication that results in hypovolemia, electrolyte imbalance, malnutrition, and immunologic deficiency. However, the management of postoperative chylous leak remains controversial. Following a diagnosis of esophageal cancer, a 64-year-old man was treated by video-assisted thoracoscopic esophagectomy, laparoscopic gastric tube formation, prophylactically thoracic duct ligation, and reconstruction with esophagogastrostomy at the neck level. Massive postoperative drainage from the thorax and abdomen did not initially meet the diagnostic criteria for chylothorax, which was ultimately diagnosed 3 weeks after the operation. Despite various treatments including total parenteral nutrition, octreotide and midodrine, reoperation (thoracic duct ligation and mechanical pleurodesis), and thoracic duct embolization, the chylous leak persisted. Finally, low-dose radiation therapy was administered with a daily dose of 2 Gy and completed at a total dose of 14 Gy. After this, the amount of pleural effusion gradually decreased over 2 weeks, and the last drainage tube was removed. The patient was alive and well at 60 months postoperatively. Herein, we describe a patient with intractable chylous leak after esophagectomy, which persisted despite conservative treatment, thoracic duct ligation, and embolization, but was finally successfully treated with radiotherapy.
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Affiliation(s)
- Seha Ahn
- Department of Thoracic and Cardiovascular Surgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 1021, Tongil-ro, Eunpyeong-gu, Seoul, 03312, Republic of Korea
| | - Heejin Lee
- Department of Thoracic and Cardiovascular Surgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 1021, Tongil-ro, Eunpyeong-gu, Seoul, 03312, Republic of Korea
| | - Joon Kyu Kang
- Department of Thoracic and Cardiovascular Surgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 1021, Tongil-ro, Eunpyeong-gu, Seoul, 03312, Republic of Korea
| | - In Sub Kim
- Department of Thoracic and Cardiovascular Surgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 1021, Tongil-ro, Eunpyeong-gu, Seoul, 03312, Republic of Korea
| | - Youngkyu Moon
- Department of Thoracic and Cardiovascular Surgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 1021, Tongil-ro, Eunpyeong-gu, Seoul, 03312, Republic of Korea
| | - Jung Suk Choi
- Department of Thoracic and Cardiovascular Surgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 1021, Tongil-ro, Eunpyeong-gu, Seoul, 03312, Republic of Korea
| | - Yoo Dong Won
- Department of Radiology, College of Medicine, Uijeongbu St. Mary's Hospital, The Catholic University of Korea, Uijeongbu, Republic of Korea
| | - Seong Cheol Jeong
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, Uijeongbu St. Mary's Hospital, The Catholic University of Korea, Uijeongbu, Republic of Korea
| | - Si Young Choi
- Department of Thoracic and Cardiovascular Surgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 1021, Tongil-ro, Eunpyeong-gu, Seoul, 03312, Republic of Korea.
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12
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Thammineedi SR, Patnaik SC, Reddy P, Shukla S, Vashist YK, Nusrath S. Impact of fluorescent thoracic duct lymphography via intranodal approach in minimal access esophageal cancer surgery. Langenbecks Arch Surg 2023; 408:426. [PMID: 37917238 DOI: 10.1007/s00423-023-03162-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 10/23/2023] [Indexed: 11/04/2023]
Abstract
PURPOSE Chyle leak resulting from thoracic duct (TD) injury poses significant morbidity and mortality challenges. We assessed the feasibility of using near-infrared (NIR) indocyanine green (ICG) imaging for intraoperative fluorescence TD lymphography during minimal access esophagectomy (MAE) in a semiprone position with inguinal nodal injection of ICG dye. METHODS Ninety-nine patients with esophageal or gastroesophageal junctional cancer undergoing MAE received inguinal node injections of 2.5 mg ICG dye (total 5 mg) under sonographic guidance during anesthesia induction. Stryker's 1688 AIM HD system was used in 76 cases, Karl Storz OPAL 1 S in 20, and in three cases the Karl Storz Rubina. RESULTS In 93 patients (94%), the TD was clearly delineated along its entire length; it was not visualized in 6 patients (6%). Fluorescence guidance facilitated TD ligation in 16 cases, while 3 cases required clipping of duct tributaries for oncological considerations. Twenty-eight patients exhibited minor duct variations. Fluorescence was sustained throughout surgery (median observation time 60 min post-injection; range 30-330). No patient experienced any chyle leak within 30 days post-surgery and no adverse reactions to ICG was evident. CONCLUSIONS Intraoperative fluorescence TD lymphography using ICG during MAE in a semiprone position with inguinal nodal injection proved safe, feasible, and effective, allowing clear visualization of the TD in almost all cases. This approach aids safe ligation and reduces chyle leak risk. It offers real-time imaging of TD anatomy and variations, providing valuable feedback to surgeons for managing TD injuries during MAE procedures and represents an excellent educational tool.
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Affiliation(s)
- Subramanyeshwar R Thammineedi
- Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, 500034, India
| | - Sujit C Patnaik
- Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, 500034, India
| | - Pratap Reddy
- Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, 500034, India
| | - Srijan Shukla
- Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, 500034, India
| | - Yogesh K Vashist
- Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Syed Nusrath
- Department of Surgical Oncology, Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, Telangana, 500034, India.
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13
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Matsuda S, Takeuchi M, Kawakubo H, Takeuchi H, Kitagawa Y. Oncological and physiological impact of thoracic duct resection in esophageal cancer. Dis Esophagus 2023; 36:doad015. [PMID: 36950928 PMCID: PMC10543365 DOI: 10.1093/dote/doad015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 03/01/2023] [Accepted: 03/06/2023] [Indexed: 03/24/2023]
Abstract
Despite advances in multidisciplinary treatment, esophagectomy remains the main curative treatment for esophageal cancer. The advantages and disadvantages of thoracic duct (TD) resection have been controversial for decades. We have herein reviewed relevant published literature regarding 'thoracic duct,' 'esophageal cancer,' and 'esophagectomy' describing the anatomy and function of the TD, and incidence of thoracic duct lymph nodes (TDLN) and TDLN metastases, as well as the oncological and physiological effects of TD resection. The presence of lymph nodes around the TD, referred to as TDLN, has been reported previously. The delineation of TDLNs is clearly defined by a thin fascial structure covering the TD and the surrounding adipose tissue. Previous studies have examined the number of TDLNs and the percentage of patients with TDLN metastasis and revealed that each patient had approximately two TDLNs. The percentage of patients with TDLN metastasis was reported to be 6-15%. Several studies have been conducted to compare the survival after TD resection with that after TD preservation. However, no consensus has been reached because all studies were retrospective, precluding firm conclusions. Although the issue of whether the risk of postoperative complications is affected by TD resection is still unclear, resecting the TD has been shown to have a long-term impact on nutritional status after surgery. In summary, TDLNs are quite common and present in most patients, while metastasis in the TDLNs occurs in a minority. However, the oncological value of TD resection in esophageal cancer surgery remains controversial due to varying findings and methodological limitations of previous comparative studies. Considering the potential but unproven oncological benefits and possible physiological drawbacks of TD resection, including postoperative fluid retention and disadvantages in the long-term nutritional outcome, clinical stage, and nutritional status should be considered before deciding whether to perform TD resection or not.
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Affiliation(s)
- Satoru Matsuda
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Masashi Takeuchi
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hirofumi Kawakubo
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hiroya Takeuchi
- Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
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14
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Nishimura E, Matsuda S, Kawakubo H, Okui J, Takemura R, Takeuchi M, Fukuda K, Nakamura R, Takeuchi H, Kitagawa Y. The impact of thoracic duct resection on the long-term body composition of patients who underwent esophagectomy for esophageal cancer and survived without recurrence. Dis Esophagus 2023; 36:doad002. [PMID: 37465862 PMCID: PMC10473448 DOI: 10.1093/dote/doad002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 12/27/2022] [Indexed: 07/20/2023]
Abstract
BACKGROUND We have reported the possible benefits of radical esophagectomy with thoracic duct (TD) resection in elective esophageal cancer surgery. However, the effect of TD resection on the long-term nutrition status remains unclear. METHODS Patients who underwent esophagectomy at Keio University between January 2006 and December 2018 were included, and those who had no recurrence for more than three years were evaluated. Changes in each body composition (muscle mass and body fat) were comparatively assessed between those who underwent TD resection or not, before and at, one, three and five years after surgery. Computed tomography images were analyzed on postoperative year 1, 3 and 5. RESULTS This study included 217 patients categorized in the TD-resected (TD-R) (156 patients) and TD-preserved (TD-P) (61 patients) groups. The loss of muscle mass was comparable between the groups. On the other hand, the loss of adipose tissues was significantly greater in the TD-R group than in the TD-P group at one and three years after surgery, while there was no statistical difference five years after surgery. Additionally, among patients with cT1N0M0 disease in whom survival advantage of TD resection has been reported previously, the loss of muscle mass did not differ between each group. CONCLUSIONS The change of muscle mass between the two groups was comparable. Although body fat mass was reduced by TD resection, it eventually recovered in the long term. In patients with esophageal cancer, TD resection may be acceptable without significant impact on body composition in the long term.
