Clinton H Doerr, Mark S Allen, Francis C Nichols, Jay H Ryu
Etiology of chylothorax in 203 patients.
Mayo Clin Proc. 2005 Jul;80(7):867-70. doi: 10.4065/80.7.867.
Abstract/Text
OBJECTIVES: To characterize the etiology of chylothorax in patients encountered at a single tertiary referral center and to compare the findings with those from previous studies.
PATIENTS AND METHODS: The medical records of all patients with chylothorax seen at the Mayo Clinic in Rochester, Minn, over a 21-year period, from January 1, 1980, to December 31, 2000, were retrospectively reviewed to ascertain the underlying cause of their condition.
RESULTS: We identified 203 patients with chylothorax; 92 were females (male-female ratio, 1.21). The median age was 54.5 years (range, 21 weeks' gestation to 93 years). Dyspnea, the most common presenting symptom, occurred in 98 (56.6%) of 173 patients in whom initial symptoms were recorded, whereas 64 (37.0%) had no respiratory symptoms. Median duration of symptoms before diagnosis was 7.5 weeks (range, 1 day to 4.5 years). Causes of chylothorax included surgery or trauma in 101 patients (49.8%), various medical conditions in 89 (43.8%), and unknown in 13 (6.4%). Among surgical procedures, esophagectomy (29 patients) and surgery for congenital heart disease (28 patients) were the most common causes of chylothorax. Among medical conditions, lymphoma (23 patients), lymphatic disorders (19 patients), and chylous ascites (16 patients) were the most common causes.
CONCLUSIONS: Chylothorax has numerous causes. In contrast to previous studies, surgery or trauma was the most common cause of chylothorax at our institution, accounting for nearly 50% of cases. Lymphoma and other malignancies caused chylothorax in only 16.7% of cases. These numbers are possibly related to the high volume of cardiothoracic surgical procedures performed at our tertiary referral center.
V Chernick, M H Reed
Pneumothorax and chylothorax in the neonatal period.
J Pediatr. 1970 Apr;76(4):624-32.
Abstract/Text
Kimihiro Shimizu, Junji Yoshida, Mituyo Nishimura, Kazuya Takamochi, Rie Nakahara, Kanji Nagai
Treatment strategy for chylothorax after pulmonary resection and lymph node dissection for lung cancer.
J Thorac Cardiovasc Surg. 2002 Sep;124(3):499-502.
Abstract/Text
OBJECTIVE: We reviewed our experience with iatrogenic chylothorax after pulmonary resections for lung cancer to evaluate our treatment strategy and to identify factors that predict the need for reoperation.
METHODS: From July 1992 through February 2000, a total of 1110 patients underwent pulmonary resection (at least lobectomy) and systematic mediastinal lymph node dissection for lung cancer at our division. Twenty-seven patients (2.4%) had postoperative chylothorax develop. We initially treated 26 of these patients conservatively with complete oral intake cessation and total parenteral nutrition, and these patients constituted the subjects in this study.
RESULTS: There were 21 men and 5 women with a median age of 62 years (range 44 to 80 years). The initial procedures were pneumonectomy in 2 cases, bilobectomy in 1 case, and lobectomy in 23 cases. Twenty-one patients (81%) had the condition cured with conservative treatment. These patients resumed a normal diet at a median of 8 days after chylothorax diagnosis (range 4-35 days). The remaining 5 patients (19%) underwent reoperation at a median of 14 days after diagnosis (range 5-35 days). Chest tube drainage of less than 500 mL during the first 24 hours after complete oral intake cessation and total parenteral nutrition predicted a cure with conservative treatment.
CONCLUSION: Although most cases of chylothorax after pulmonary resection with systematic mediastinal lymph node dissection can be cured with a conservative strategy, early surgical intervention may be indicated if chest tube drainage is more than 500 mL during the first 24 hours after complete oral intake cessation and total parenteral nutrition.
D Dougenis, W S Walker, E W Cameron, P R Walbaum
Management of chylothorax complicating extensive esophageal resection.
Surg Gynecol Obstet. 1992 Jun;174(6):501-6.
Abstract/Text
Between January 1983 and May 1987, 255 esophagectomies were performed for carcinoma of the middle (40 patients) or lower (215 patients) esophagus. All patients were operated upon through a left thoracolaparotomy and underwent a radical en bloc resection of the tumor along with all palpable mediastinal nodes. Ten patients had chylothorax develop postoperatively. There were seven men and three women with a mean age of 65.7 years (range of 37.0 to 81.0 years). Parameters that were statistically evaluated for possible correlation to increased incidence of chylous fistula were age, sex, site and size of tumor, histologic type, mediastinal lymphatic involvement and elective prophylactic ligation of the major thoracic duct (MTD) at the conclusion of the procedure. It was found that elective ligation of the MTD was associated with a lower occurrence of chylothorax (2.1 per cent) as compared with those with no routine ligation (9 per cent), p less than 0.05. The leak was successfully treated by repeated thoracotomy and mass ligation of the MTD in eight patients, while one patient underwent closed tube thoracostomy. In one instance, only a pleuroperitoneal shunt was performed. The over-all hospital mortality rate from chylothorax was 10 per cent and there was a late death because of pneumonia. We recommend prophylactic ligation of the MTD in all instances of extensive esophageal resection for the prevention of chylothorax, as well as early thoracotomy for the management of established leaks.