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Affiliation(s)
- Erica Nishimura
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Satoru Matsuda
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hirofumi Kawakubo
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Jun Okui
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
- Department of Preventive Medicine and Public Health, Keio University School of Medicine, Tokyo, Japan
| | - Ryo Takemura
- Biostatistics Unit, Clinical and Translational Research Center, Keio University School of Medicine, Tokyo, Japan
| | - Masashi Takeuchi
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Kazumasa Fukuda
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Rieko Nakamura
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Hiroya Takeuchi
- Department of Surgery, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
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15
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Choe J, Koo HJ, Ahn Y, Lee GD, Yang DH, Kang JW, Lee JE, Shin JH. Evaluation of Chylothorax Using Dynamic Contrast-Enhanced Magnetic Resonance Lymphangiography After Lung Cancer Surgery. Lymphat Res Biol 2023; 21:343-350. [PMID: 36880884 DOI: 10.1089/lrb.2022.0039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023] Open
Abstract
Background: To determine the role of dynamic contrast-enhanced magnetic resonance lymphangiography (DCMRL) in the management of postoperative chylothorax after lung cancer surgery. Methods and Results: Between July 2017 and November 2021, patients who developed postoperative chylothorax following pulmonary resection and mediastinal lymph node dissection were assessed and those who underwent DCMRL for the evaluation of chyle leak were evaluated. The findings of DCMRL and conventional lymphangiography were compared. The incidence of postoperative chylothorax was 0.9% (50/5587). Among the patients with chylothorax, a total of 22 patients (44.0% [22/50]; mean age, 67.6 ± 7.9 years; 15 men) underwent DCMRL. Treatment outcomes were compared between patients with conservative management (n = 10) and those with intervention (n = 12). The patients demonstrated unilateral pleural effusion, ipsilateral to the operation site, and showed right-sided dominance. The most frequent site of thoracic duct injury showing contrast media leakage was visualized at the subcarinal level. No DCMRL-related complication occurred. DCMRL showed comparable performance to conventional lymphangiography in visualizing the central lymphatics, including cisterna chyli (DCMRL vs. conventional lymphangiography, 72.7% vs. 45.5%, p = 0.25) and thoracic duct (90.9% vs. 54.5%, p = 0.13), and in localizing thoracic duct injury (90.9% vs. 54.5%, p = 0.13). On follow-up, the amount of chest tube drainage after lymphatic intervention showed a significant difference over time from that after medical treatment only (p = 0.02). Conclusion: DCMRL can provide detailed information about the leak site and the central lymphatic anatomy in patients with chylothorax after lung cancer surgery. The findings of DCMRL can guide subsequent treatment planning for optimal outcomes.
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Affiliation(s)
- Jooae Choe
- Department of Radiology and Research Institute of Radiology and University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Hyun Jung Koo
- Department of Radiology and Research Institute of Radiology and University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Yura Ahn
- Department of Radiology and Research Institute of Radiology and University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Geun Dong Lee
- Department of Thoracic and Cardiovascular Surgery, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Dong Hyun Yang
- Department of Radiology and Research Institute of Radiology and University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Joon-Won Kang
- Department of Radiology and Research Institute of Radiology and University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Ja Eun Lee
- Department of Radiology and Research Institute of Radiology and University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Ji Hoon Shin
- Department of Radiology and Research Institute of Radiology and University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
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16
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He X, Zhao X, Wang M, Gao C, Wang H. Thoracic ductal variations and treatment of chylothorax after thoracic surgery. Minerva Surg 2023; 78:465-467. [PMID: 35708446 DOI: 10.23736/s2724-5691.22.09621-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Affiliation(s)
- Xu He
- Department of Thoracic Surgery, The Fourth Affiliated Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xiaopeng Zhao
- Department of Thoracic Surgery, The Fourth Affiliated Hospital of Hebei Medical University, Shijiazhuang, China
| | - Miao Wang
- Department of Thoracic Surgery, The Fourth Affiliated Hospital of Hebei Medical University, Shijiazhuang, China
| | - Chuan Gao
- Department of Thoracic Surgery, Cixian People's Hospital, Handan, China
| | - Hongyan Wang
- Department of Thoracic Surgery, The Fourth Affiliated Hospital of Hebei Medical University, Shijiazhuang, China -
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17
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Oshikiri T, Numasaki H, Oguma J, Toh Y, Watanabe M, Muto M, Kakeji Y, Doki Y. Prognosis of Patients with Esophageal Carcinoma After Routine Thoracic Duct Resection: A Propensity-matched Analysis of 12,237 Patients Based on the Comprehensive Registry of Esophageal Cancer in Japan. Ann Surg 2023; 277:e1018-e1025. [PMID: 34913902 DOI: 10.1097/sla.0000000000005340] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To clarify whether routine thoracic duct (TD) resection improves the prognosis of patients with esophageal cancer after radical esophagectomy. SUMMARY OF BACKGROUND DATA Although TD resection can cause nutritional disadvantage and immune suppression, it has been performed for the resection of surrounding lymph nodes. METHODS We analyzed 12,237 patients from the Comprehensive Registry of Esophageal Cancer in Japan who underwent esophagectomy between 2007 and 2012. TD resection and preservation groups were compared in terms of prognosis, perioperative outcomes, and initial recurrent patterns using strict propensity score matching. Particularly, the year of esophagectomy and history of primary cancer of other organs were added as covariates. RESULTS After propensity score matching, 1638 c-Stage I-IV patients participated in each group. The 5 year overall survival and cause-specific survival rates were 57.5% and 65.6% in the TD-resected group and 55.2% and 63.4% in the TD-preserved group, respectively, without significant differences. The TD-resected group had significantly more retrieved mediastinal nodes (30 vs 21, P < 0.0001) and significantly fewer lymph node recurrence (376 vs 450, P = 0.0029) compared with the TD-preserved group. However, the total number of distant metastatic organs was significantly greater in TD-resected group than in the TD-preserved group (499 vs 421, P = 0.0024). CONCLUSIONS TD resection did not improve survival in patients with esoph-ageal cancer. Despite having retrieved more lymph nodes, TD resection caused distant metastases in more organs compared to TD preservation. Hence, prophylactic TD resection should not be recommended in patients with esophageal cancer.
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Affiliation(s)
- Taro Oshikiri
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Hyogo, Japan
| | - Hodaka Numasaki
- Department of Medical Physics and Engineering, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Junya Oguma
- Division of Esophageal Surgery, National cancer center Hospital, Tokyo, Japan
| | - Yasushi Toh
- Department of Gastroenterological Surgery, National Hospital Organization Kyushu Cancer Center, Fukuoka, Japan
| | - Masayuki Watanabe
- Department of Gastroenterological Surgery, cancer institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Manabu Muto
- Department of Therapeutic Oncology, Kyoto University Graduate School of Medicine, Kyoto, Japan; and
| | - Yoshihiro Kakeji
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Hyogo, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Osaka, Japan
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18
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Ushinsky A, Kim SK, Guevara CJ. Percutaneous Thermal Ablation for Refractory Thoracic Duct Leak after Esophageal Surgery. J Vasc Interv Radiol 2023; 34:501-502. [PMID: 36442742 DOI: 10.1016/j.jvir.2022.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 11/07/2022] [Accepted: 11/22/2022] [Indexed: 11/27/2022] Open
Affiliation(s)
- Alexander Ushinsky
- Department of Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University St Louis School of Medicine, 510 S Kings Highway Boulevard, Campus Box 8131, St Louis, MO 63110.
| | - Seung Kwon Kim
- Department of Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University St Louis School of Medicine, 510 S Kings Highway Boulevard, Campus Box 8131, St Louis, MO 63110
| | - Carlos J Guevara
- Department of Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University St Louis School of Medicine, 510 S Kings Highway Boulevard, Campus Box 8131, St Louis, MO 63110
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19
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Ghelfi J, Brusset B, Teyssier Y, Sengel C, Gerster T, Girard E, Roth G, Bellier A, Bricault I, Decaens T. Endovascular Lymphatic Decompression via Thoracic Duct Stent Placement for Refractory Ascites in Patients with Cirrhosis: A Pilot Study. J Vasc Interv Radiol 2023; 34:212-217. [PMID: 36306988 DOI: 10.1016/j.jvir.2022.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 09/26/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022] Open
Abstract
PURPOSE To evaluate the technical and clinical success of endovascular lymphatic decompression via thoracic duct (TD) stent placement in patients with cirrhosis with refractory ascites. MATERIALS AND METHODS Nine patients (6 men and 3 women; median age, 66 [interquartile range {IQR}, 65-68] years; range, 62-78 years) who underwent TD stent placement for refractory ascites with contraindications for liver transplantation and transjugular intrahepatic portosystemic shunt creation were included in this retrospective study. TD stent placement was performed under local anesthesia using retrograde access from the venous system. Self-expanding stents from 5 to 8 mm in diameter were used and extended into the subclavian vein by approximately 1 cm. Technical (correct positioning of the stent) and clinical success (no more requirement of paracentesis) were evaluated. In addition, the safety of the procedure and TD pressure evolution were evaluated. RESULTS The technical success rate was 100%, and 3 (33%) patients reported clinical success. Five (56%) patients reported 7 minor adverse events (Grade I), among which 2 TD perforations were induced by stent angioplasty, with no clinical manifestation or treatment required. The median TD pressure decreased from 19 mm Hg (IQR, 11-24 mm Hg) at the beginning of the procedure to 6 mm Hg (IQR, 5-11 mm Hg) after TD stent placement. The median survival time after the procedure was 7.1 months. CONCLUSIONS Endovascular lymphatic decompression via TD stent placement is feasible and safe and was effective on ascites in some patients with cirrhosis with refractory ascites.
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Affiliation(s)
- Julien Ghelfi
- University of Grenoble-Alpes, Grenoble, France; Department of Radiology, Grenoble-Alpes University Hospital, Grenoble, France; Institute for Advanced Biosciences-Institut national de la santé et de la recherche médicale (Inserm) U1209, University of Grenoble-Alpes, Grenoble, France.
| | - Bleuenn Brusset
- University of Grenoble-Alpes, Grenoble, France; Department of Hepatology and Gastrointestinal Medical Oncology, Grenoble-Alpes University Hospital, Grenoble, France; Institute for Advanced Biosciences-Institut national de la santé et de la recherche médicale (Inserm) U1209, University of Grenoble-Alpes, Grenoble, France
| | - Yann Teyssier
- University of Grenoble-Alpes, Grenoble, France; Department of Radiology, Grenoble-Alpes University Hospital, Grenoble, France
| | - Christian Sengel
- Department of Radiology, Grenoble-Alpes University Hospital, Grenoble, France
| | - Teophile Gerster
- University of Grenoble-Alpes, Grenoble, France; Department of Hepatology and Gastrointestinal Medical Oncology, Grenoble-Alpes University Hospital, Grenoble, France
| | - Edouard Girard
- University of Grenoble-Alpes, Grenoble, France; Division of Hepato-Pancreato-Biliary Surgery and Transplantation, Department of Digestive and Emergency Surgery, Grenoble-Alpes University Hospital, France; Translational Innovation in Medicine and Complexity (TIMC) Laboratory, La Tronche, France
| | - Gael Roth
- University of Grenoble-Alpes, Grenoble, France; Department of Hepatology and Gastrointestinal Medical Oncology, Grenoble-Alpes University Hospital, Grenoble, France; Institute for Advanced Biosciences-Institut national de la santé et de la recherche médicale (Inserm) U1209, University of Grenoble-Alpes, Grenoble, France
| | - Alexandre Bellier
- University of Grenoble-Alpes, Grenoble, France; Clinical Research Department, Grenoble-Alpes University Hospital, Grenoble, France
| | - Ivan Bricault
- University of Grenoble-Alpes, Grenoble, France; Department of Radiology, Grenoble-Alpes University Hospital, Grenoble, France
| | - Thomas Decaens
- University of Grenoble-Alpes, Grenoble, France; Department of Hepatology and Gastrointestinal Medical Oncology, Grenoble-Alpes University Hospital, Grenoble, France; Institute for Advanced Biosciences-Institut national de la santé et de la recherche médicale (Inserm) U1209, University of Grenoble-Alpes, Grenoble, France
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20
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Schafrat PJM, Henckens SPG, Hagens ERC, Eshuis WJ, Gisbertz SS, Laméris W, van Berge Henegouwen MI. Clinical implications of chyle leakage following esophagectomy. Dis Esophagus 2023; 36:doac047. [PMID: 35830862 PMCID: PMC9885733 DOI: 10.1093/dote/doac047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 05/19/2022] [Accepted: 06/14/2022] [Indexed: 02/02/2023]
Abstract
The clinical consequences of chyle leakage following esophagectomy are underexposed. The aim of this study was to investigate the clinical implications of chyle leakage following esophagectomy. This retrospective study of prospectively collected data included patients who underwent transthoracic esophagectomy in 2017-2020. Routinely, the thoracic duct was resected en bloc as part of the mediastinal lymphadenectomy. Chyle leakage was defined as milky drain fluid for which specific treatment was initiated and/or a triglyceride level in drain fluid of ≥1.13 mmol/L, according to the Esophagectomy Complications Consensus Group (ECCG) classification. Primary endpoints were the clinical characteristics of chyle leakage (type, severity and treatment). Secondary endpoints were the impact of chyle leakage on duration of thoracic drainage and hospital stay. Chyle leakage was present in 43/314 patients (14%), of whom 24 (56%) were classified as severity A and 19 (44%) as severity B. All patients were successfully treated with either medium chain triglyceride diet (98%) or total parental nutrition (2%). There were no re-interventions for chyle leakage during initial admission, although one patient needed additional pleural drainage during readmission. Patients with chyle leakage had 3 days longer duration of thoracic drainage (bias corrected accelerated (BCa) 95%CI:0.46-0.76) and 3 days longer hospital stay (BCa 95%CI:0.07-0.36), independently of the presence of other complications. Chyle leakage is a relatively frequent complication following esophagectomy. Postoperative chyle leakage was associated with a significant longer duration of thoracic drainage and hospital admission. Nonsurgical treatment was successful in all patients with chyle leakage.
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Affiliation(s)
- Pascale J M Schafrat
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Meibergdreef 9, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
- Amsterdam UMC, location University of Amsterdam, Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Meibergdreef 9, Amsterdam, The Netherlands
| | - Sofie P G Henckens
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Meibergdreef 9, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
- Amsterdam UMC, location University of Amsterdam, Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Meibergdreef 9, Amsterdam, The Netherlands
| | - Eliza R C Hagens
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Meibergdreef 9, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
- Amsterdam UMC, location University of Amsterdam, Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Meibergdreef 9, Amsterdam, The Netherlands
| | - Wietse J Eshuis
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Meibergdreef 9, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
- Amsterdam UMC, location University of Amsterdam, Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Meibergdreef 9, Amsterdam, The Netherlands
| | - Suzanne S Gisbertz
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Meibergdreef 9, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
- Amsterdam UMC, location University of Amsterdam, Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Meibergdreef 9, Amsterdam, The Netherlands
| | - Wytze Laméris
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Meibergdreef 9, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
- Amsterdam UMC, location University of Amsterdam, Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Meibergdreef 9, Amsterdam, The Netherlands
| | - Mark I van Berge Henegouwen
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Meibergdreef 9, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
- Amsterdam UMC, location University of Amsterdam, Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Meibergdreef 9, Amsterdam, The Netherlands
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21
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Agrawal A, Chaddha U, Kaul V, Desai A, Gillaspie E, Maldonado F. Multidisciplinary Management of Chylothorax. Chest 2022; 162:1402-1412. [PMID: 35738344 DOI: 10.1016/j.chest.2022.06.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 05/04/2022] [Accepted: 06/10/2022] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Abhinav Agrawal
- Interventional Pulmonology, Division of Pulmonary, Critical Care & Sleep Medicine, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY.
| | - Udit Chaddha
- Interventional Pulmonology, Division of Pulmonary, Critical Care & Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Viren Kaul
- Division of Pulmonary and Critical Care Medicine, Crouse Health/SUNY Upstate Medical University, Syracuse, NY
| | - Ajinkya Desai
- Interventional Radiology, Department of Radiology, University of Mississippi Medical Center, Jackson, MS
| | - Erin Gillaspie
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Fabien Maldonado
- Interventional Pulmonology, Department of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
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Yang Q, Bai X, Bao H, Li Y, Men W, Lv L, Liu Z, Han X, Li W. Invasive treatment of persistent postoperative chylothorax secondary to thoracic duct variation injury: Two case reports and literature review. Medicine (Baltimore) 2022; 101:e31383. [PMID: 36316910 PMCID: PMC9622594 DOI: 10.1097/md.0000000000031383] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
RATIONALE Postoperative chylothorax is a rare complication after pulmonary resection. Thoracic duct variations may play a key role in postoperative chylothorax occurrence and make treatment difficult. No studies in the literature have reported the successful treatment of chylothorax second to thoracic duct variation by lipiodol-based lymphangiography. PATIENT CONCERNS A 63-year-old male and a 28-year-old female with primary lung adenocarcinoma were treated by video-assisted thoracoscopic cancer resection, and suffered postoperative chylothorax. Conservative treatment was ineffective, including nil per os, persistent thoracic drainage, fatty food restriction, and somatostatin administration. DIAGNOSIS Postoperative chylothorax. INTERVENTIONS Patients received lipiodol-based lymphangiography under fluoroscopic guidance. Iatrogenic injuries were identified at thoracic duct variations, including an additional channel in case 1 and the lymphatic plexus instead of the thoracic duct in case 2. OUTCOMES Thoracic duct variations were identified by lipiodol-based lymphangiography, and postoperative chylothorax was successfully treated by lipiodol embolizing effect. LESSONS Thoracic duct variations should be considered after the failure of conservative treatment for postoperative chylothorax secondary to pulmonary resection. Lipiodol-based lymphangiography is valuable for identifying the thoracic duct variations and embolizing chylous leakage.
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Affiliation(s)
- Qiwei Yang
- Department of Thorax, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Xu Bai
- Department of Interventional Radiology, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Han Bao
- Department of Interventional Radiology, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Yukang Li
- Department of Interventional Radiology, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Wanfu Men
- Department of Thorax, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Ling Lv
- Department of Thorax, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Zhenghua Liu
- Department of Thorax, The First Hospital of China Medical University, Shenyang, Liaoning, China
| | - Xiangjun Han
- Department of Interventional Radiology, The First Hospital of China Medical University, Shenyang, Liaoning, China
- *Correspondence: Xiangjun Han, Department of Interventional Radiology, The First Hospital of China Medical University, Shenyang 110001, Liaoning, China (e-mail: )
| | - Wenya Li
- Department of Thorax, The First Hospital of China Medical University, Shenyang, Liaoning, China
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Yang RF, Sui SJ, Yu LL, Li HY, Zhang RQ, Wang P. Survival Analysis of Patients with Thoracic Duct Ligation during Thoracoscopic Esophagectomy. J Coll Physicians Surg Pak 2022; 32:288-292. [PMID: 35148577 DOI: 10.29271/jcpsp.2022.03.288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 12/29/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To determinate the effect of thoracic duct ligation during thoracoscopic esophagectomy on esophageal cancer patients survival. STUDY DESIGN A descriptive study. PLACE AND DURATION OF STUDY Tai'an City Central Hospital, Tai'an, Shandong, China, from June, 2016 to June, 2021. METHODOLOGY All cT1b-3N0M0 stage esophageal cancer patients were randomly divided into thoracic duct ligation group and non-ligation group. In addition to thoracoscopic esophagectomy, thoracic duct ligation was also performed in the experimental group. The general data of two groups were compared by Chi-square test, with statistical significance at p <0.05. The effect of thoracic duct ligation on disease-free survival (DFS) and overall survival (OS) was analysed by Kaplan-Meier and Cox regression. RESULT There was no significant difference in gender, age, tumor location, depth of invasion, degree of differentiation and presence of tumor thrombus between the ligation group (33 cases, 47.8%), and the non-ligation group (36 cases, 52.2%). Cox regression analysis showed that depth of invasion (p = 0.0014), degree of differentiation (p = 0.0036), presence of tumor thrombus (p = 0.0367) and thoracic duct ligation (p = 0.0057) were independent factors affecting DFS. Meanwhile, the depth of invasion (p <0.0001), presence of tumor thrombus (p = 0.0073) and age (p = 0.0129) were independent factors affecting OS. CONCLUSION Thoracic duct ligation during thoracoscopic esophagectomy can affect DFS in patients with pT1b-3N0M0 esophageal squamous cell carcinoma, and the thoracic duct ligation, depth of invasion, degree of differentiation and presence of tumor thrombus are independent factors. Meanwhile, the depth of invasion, presence of tumor thrombus and age were independent factors affecting OS. Key Words: Esophageal cancer, VATS, Esophagectomy, Thoracic duct ligation, DFS, OS.