L Bonavina, G Saino, D Bona, M Abraham, A Peracchia
Thoracoscopic management of chylothorax complicating esophagectomy.
J Laparoendosc Adv Surg Tech A. 2001 Dec;11(6):367-9. doi: 10.1089/10926420152761888.
Abstract/Text
BACKGROUND: Chylothorax is a relatively uncommon complication of esophageal surgery that may lead to severe respiratory, nutritional, and immunologic deficiencies.
PATIENTS AND METHODS: Between 1992 and 2000, 3 of 316 patients (0.9%) undergoing transthoracic esophagectomy for carcinoma developed postoperative chylothorax. Two of them had previously been treated with neoadjuvant chemoradiation, and one had been submitted to esophagogastric resection through a left thoracotomy. After a 2-week trial of total parenteral nutrition and drainage, two patients underwent thoracic duct ligation via thoracotomy. In the last patient, the operation was completed by thoracoscopy. The azygos vein and the periaortic tissue above the diaphragm were encircled en bloc by a right-angled clamp, and a roticulating endostapler was applied.
RESULTS: Reoperation was successful in all patients. The postoperative hospital stay was 4 days.
CONCLUSION: Thoracoscopy is a safe and effective procedure for the treatment of chylothorax complicating esophagectomy. Given the minimal trauma to the patient, early thoracoscopic reoperation can be advocated in patients with high-output chyle loss in order to reduce the hospital stay.
H Zabeck, T Muley, H Dienemann, H Hoffmann
Management of chylothorax in adults: when is surgery indicated?
Thorac Cardiovasc Surg. 2011 Jun;59(4):243-6. doi: 10.1055/s-0030-1250374. Epub 2011 Mar 21.
Abstract/Text
BACKGROUND: The aim of this retrospective study was to analyze the etiology, management and outcome of patients with chylothorax and identify clinical parameters for appropriate treatment decisions.
METHODS: We analyzed 82 cases of chylothorax in 75 patients. In 37 cases (45 %) the cause of chylothorax was surgery, in 45 cases (55 %), the etiology was nonsurgical (malignancy n = 17 [21 %], lymphatic disorders n = 5 [6 %], hepatic cirrhosis, n = 4 [5 %], trauma n = 1 and other causes n = 18 [22 %]).
RESULTS: Conservative treatment was successful in 13 (16 %) cases. In 25 cases (total 31 %, postsurgical n = 19 [51 %], nonsurgical n = 6 [13 %]) a (redo) thoracotomy with ligation of the thoracic duct or repeat surgical procedure was performed. The quantity of chyle drained per 24 hours appeared to be the best indicator to guide management decisions.
CONCLUSION: Chylothoraces that occur postoperatively following thoracic procedures require redo operations in approximately 50 % of cases, whereas nonsurgical causes rarely require surgical intervention. In postoperative chylothoraces with a high flow leak > 900 mL/24 h revision should be performed early on, since conservative management is likely to be unsuccessful.
© Georg Thieme Verlag KG Stuttgart · New York.
Fabien Maldonado, Rodrigo Cartin-Ceba, Finn J Hawkins, Jay H Ryu
Medical and surgical management of chylothorax and associated outcomes.
Am J Med Sci. 2010 Apr;339(4):314-8. doi: 10.1097/MAJ.0b013e3181cdcd6c.
Abstract/Text
Chylothorax is an uncommon form of pleural effusion that can be associated with traumatic and nontraumatic causes. Optimal management and outcome for patients with chylothorax remain unclear. This retrospective single-center study assessed the modes of management for chylothorax in 74 adult patients (> or =18 years old) and associated outcomes. The role of lymphangiographic imaging was also evaluated. Initial treatment approach was nonsurgical in 57 patients (77%) but a surgical procedure (pleurodesis, thoracic duct ligation, and/or surgical repair) was eventually performed in 44 patients (59%). The rate of resolution with initial treatment measures was significantly worse for patients with nontraumatic chylothorax compared with those with traumatic causes (27% versus 50%, P = 0.048). Even after additional therapeutic maneuvers including surgery, chylous effusion recurred more commonly in nontraumatic chylothorax when compared with the traumatic group (50% versus 13%, respectively, P < 0.001). Lymphatic imaging did not seem to materially influence management. Nonsurgical approaches may lead to resolution of the chylothorax in nearly one half of patients with traumatic chylothorax but in only a minority of those with nontraumatic chylothorax. The majority of patients with nontraumatic chylothorax will eventually require surgical maneuvers, but one third of such patients still fail to resolve their chylothorax.
Bojiang Chen, Zuohong Wu, Qin Wang, Weimin Li, Deyun Cheng
Dasatinib-induced chylothorax: report of a case and review of the literature.
Invest New Drugs. 2020 Oct;38(5):1627-1632. doi: 10.1007/s10637-020-00932-3. Epub 2020 Apr 4.