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Affiliation(s)
- Rui-Feng Yang
- Department of Thoracic Surgery, Tai'an City Central Hospital, Tai'an, Shandong, China
| | - Shu-Jing Sui
- Department of Gastroenterology, Tai'an City Central Hospital, Tai'an, Shandong, China
| | - Lei-Lei Yu
- Department of Endocrine, Tai'an City Central Hospital, Tai'an, Shandong, China
| | - Hong-Yan Li
- Department of Anesthesiology, Tai'an City Central Hospital, Tai'an, Shandong, China
| | - Run-Qi Zhang
- Department of Thoracic Surgery, Tai'an City Central Hospital, Tai'an, Shandong, China
| | - Peng Wang
- Department of Thoracic Surgery, Tai'an City Central Hospital, Tai'an, Shandong, China
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24
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Tulinský L, Mitták M, Ihnát P. Thoracoscopic approach in the treatment of thoracic duct injuries - case reports and review of the literature. Cas Lek Cesk 2022; 161:144-146. [PMID: 36100454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Thoracic duct injuries are very rare due to its protected location. Duct is most often injured in polytraumas and during operations in his vicinity. Treatment is primarily conservative, based on a low-fat diet or parenteral nutrition and adequate chest drainage. If the conservative management fails, a surgical duct ligation via thoracotomy, or more conveniently thoracoscopic approach, is necessary. The presented case reports describe the surgical treatment of isolated injury of the thoracic duct via thoracoscopic approach.
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25
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Parshin VD, Saliba MB, Anokhina VM, Bolotskaya AA, Kryuchkova KY, Parshin AV. [Surgery for chyloptysis]. Khirurgiia (Mosk) 2022:120-125. [PMID: 35593636 DOI: 10.17116/hirurgia2022051120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Chyloptysis is a rare disease characterized by formation of bronchial casts containing chyle and repeating bronchial tree branching. The authors report a 56-year-old woman with chyloptysis accompanied by cough and expectoration of milky bronchial casts, as well several episodes of asphyxia. Stages of diagnosis and successful treatment including thoracic duct ligation and skeletonization of the root of the left lung are described. The authors also analyze literature data on etiology, pathogenesis and feasibility of conservative and surgical treatment of these patients.
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Affiliation(s)
- V D Parshin
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - M B Saliba
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - V M Anokhina
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - A A Bolotskaya
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - K Yu Kryuchkova
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - A V Parshin
- Sechenov First Moscow State Medical University, Moscow, Russia
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26
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Lee J, Stanley K, Lowe MC. Plastic bronchitis: A rare complication following a motor vehicle collision. Lymphology 2022; 55:65-69. [PMID: 36170580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Plastic bronchitis, more appropriately termed chyloptysis, is a rare and potentially fatal condition caused by chylous coating of the airways. These cast coating can dislodge and become an obstructive mass in the patient's airway, necessitating rapid intervention. PB is well described to occur following single ventricle physiology heart disease corrective procedures, particularly following Fontan procedures. It is less commonly seen in traumatic settings. We present the youngest known case of a traumatic injury induced plastic bronchitis. A 19-year-old man was involved in a motor vehicle accident with airbag deployment. The airbags struck him in the chest; however, the patient felt well at the time and did not seek medical attention. Several months later the patient began coughing up milky white masses identified as casts. He was initially diagnosed with asthma but did not respond to therapy. He ultimately was found to have evidence of thoracic duct injury. Options for therapy were discussed, including possible thoracic duct ligation. The patient opted to continue a lowfat diet and has remained cast free. This case highlights the importance of considering plastic bronchitis in patients with cast production and a history of trauma to the chest.
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Affiliation(s)
- J Lee
- Pediatric Residency, Department of Pediatrics, University of Arizona College of Medicine-Tucson, Tucson, Arizona, USA
| | - K Stanley
- Pediatric Residency, Department of Pediatrics, University of Arizona College of Medicine-Tucson, Tucson, Arizona, USA
| | - M C Lowe
- Division of Pediatric Hospital Medicine, University of Arizona College of Medicine-Tucson, Tucson, Arizona, USA
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27
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Planchette J, Jaccard C, Nigron A, Chadeyras JB, Le Guenno G, Castagne B, Jamilloux Y, Resseguier AS, Sève P. Recurrent thoracic duct cyst of the left supraclavicular fossa: A retrospective study of 6 observational case series and literature review. Medicine (Baltimore) 2021; 100:e28213. [PMID: 34918683 PMCID: PMC8678004 DOI: 10.1097/md.0000000000028213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 10/21/2021] [Accepted: 11/20/2021] [Indexed: 01/05/2023] Open
Abstract
ABSTRACT The transient occlusion of the terminal thoracic duct is a rare disease responsible for renitent supraclavicular cysts. The aim of this study was to describe the clinical characteristics, evolution, and treatment.A retrospective multicenter study and literature review was carried out. The literature search (PubMed) was conducted including data up to 31 December 2020 and PRISMA guidelines were respected.This study identified 6 observational cases between September 2010 and December 2020. The search results indicated a total of 24 articles of which 19 were excluded due to the lack of recurrent swelling or the unavailability of full texts (n = 5). Fourteen patients (8 from literature) mostly reported a noninflammatory, painless renitent mass in the supraclavicular fossa which appeared rapidly over a few hours and disappeared spontaneously over an average of 8 days (range: from about 2 hours to 10 days). Anamnesis indicated a high-fat intake during the preceding days in all cases and 7 from literature found in the Medline databases. Recurrences were noted in 10 patients. Thoracic duct imaging was performed in all cases to detect abnormalities or extrinsic compression as well as to eliminate differential diagnoses.A painless, fluctuating, noninflammatory, and recurrent swelling of the left supraclavicular fossa in patients evoking an intermittent obstruction of the terminal portion of the thoracic duct was identified. A low-fat diet was found as safe and effective treatment.
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Affiliation(s)
- Julie Planchette
- Department of Internal Medicine and Rheumatology, Hospital Emile Roux, Le Puy en Velay, France
| | - Clara Jaccard
- Department of Internal Medicine and Rheumatology, Hospital Emile Roux, Le Puy en Velay, France
| | - Audrey Nigron
- Department of Radiology, Hopital Emile Roux, Le Puy en Velay, France
| | | | | | - Benjamin Castagne
- Department of Internal Medicine and Rheumatology, Hospital Emile Roux, Le Puy en Velay, France
| | - Yvan Jamilloux
- Department of Internal Medicine, Lyon University Hospital, Lyon, France
| | - Anne-Sophie Resseguier
- Department of Internal Medicine and Rheumatology, Hospital Emile Roux, Le Puy en Velay, France
| | - Pascal Sève
- Department of Internal Medicine, Lyon University Hospital, Lyon, France
- Université Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM Lyon, France
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28
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Barnes TG, MacGregor T, Sgromo B, Maynard ND, Gillies RS. Near infra-red fluorescence identification of the thoracic duct to prevent chyle leaks during oesophagectomy. Surg Endosc 2021; 36:5319-5325. [PMID: 34905086 PMCID: PMC9160097 DOI: 10.1007/s00464-021-08912-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 11/21/2021] [Indexed: 11/25/2022]
Abstract
Background Chyle leaks following oesophagectomy are a frustrating complication of surgery with considerable morbidity. The use of near infra-red (NIR) fluorescence in surgery is an emerging technology and the use of fluorescence to identify the thoracic duct has been demonstrated in animal work and early human case reports. This study evaluated the use mesenteric and enteral administration of indocyanine green (ICG) in humans to identify the thoracic duct during oesophagectomy.
Methods Patients undergoing oesophagectomy were recruited to the study. Administration of ICG via an enteral route or mesenteric injection was evaluated. Fluorescence was assessed using a NIR fluorescence enabled laparoscope system with a visual scoring system and signal to background ratios. Visualisation of the thoracic duct under white light and NIR fluorescence was compared as well as any identification of active chyle leak. Patients were followed up post-operatively for adverse events and chyle leak.
Results 20 patients received ICG and were included in the study. The enteral route failed to fluoresce the thoracic duct. Mesenteric injection (17 patients) identified the thoracic duct under fluorescence prior to white light in 70% of patients with a mean signal to background ratio of 5.35. In 6 participants, a possible active chyle leak was identified under fluorescence with 4 showing active chyle leak from what was identified as the thoracic duct. Conclusion This study demonstrates that ICG administration via mesenteric injection can highlight the thoracic duct during oesophagectomy and may be a potential technology to reduce chyle leak following surgery. Clinical trial registration Clinical trials.gov (NCT03292757).
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Affiliation(s)
- Thomas G Barnes
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK.
- Department of Oesophagogastric Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
| | - Thomas MacGregor
- Department of Oesophagogastric Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Bruno Sgromo
- Department of Oesophagogastric Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Nicholas D Maynard
- Department of Oesophagogastric Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Richard S Gillies
- Department of Oesophagogastric Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Sawazaki S, Higuchi A, Tsuchiya K, Minowa K, Akimoto N, Yasukawa M, Kurihara M, Kanno K, Kato A, Kawabe T, Rino Y, Matsukawa H, Saeki H. [A Case of Refractory Chylothorax after Surgery for Esophageal Cancer in Which Lymphangiography and Thoracic Duct Ligation Was Useful]. Gan To Kagaku Ryoho 2021; 48:1296-1298. [PMID: 34657069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Chylothorax after esophagectomy is a relatively rare complication that can be difficult to manage. Here, we report a case of refractory chylothorax after surgery for esophageal cancer treated with lymphatic duct lipiodol imaging by inguinal lymph node puncture to confirm patency of the thoracic duct and thoracic duct ligation. A 71-year-old female with esophageal cancer(cT3N0M0)underwent video-assisted thoracoscopic esophagectomy with 2-field lymph node dissection, intrathoracic gastric tube reconstruction, and an enterostomy. A chylothorax appeared when we started enteral nutrition on the day after surgery. She became markedly dehydrated due to over 2,000 mL/day of drainage from the chest drain, and we managed her general condition in the ICU. We started octreotide acetate on postoperative day(POD)6 and etilefrine on POD 8, but neither was effective. Lymphatic duct lipiodol imaging by bilateral inguinal lymph node puncture was performed, and we confirmed leakage from the main thoracic duct. On POD 11, a thoracic duct ligation performed via a thoracotomy revealed that the volume of the chylothorax was remarkably decreased. The chest tube was removed on re-POD 12.
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Affiliation(s)
- Sho Sawazaki
- Dept. of Surgery, Yokohama Minami Kyousai Hospital
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30
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Nakanishi K. [Reoperation for Chylothorax after Lung Resection]. Kyobu Geka 2021; 74:862-866. [PMID: 34548460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Chylothorax is not a rare complication of lung surgery. Diagnosis is easy in most cases, but treatment is sometimes difficult. Dietary restriction is effective in reducing the chyle but does not always cease the lymph and chyle. Two surgical procedures for postoperative chylothorax are well known:direct closure of the ruptured lymph vessel and ligation of the thoracic duct. Direct closure often fails. It is difficult to detect lymphatic leakage pre- and peri-reoperation. Early reoperation decisions are important for successful direct closure. Thoracic duct ligation is ordinarily performed using the right thoracoscopic approach because the thoracic duct runs in front of the vertebrae along the azygos vein near the diaphragm in the right pleural cavity. The effect of the ligation should be shown immediately. Unfortunately, even if the thoracic duct is confirmed to have been ligated, it sometimes fails to cease the chyle pleural effusion. This may be due to the existence or formation of lymphatic bypass routes.
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Affiliation(s)
- Kozo Nakanishi
- Department of General Thoracic Surgery, National Hospital Organization, Saitama Hospital, Wako, Japan
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31
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Takhellambam L, Yadav TD, Kumar H, Gupta V, Tandup C, Gorsi U, Sharma V, Mandhavdhare H, Samra T, Singh H. Prophylactic ligation of the opacified thoracic duct in minimally invasive esophagectomy - feasibility and safety. Langenbecks Arch Surg 2021; 406:2515-2520. [PMID: 34410481 DOI: 10.1007/s00423-021-02300-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 08/09/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Chyle leak is a rare but morbid complication of esophagectomy. We assessed the feasibility of visualization and prophylactic ligation of the opacified thoracic duct (TD) after administration of 50 ml of olive oil. METHODS This prospective single center study considered all patients with carcinoma of the middle and lower thirds of the thoracic esophagus including the gastroesophageal junction (GEJ), managed from January 2018 to December 2019, for inclusion. All patients underwent McKeown minimally invasive esophagectomy. After anesthesia and endotracheal intubation, 50 ml of olive oil was administered through a nasogastric (NG) tube. During thoracoscopic esophageal mobilization, the opacified thoracic duct was identified and ligated using Weck Hem-o-lok clips immediately above the diaphragmatic hiatus. Postoperatively, the nature, volume, and triglyceride levels of the fluid from the chest drain were recorded. RESULTS Forty-three patients with carcinoma of the esophagus were assessed for inclusion and eventually, 33 were enrolled. The median age of the study population was 55 years, and there were 20 males. The tumor site was the lower esophagus in 24 (72.7%) patients. The most common histolopathological finding was squamous cell carcinoma (97%). The opacified thoracic duct could be identified and ligated in 31 (93.9%) patients. The median duration from the administration of olive oil to the ligation of the thoracic duct was 100 min. The median chest drain output and triglyceride levels on postoperative day (POD) one were 250 ml and 48 mg% respectively. No patient developed postoperative chylothorax. CONCLUSION Opacification and visualization of the thoracic duct during thoracoscopy can be aided by administering olive oil. Ligation of this opacified duct is feasible and safe.
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Affiliation(s)
- Lunkhomba Takhellambam
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Thakur Deen Yadav
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Hemanth Kumar
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vikas Gupta
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Cherring Tandup
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ujjwal Gorsi
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Vishal Sharma
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Harshal Mandhavdhare
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Tanvir Samra
- Department of Anaesthesiology and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Harjeet Singh
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
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Rabattu PY, Sole Cruz E, El Housseini N, El Housseini A, Bellier A, Verot PL, Cassiba J, Quillot C, Faguet R, Chaffanjon P, Piolat C, Robert Y. Anatomical study of the thoracic duct and its clinical implications in thoracic and pediatric surgery, a 70 cases cadaveric study. Surg Radiol Anat 2021; 43:1481-1489. [PMID: 34050781 DOI: 10.1007/s00276-021-02764-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 05/04/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Given the high variability and fragility of the thoracic duct, good knowledge of its anatomy is essential for its repair or to prevent iatrogenic postoperative chylothorax. The objective of this study was to define a site where the thoracic duct is consistently found for its ligation. The second objective was to define an anatomically safe surgical pathway to prevent iatrogenic chylothorax in surgery for aortic arch anomalies with vascular ring, through better knowledge of the anatomical relationships of the thoracic duct. METHODS Seventy adult formalin-fixed cadavers were dissected. The anatomical relationships of the thoracic duct were reported at the postero-inferior mediastinum, at levels T3 and T4. RESULTS The thoracic duct was consistently situated between the left anterolateral border of the azygos vein and the right border of the aorta between levels T9 and T10, whether it was simple, double, or plexiform. It was located medially, anteromedially, or posteriorly to the left subclavian artery in 51%, 21%, and 28% of the cases, respectively, at the level of T3. At T4, it was posteromedial in 27% of the cases or had no direct relationship with the aortic arch. CONCLUSION These results favor mass ligation of the thoracic duct at levels T9-T10 between the right border of the aorta and the azygos vein, eventually including the latter. To prevent iatrogenic postoperative chylothorax in aortic arch anomalies with vascular ring surgery, we recommend remaining strictly lateral to the left subclavian artery at the level of T3 to reach the aortic arch anomalies with vascular ring at T4.
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Affiliation(s)
- P Y Rabattu
- LADAF, Anatomical Laboratory, Univ. Grenoble Alpes, Grenoble University Hospital, 38000, Grenoble, France
- Department of Pediatric Surgery, Children's Hospital, University Hospital of Grenoble, 38000, Grenoble, France
| | - E Sole Cruz
- LADAF, Anatomical Laboratory, Univ. Grenoble Alpes, Grenoble University Hospital, 38000, Grenoble, France
- Department of Pediatric Surgery, Children's Hospital, University Hospital of Grenoble, 38000, Grenoble, France
- ID17 Biomedical Beamline, European Synchrotron Radiation Facility, 38000, Grenoble, France
| | - N El Housseini
- LADAF, Anatomical Laboratory, Univ. Grenoble Alpes, Grenoble University Hospital, 38000, Grenoble, France
| | - A El Housseini
- LADAF, Anatomical Laboratory, Univ. Grenoble Alpes, Grenoble University Hospital, 38000, Grenoble, France
| | - A Bellier
- LADAF, Anatomical Laboratory, Univ. Grenoble Alpes, Grenoble University Hospital, 38000, Grenoble, France
| | - P L Verot
- Department of Pediatric Surgery, Children's Hospital, University Hospital of Grenoble, 38000, Grenoble, France
| | - J Cassiba
- Department of Pediatric Reanimation, Children's Hospital, University Hospital of Grenoble, 38000, Grenoble, France
| | - C Quillot
- Department of Digestive Surgery, Nantes University Hospital, 44000, Nantes, France
| | - R Faguet
- Department of Pediatric Surgery, Children's Hospital, University Hospital of Grenoble, 38000, Grenoble, France
| | - P Chaffanjon
- LADAF, Anatomical Laboratory, Univ. Grenoble Alpes, Grenoble University Hospital, 38000, Grenoble, France
- GIPSA-Lab, Univ. Grenoble Alpes, CNRS, Grenoble INP, 38000, Grenoble, France
| | - C Piolat
- Department of Pediatric Surgery, Children's Hospital, University Hospital of Grenoble, 38000, Grenoble, France
| | - Y Robert
- LADAF, Anatomical Laboratory, Univ. Grenoble Alpes, Grenoble University Hospital, 38000, Grenoble, France.
- Department of Pediatric Surgery, Children's Hospital, University Hospital of Grenoble, 38000, Grenoble, France.
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Abstract
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.
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Affiliation(s)
- Shelby Champion
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | | | - Daniele Wiseman
- Department of Medical Imaging, London Health Science Centre, London, Ontario, Canada
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Donlon NE, Nugent TS, Power R, Butt W, Kamaludin A, Dolan S, Guiney M, Mc Eniff N, Ravi N, Reynolds JV. Embolization or disruption of thoracic duct and cisterna chyli leaks post oesophageal cancer surgery should be first line management for ECCG-defined type III chyle fistulae. Ir J Med Sci 2020; 190:1111-1116. [PMID: 33040261 DOI: 10.1007/s11845-020-02396-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 10/07/2020] [Indexed: 11/27/2022]
Abstract
Chyle leakage from the thoracic duct or cisterna chyli is a relatively rare complication of oesophageal cancer surgery. The majority of cases settle with conservative measures, but high volume leaks may be refractory and result in significant morbidity and require intervention with reoperation or embolization. In the experience of this high-volume centre over the last decade, 3 (0.5%) patients required reoperation and ligation of the thoracic duct; for the so-called type III leaks, interventional radiological approaches were not considered. This article is built around two recent cases, where interventional radiology to embolize and disrupt complex fistulae was successfully performed. The lessons from this experience will change practice at this centre to initial lymphangiography with a view to embolization or disruption of thoracic duct and cisterna chyli leaks as first line therapy for type III chyle leaks, with surgery reserved for where this fails.
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Affiliation(s)
- Noel E Donlon
- Department of Surgery, National Oesophageal and Gastric Cancer Center, St. James's Hospital and Trinity College Dublin, Dublin, Ireland.
| | - Tim S Nugent
- Department of Surgery, National Oesophageal and Gastric Cancer Center, St. James's Hospital and Trinity College Dublin, Dublin, Ireland
| | - Robert Power
- Department of Surgery, National Oesophageal and Gastric Cancer Center, St. James's Hospital and Trinity College Dublin, Dublin, Ireland
| | - Waqas Butt
- Department of Surgery, National Oesophageal and Gastric Cancer Center, St. James's Hospital and Trinity College Dublin, Dublin, Ireland
| | - Ahmad Kamaludin
- Department of Surgery, National Oesophageal and Gastric Cancer Center, St. James's Hospital and Trinity College Dublin, Dublin, Ireland
| | - Steven Dolan
- Department of Interventional Radiology, St. James's Hospital and Beacon Hospital, Dublin, Ireland
| | - Michael Guiney
- Department of Interventional Radiology, St. James's Hospital and Beacon Hospital, Dublin, Ireland
| | - Niall Mc Eniff
- Department of Interventional Radiology, St. James's Hospital and Beacon Hospital, Dublin, Ireland
| | - Narayanasamy Ravi
- Department of Surgery, National Oesophageal and Gastric Cancer Center, St. James's Hospital and Trinity College Dublin, Dublin, Ireland
| | - John V Reynolds
- Department of Surgery, National Oesophageal and Gastric Cancer Center, St. James's Hospital and Trinity College Dublin, Dublin, Ireland
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Bundy JJ, Shin DS, Chick JFB, Monsky WL, Jones ST, List J, Hage AN, Vaidya SS. Percutaneous Extra-Anatomic Lymphovenous Bypass Creation: Toward Treatment of Central Conducting Lymphatic Obstructions. Cardiovasc Intervent Radiol 2020; 43:1392-1397. [PMID: 32444921 DOI: 10.1007/s00270-020-02457-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 03/12/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Protein-losing enteropathy manifests as a loss of serum proteins through the gastrointestinal tract, resulting in hypoproteinemia, extravascular fluid retention, and edema. Management consists of nutritional maintenance in conjunction with interventions targeted at treating the underlying etiology. MATERIALS AND METHODS This report describes a patient with protein-losing enteropathy from a central conducting lymphatic obstruction who was treated with percutaneous extra-anatomic lymphovenous bypass creation. RESULTS A modified gun-sight technique was used to create a lymphovenous bypass between an occluded terminal thoracic duct and the left internal jugular vein. CONCLUSION A percutaneous technique to reconstruct the terminal thoracic duct via lymphovenous bypass creation was feasible.
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Affiliation(s)
- Jacob J Bundy
- Division of Interventional Radiology, Wake Forest Baptist HealthOne Medical Center Boulevard, Winston-Salem, NC, USA
| | - David S Shin
- Division of Interventional Radiology, University of Washington, 1959 Northeast Pacific Street, Seattle, WA, 98195, USA
| | - Jeffrey Forris Beecham Chick
- Division of Interventional Radiology, University of Washington, 1959 Northeast Pacific Street, Seattle, WA, 98195, USA.
| | - Wayne L Monsky
- Division of Interventional Radiology, University of Washington, 1959 Northeast Pacific Street, Seattle, WA, 98195, USA
| | - Sean T Jones
- Division of Interventional Radiology, University of Washington, 1959 Northeast Pacific Street, Seattle, WA, 98195, USA
| | - Jeb List
- Division of Interventional Radiology, University of Washington, 1959 Northeast Pacific Street, Seattle, WA, 98195, USA
| | - Anthony N Hage
- Division of Interventional Radiology, Thomas Jefferson University Hospital, 111 South 11th Street, Philadelphia, PA, USA
| | - Sandeep S Vaidya
- Division of Interventional Radiology, University of Washington, 1959 Northeast Pacific Street, Seattle, WA, 98195, USA
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Lindenblatt N, Puippe G, Broglie MA, Giovanoli P, Grünherz L. Lymphovenous Anastomosis for the Treatment of Thoracic Duct Lesion: A Case Report and Systematic Review of Literature. Ann Plast Surg 2020; 84:402-408. [PMID: 31800553 DOI: 10.1097/sap.0000000000002108] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Chylous leak is an uncommon complication after head and neck surgery and typically results from a lesion of the thoracic duct (TD). Beside conservative treatment, different minimally invasive and surgical procedures exist, of which almost all lead to a total closure of the TD. METHODS We report on a rare case of microsurgical lymphovenous anastomosis to treat a TD lesion. An additional systematic review on surgical procedures to treat TD lesions with special attention to lymphovenous anastomoses was performed according to the PRISMA guidelines. RESULTS A 52-year-old patient with a chylous fistula after modified radical neck dissection was successfully treated by a lymphovenous anastomosis of the TD and external jugular vein with additional coverage by sternocleidomastoid muscle flap. The patient showed a complete resolution of chylous leak with an uneventful postoperative course.The systematic search of literature yielded 684 articles with 4 case reports on lymphovenous anastomosis in chylous leak with a high success rate. Other surgical techniques include transcervical, thoracoscopic, or video-assisted thoracoscopic TD ligation, either alone or combined with a local muscle flap. CONCLUSIONS Lymphovenous anastomosis of the TD is a feasible and safe technique allowing for treatment of cervical TD lesions, especially if minimally invasive procedures fail. Compared with other techniques, lymphatic circulation can successfully be maintained.
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Affiliation(s)
| | | | - Martina A Broglie
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, Zurich, Switzerland
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Ahmed U, Davakis S, Syllaios A, Sdralis E, Lorenzi B, Mastoraki A, Charalabopoulos A. Prone position thoracoscopic management of neck chyle leak following major head and neck surgery. A case series. Ann Ital Chir 2020; 91:265-272. [PMID: 32877384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Chyle leak is a major compication following head and neck surgery, with reported incidence of 0.5% up to 8.3% in published literature. Cervical chyle leak may be challenging to manage with significant morbidity, resulting from extensive fluid and nutritional losses. This manuscript presents four cases of cervical chyle leak after head and neck surgery. Cervical thoracic duct injury had been identified intra-operatively. Conservative treatment failed to reduce chylous output post-operatively. All patients were offered thoracocscopic thoracic duct ligation in prone position; thoracic duct was dissected above the right diaphragm and ligated. Immediate resolution of their symptoms followed, with no recurrence at the follow-up period. Intra-operative repair of cervical thoracic duct remains controversial, while when identified early reduces the following comorbidities. Conservative management addresses reduction of chylous output, while amplifying hydration and alimentation. Thoracoscopic thoracic duct ligation offers a safe and feasible treatment for cervival chyle leak following head and neck surgery with all the advances of minimally-invasive surgery. KEY WORDS: Chyle leak, Head and Neck Surgery, Thoracoscopic, Thorasic Duct, Ligation, Minimally-Invasive.
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38
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McGregor H, Woodhead G, Patel M, Hennemeyer C. Thoracic duct stent-graft decompression with 3-month patency: Revisiting a historical treatment option for portal hypertension. Lymphology 2020; 53:81-87. [PMID: 33190431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
This report introduces the rationale for thoracic duct stent-graft decompression in cirrhotic patients with portal hypertension and provides a case example with 3-month stentgraft patency. Thoracic duct flow and pressure are elevated in cirrhosis. Historically, complications of portal hypertension have been successfully treated with external drainage of the thoracic duct or surgical lymphovenous bypass. A 45-year-old woman with cirrhosis, chronic portosplenomesenteric thrombosis, and acute variceal hemorrhage underwent percutaneous thoracic duct stent-graft placement across the lymphovenous junction. The hemorrhage subsequently resolved and follow up endoscopy demonstrated decompression of the bleeding varices. Venography 40 days later demonstrated a partially patent stent-graft with fibrin sheath formation distally. The stent-graft was extended distally to the right atrium and was fully patent on venography 3 months later. The patient had no further episodes of hemorrhage.
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Affiliation(s)
- H McGregor
- Department of Medical Imaging, University of Arizona, Tucson, Arizona USA
| | - G Woodhead
- Department of Medical Imaging, University of Arizona, Tucson, Arizona USA
| | - M Patel
- Department of Medical Imaging, University of Arizona, Tucson, Arizona USA
| | - C Hennemeyer
- Department of Medical Imaging, University of Arizona, Tucson, Arizona USA
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Witte MH. Thoracic duct decompression: An idea whose time has come - again. Lymphology 2020; 53:51-54. [PMID: 33190427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
[Editorial] Thoracic duct decompression (TDD) is an idea first proposed and applied as a novel therapeutic strategy by lymphologists in the 1960's. TDD is recently being reexamined and, in selected patients with portal hypertension from hepatic cirrhosis or with central venous hypertension from isolated right-sided heart failure, undertaken using advanced surgical and image-guided interventional radiologic approaches.
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Affiliation(s)
- M H Witte
- Department of Surgery, University of Arizona College of Medicine, Tucson, Arizona, USA
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Dickerson VM, Grimes JA, Secrest SA, Wallace ML, Schmiedt CW. Abdominal lymphatic drainage after thoracic duct ligation and cisterna chyli ablation in clinically normal cats. Am J Vet Res 2019; 80:885-890. [PMID: 31449451 DOI: 10.2460/ajvr.80.9.885] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To characterize abdominal lymphatic drainage in cats after thoracic duct ligation (TDL) and cisterna chyli ablation (CCA). ANIMALS 7 purpose-bred research cats. PROCEDURES Baseline CT lymphangiography was performed. A popliteal lymph node was injected with iohexol, and images were acquired at 5-minute intervals for 15 minutes. Cats underwent TDL and CCA; methylene blue was used to aid in identifying lymphatic vessels. The CT lymphangiography was repeated immediately after and 30 days after surgery. All cats were euthanized and necropsied. RESULTS Results of baseline CT lymphangiography were unremarkable for all 7 cats. Only 5 cats completed the study. Leakage of contrast medium at the level of the cisterna chyli was seen on CT lymphangiography images obtained from all cats immediately after surgery. Evaluation of 30-day postoperative CT lymphangiography images revealed small branches entering the caudal vena cava in 2 cats, leakage of contrast medium into the caudal vena cava with no visible branches in 1 cat, and no contrast medium in the caudal vena cava in 2 cats. Contrast medium did not flow beyond the level of the cisterna chyli in any cat. Gross examination during necropsy revealed that all cats had small lymphatic vessels that appeared to connect to local vasculature identified in the region of the cisterna chyli. CONCLUSIONS AND CLINICAL RELEVANCE Abdominal lymphaticovenous anastomoses formed after TDL and CCA in cats. This would support use of these procedures for treatment of cats with idiopathic chylothorax, although additional studies with clinically affected cats are warranted.
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Caronia FP, Fatica F, Librizzi D, Fiorelli A. Uniportal Thoracoscopic Thoracic Duct Clipping in Poirier's Triangle for Postoperative Chylothorax. Ann Thorac Surg 2018; 107:e415-e416. [PMID: 30444992 DOI: 10.1016/j.athoracsur.2018.09.062] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 09/18/2018] [Accepted: 09/19/2018] [Indexed: 11/18/2022]
Abstract
Postoperative chylothorax is a rare but potentially life-threatening complication. Conservative treatment is usually unsuccessful in patients with high-output chylothorax, for whom early surgical thoracic duct ligation has been advocated to minimize morbidity and mortality. This report describes left uniportal thoracoscopic closure of persistent high-output chylothorax through Poirier's triangle in a patient undergoing thoracoscopic thymectomy. After resection of pleural adhesions, the mediastinal pleura was resected at the level of the aortic arch, left subclavian artery, and vertebral column, the anatomic limits of Poirier's triangle. The thoracic duct was then isolated from the esophagus and successfully clipped along its path.
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Affiliation(s)
| | - Federica Fatica
- Thoracic Surgery Unit, Ospedale Civico di Palermo, Palermo, Italy
| | - Damiano Librizzi
- Thoracic Surgery Unit, Ospedale Civico di Palermo, Palermo, Italy
| | - Alfonso Fiorelli
- Thoracic Surgery Unit, Università della Campania Luigi Vanvitelli, Naples, Italy.
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42
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Azuma Y, Iyoda A. [Energy Device and Soft Coagulation System in Thoracic Surgery]. Kyobu Geka 2018; 71:759-762. [PMID: 30310023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
While the recent emergence of energy-based surgical techniques and soft coagulation has made surgical procedures less invasive, the safety and proper use of such advances have yet to be investigated. Herein we review the experimental and clinical use of ultrasonically-activated coagulating shears, a vessel sealing system, incorporating ultrasonic and vessel sealing technology, and a soft coagulation system in thoracic surgery. All energy devices have been reported to be safe for use on pulmonary vessels, and use in combination with a ligature appears to be adequate. The thoracic duct has been reported to be sealed with sufficient pressure using energy devices, which are expected to prevent chylothorax formation. Bipolar scissors can be safely and efficiently applied for dissection of pulmonary vessels without damage to the vessel wall. Monopolar soft coagulation can be applied to shrink bullous changes and stop air leakage or bleeding within the lung.
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Affiliation(s)
- Yoko Azuma
- Division of Chest Surgery, Department of Surgery, Toho University School of Medicine, Tokyo, Japan
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43
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Lei Y, Feng Y, Zeng B, Zhang X, Chen J, Zou J, Su C, Liu Z, Luo H, Zhang S. Effect of Prophylactic Thoracic Duct Ligation in Reducing the Incidence of Postoperative Chylothorax during Esophagectomy: A Systematic Review and Meta-analysis. Thorac Cardiovasc Surg 2018; 66:370-375. [PMID: 28464192 DOI: 10.1055/s-0037-1602259] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVES There is no consensus on the effectiveness of prophylactic thoracic duct ligation (PLG) in esophagectomy for reducing the incidence of postoperative chylothorax. We performed a systemic review and meta-analysis to study its efficacy. METHODS A systemic review of the publications was performed on three databases to identify all the relevant literature on comparative outcomes of PLG and nonprophylactic thoracic duct ligation (NPLG). The primary end point was the incidence of postoperative chylothorax. RESULTS Seven studies with comparative data on PLG (n = 2,178) versus NPLG (n = 3,048) were identify from the current publications. Comparison showed no significant difference between PLG and NPLG on the incidence of postoperative chylothorax (relative risk = 0.431; 95% confidence interval, 0.186 to 1.002; p = 0.050). CONCLUSIONS Although some studies showed that PLG during the esophagectomy was effective to lower the incidence of postoperative chylothorax, no evidence was observed in the present meta-analysis. Further research is warranted to validate the findings.
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Affiliation(s)
- Yiyan Lei
- Department of Thoracic Surgery, Sun Yat-sen University, the First Affiliated Hospital, Guangzhou, Guangdong, P. R. China
| | - Yanfen Feng
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, P. R. China
- Department of Pathology, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, P. R. China
| | - Bo Zeng
- Department of Thoracic Surgery, Sun Yat-sen University, the First Affiliated Hospital, Guangzhou, Guangdong, P. R. China
| | - Xin Zhang
- Department of Thoracic Surgery, Sun Yat-sen University, the First Affiliated Hospital, Guangzhou, Guangdong, P. R. China
| | - Jingfu Chen
- Department of Oncology, The Third People's Hospital of Dongguan City, Dongguan, Guangdong, P. R. China
| | - Jianyong Zou
- Department of Thoracic Surgery, Sun Yat-sen University, the First Affiliated Hospital, Guangzhou, Guangdong, P. R. China
| | - Chunhua Su
- Department of Thoracic Surgery, Sun Yat-sen University, the First Affiliated Hospital, Guangzhou, Guangdong, P. R. China
| | - Zhenguo Liu
- Department of Thoracic Surgery, Sun Yat-sen University, the First Affiliated Hospital, Guangzhou, Guangdong, P. R. China
| | - Honghe Luo
- Department of Thoracic Surgery, Sun Yat-sen University, the First Affiliated Hospital, Guangzhou, Guangdong, P. R. China
| | - Shuishen Zhang
- Department of Thoracic Surgery, Sun Yat-sen University, the First Affiliated Hospital, Guangzhou, Guangdong, P. R. China
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Majdalany BS, Khayat M, Sanogo ML, Saad WE, Khaja MS. Direct trans-cervical endolymphatic thoracic duct stent-graft for plastic bronchitis. Lymphology 2018; 51:97-101. [PMID: 30422431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Plastic bronchitis is a poorly understood and uncommon diagnosis, arising from multiple etiologies. Traditional treatment consists of steroids and vasodilators, with thoracic duct embolization emerging as a new procedural therapy. Herein, abnormal lymphatic vessels were noted on lymphangiography in an adult patient with debilitating plastic bronchitis, but anterograde lymphatic access was not feasible due to the patient's morbid obesity and non-visualization of retroperitoneal lymphatics. After trans-venous thoracic duct access could not be established, direct trans-cervical thoracic duct access was performed. A thoracic duct stent-graft was placed, excluding the abnormal bronchial lymphatics and maintaining physiologic anterograde flow through the central lymphatics. At three-month follow-up, the patient's condition had resolved.
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Affiliation(s)
- B S Majdalany
- Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - M Khayat
- Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - M L Sanogo
- Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - W E Saad
- Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - M S Khaja
- Department of Radiology, Division of Vascular and Interventional Radiology, University of Michigan Health System, Ann Arbor, Michigan, USA
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Abstract
Bilateral chylothorax following anterior cervical spine surgery is very rare. This report documents the first case of chylothorax after anterior cervical spine surgery through a right-side surgical approach. Unidentified chyle leakage can easily remain unrecognized and, thus, is difficult to treat. For early diagnosis and treatment, it is very important to consider the possibility of chylothorax following anterior cervical spine surgery, even when using a right-side surgical approach.
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Affiliation(s)
- Jung Sik Bae
- Department of Neurosurgery, Nanoori Gangseo Hospital, Seoul, South Korea
| | - Jeong Hyun Park
- Department of Neurosurgery, Nanoori Jooan Hospital, Incheon, South Korea
| | - Il-Tae Jang
- Department of Neurosurgery, Nanoori Gangnam Hospital, 731 Eonju-ro, Gangnam-gu, Seoul, 06048, Republic of Korea.
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Abstract
BACKGROUND Chylothorax is a disease that has various causes such as neoplasm, infection, post-surgery trauma, congenital, and venous thrombosis. In approximately 15% of cases of chylothorax, the exact cause is unknown. We report a case of delayed occurrence of right chylothorax in a patient who had multiple segmental ribs fracture on his left side. CASE PRESENTATION A 70-year-old Asian man had a "rollover" accident in which the cultivator he was driving overturned. He presented to our hospital with the main complaint of severe dyspnea. On chest computed tomography, multiple ribs fracture from the first to the eighth rib of the left side of his chest and left-sided hemopneumothorax were presented, but there was no evidence of fracture in the right side of his chest. After closed thoracostomy, an emergency operation for open reduction of fractured ribs was performed. On the fifth postoperative day, tubal feeding was performed. On the next day, a plain chest X-ray image showed pleural effusion of the right side of his chest. After insertion of a small-bore chest tube, 3390 ml of fluid for 24 hours was drained. The body fluid analysis revealed triglycerides levels of 1000 mg/dL, which led to a diagnosis of chylothorax. Although non-oral feeding and total parenteral nutrition were sustained, drain amount was increased on the fifth day. Surgical treatment (thoracoscopic thoracic duct ligation and pleurectomy) was performed in the early phase. The right chest tube was removed on the 14th postoperative day after the effusion completely resolved and he was uneventfully discharged. CONCLUSIONS In this case, as our patient was in old age and had multiple traumas, surgical treatment for chylothorax needed to be performed in the early phase.
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Affiliation(s)
- Jonggeun Lee
- Department of Thoracic and Cardiovascular Surgery, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, South Korea
| | - Jeong Su Cho
- Department of Thoracic and Cardiovascular Surgery, Pusan National University School of Medicine, Medical Research Institute, Pusan National University Hospital, 179 Gudeok-Ro, Seo-Gu, Busan, 602-739 Republic of Korea
| | - Hoseok I
- Department of Thoracic and Cardiovascular Surgery, Pusan National University School of Medicine, Medical Research Institute, Pusan National University Hospital, 179 Gudeok-Ro, Seo-Gu, Busan, 602-739 Republic of Korea
| | - Yeong Dae Kim
- Department of Thoracic and Cardiovascular Surgery, Pusan National University School of Medicine, Medical Research Institute, Pusan National University Hospital, 179 Gudeok-Ro, Seo-Gu, Busan, 602-739 Republic of Korea
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Yang RF, Jiang ZM, Zhang RQ, Yu B, Wang XH, Wang P. Effect of Ligation of the Thoracic Duct During Oesophagectomy on the Absorption of D-xylose. J Coll Physicians Surg Pak 2017; 27:153-156. [PMID: 28406774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Accepted: 03/14/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To assess if prophylactic thoracic duct ligation during oesophagectomy influences the absorptive function of oesophageal cancer patients. STUDY DESIGN Randomized controlled trial. PLACE AND DURATION OF STUDY Department of Thoracic Surgery, Tai'an City Central Hospital, Tai'an, from August 2014 to December 2015. METHODOLOGY Based on the management of the thoracic duct during oesophagectomy, 60 patients were randomized into two groups. D-xylose absorption test was used to evaluate the absorptive function. The two-independent-samples t-test was employed for statistical analysis with statistical significance at p < 0.05. RESULTS The serum D-xylose concentration of ligation-group was significantly lower than that of no-ligation group on the first day after operation, (t=2.82, p=0.0066). However, there was no significant differences between them even before operation (t=1.34, p=0.1849). CONCLUSION Ligation of the thoracic duct during oesophagectomy immediately affected the absorption of D-xylose, which may lead to malabsorption in the long run.
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Affiliation(s)
- Rui -Feng Yang
- Department of Thoracic Surgery, Qianfoshan Hospital of Shandong Province, Shandong University, Ji'nan, Shandong 250012, China
- Department of Thoracic Surgery, Tai'an City Central Hospital, Tai'an, Shandong 271000, China
| | - Zhong -Min Jiang
- Department of Thoracic Surgery, Qianfoshan Hospital of Shandong Province, Shandong University, Ji'nan, Shandong 250012, China
| | - Run -Qi Zhang
- Department of Thoracic Surgery, Tai'an City Central Hospital, Tai'an, Shandong 271000, China
| | - Bing Yu
- Department of Colorectal Surgery , Tai'an City Central Hospital, Tai'an, Shandong 271000, China
| | - Xiao -Hong Wang
- Department of Digestive System, Tai'an City Central Hospital, Tai'an, Shandong 271000, China
| | - Peng Wang
- Department of Thoracic Surgery, Tai'an City Central Hospital, Tai'an, Shandong 271000, China
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PRrhin VD, Vvzhiaina MA, Bunvatvan AA, Parshin AV, Zhukova SG. TREATMENT OF CHYLOTHORAX - ANESTHESIOLOGICAL OR SURGICAL PROBLEM? Anesteziol Reanimatol 2017; 62:63-68. [PMID: 29932585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND The progress of surgery, the widespread use in the clinic of cardiac surgery and extended lymphadenectomy in thoracic surgery led to a greater incidence of the thoracic lymphatic duct ' trauma. That is why the actuality of treatment of chylothorax and chylorrhea is increased. The aim; improvement of diagnostics, prevention and treatment results ofpatients with chylothorax and chylorrhea. MATERIALS AND METHODS 37 patients (14 women and 23 men) with chylothorax had been treating with our participation in different hospitals from 2004 to 2014. The age of the patients was from 32 to 71 years. In 34 patients chylothorax occurred after surgery, in 3 patients - during the decompensation of the therapy diseases with the use of central venous catheterization, with an earlier clinic of thrombosis of the large veins of the neck. RESULTS Conservative therapy had good clinical effect of 83.8%. 1 patient died due to pneumonia of the single lung on the background of chylothorax developed in the postoperative period after right-sided pneumonectomy. In other cases, chylothorax was eliminated and in the late period had no recurrence. CONCLUSION prevention of chylothorax depends on the experience of the operating surgeon. If there is doubt intact thoracic lymphatic duct, it has tightened with the stitching surrounding adipose tissue. Conservative therapy is the method of choice in the treatment of chylothorax. Surgery is indicated for failure of conservative therapy within the first two weeks, or when massive chylorrhea takes place.
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Liu S, Wang Z, Wang F. [Optimal lymphadenectomy for thoracic esophageal cancer: three-field or modified two-field lymphadenectomy]. Zhonghua Wei Chang Wai Ke Za Zhi 2016; 19:975-978. [PMID: 27680062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Differences in operative procedure and knowledge of esophageal cancer exist among surgeons from different countries and regions. There is controversy in the surgical treatment of esophageal cancer, especially in the extent of lymphadenectomy. Until now, results of the three-field lymphadenectomy and two-field lymphadenectomy are mostly reported by retrospective studies from Japan and China. Three-field lymphadenectomy has been initiated in Fujian Provincial Cancer Hospital since 1990s. After evaluating our database, we found that three-field was superior to two-field lymphadenectomy in terms of long-term survival for patients with upper thoracic esophageal cancer, whereas for those with middle or lower thoracic esophageal cancer, the survival benefit of three-field lymphadenectomy was reduced. Therefore, we propose to perform three-field lymphadenectomy for upper thoracic esophageal cancer. In middle or lower thoracic esophageal cancer, we suggest to perform modified two-field lymphadenectomy in most cases, and three-field lymphadenectomy in selective cases. Video-assisted two-field lymphadenectomy is feasible. Based on the national condition of China, we advise to perform thoracic duct removal only in patients with posterior mediastinal or peri-ductus node metastasis to achieve curative effect.
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Affiliation(s)
- Shuoyan Liu
- Department of Thoracic Surgery, Fujian Provincial Tumor Hospital, Fujian Medical University, Fuzhou 350014, China.
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Bellini C, Cabano R, Bellini T, Boccardo F, Morcaldi G, Ramenghi LA. Congenital Chylothorax of the Newborn: Diagnosis and Treatment in Three Pictures. Lymphology 2016; 49:150-156. [PMID: 29906078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
There is general agreement regarding the evident need for an international, multicenter trial including long-term follow-up to establish the correct criteria for diagnosing and managing congenital chylothorax. In an attempt to identify these criteria, which could then be used to draft a prospective multicenter trial, we propose three flow-charts showing three algorithms that could be used to: 1) obtain a definitive diagnosis of pleural chylous effusion; 2) specifically focus on chyle leakage evolution and etiology of chylothorax; and 3) focus on the management of congenital chylothorax. The aim of the algorithms we propose is to build the basis on which a strongly needed multicenter trial might be structured.
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