Abstract/Text
Dasatinib is a tyrosine kinase inhibitor for the treatment of BCR-ABL-positive chronic myeloid leukaemia (CML) or Philadelphia chromosome-positive acute lymphoblastic leukaemia (ALL). Although fluid retention is a common adverse event associated with dasatinib, chylothorax is exceptionally rare. The pathological mechanism, clinical manifestation and management of dasatinib-induced chylothorax are completely unclear. A 71-year-old man treated with dasatinib for CML was admitted for progressive dyspnea. Computed tomography (CT) showed a pleural effusion that was more prominent on the right thoracic cavity. Thoracentesis showed thick milky pleural fluid, which was then confirmed as chylothorax by chylum qualitative tests and triglyceride measurements. Radionuclide lymphoscintigraphy yielded an obstruction at the end segment of the thoracic duct, but no leakage points were found. After excluding common causes, drug-induced chylothorax was presumed. Then, dasatinib was withdrawn, and 1 week later, chylothorax resolved. To further elucidate the relationship between the medication and chylothorax, dasatinib was resumed tentatively for 2 days. As expected, pleural effusion recurred soon. Based on these clinical manifestations, the diagnosis of dasatinib-induced chylothorax was identified. The patient was suggested to stop dasatinib and use an alternative drug as recommended by the haematologist. Pleural effusion is the common adverse reaction of dasatinib, but chylothorax is rare. Only six cases of dasatinib-induced chylothorax have been reported, and our patient is the seventh case. Once a patient with dasatinib treatment develops chylothorax, dasatinib should be considered one of the possible causes. If no other definitive aetiological factor is identified, dasatinib discontinuation might be the optimum scheme.
Abdullah Al-Abcha, Mian Harris Iftikhar, Fawzi Abu Rous, Heather Laird-Fick
Chylothorax: complication attributed to dasatinib use.
BMJ Case Rep. 2019 Dec 16;12(12). doi: 10.1136/bcr-2019-231653. Epub 2019 Dec 16.
Abstract/Text
A 63-year-old woman with a medical history of chronic myelogenous leukaemia treated with dasatinib, chronic obstructive pulmonary disease and heart failure with preserved ejection fraction presented with difficulty in breathing. Chest X-ray showed large right-sided pleural effusion, which was confirmed on a CT angiogram of the chest. Echocardiogram showed an ejection fraction of 61% with moderate to severely dilated right ventricle and right ventricular systolic pressure of 60 mm Hg. Diagnostic and therapeutic thoracentesis was performed, and 2.2 L of pleural fluid was removed. Pleural fluid analysis was consistent with chylothorax. Significant symptomatic improvement was noted after thoracentesis. In the absence of an alternate explanation, chylothorax was attributed to dasatinib, which was switched to nilotinib. This resulted in resolution of her pleural effusions.
© BMJ Publishing Group Limited 2019. No commercial re-use. See rights and permissions. Published by BMJ.
リチャード・W・ライト（家城隆次, 慶長直人, 他監訳）: 胸膜疾患のすべて. 診断と治療社、2015; 415-433.
V G Valentine, T A Raffin
The management of chylothorax.
Chest. 1992 Aug;102(2):586-91.
Abstract/Text
B A Staats, R D Ellefson, L L Budahn, D E Dines, U B Prakash, K Offord
The lipoprotein profile of chylous and nonchylous pleural effusions.
Mayo Clin Proc. 1980 Nov;55(11):700-4.
Abstract/Text
The lipoprotein electrophoregrams and the cholesterol and triglyceride levels of the pleural fluid were evaluated for patients with chylous pleural effusions, as defined by the presence of a distinctive band of chylomicrons on the lipoprotein electrophoregram, and in patients with nonchylous effusions of various causes. One hundred forty-one patients were studied during a 3-year period. The chylous effusions had strikingly higher triglyceride levels (median 249, range 49 to 2,270 mg/dl) than the nonchylous group (median 33, range 13 to 107 mg/dl); there were no significant differences in cholesterol or protein between the two groups. The gross description of the fluid was a poor indicator of its origin, being described as consistent with chyle in less than 50% of cases of chylous effusions. The triglyceride values distinguished chylous effusion from nonchylous effusion; values greater than 110 mg/dl are highly suggestive of a chylous effusion. Equivocal cases--triglyceride values between 50 and 110 mg/dl--required lipoprotein analysis. Pleural effusions of undetermined cause, regardless of gross appearance of the fluid, require that a screening triglyceride value be obtained to rule out a chylous effusion.
R L Hughes, R A Mintzer, D F Hidvegi, R K Freinkel, D W Cugell
The management of chylothorax. Clinical conference in pulmonary disease from Northwestern University Medical School, Chicago.
Chest. 1979 Aug;76(2):212-8.
Abstract/Text
Fabien Maldonado, Finn J Hawkins, Craig E Daniels, Clinton H Doerr, Paul A Decker, Jay H Ryu
Pleural fluid characteristics of chylothorax.
Mayo Clin Proc. 2009 Feb;84(2):129-33. doi: 10.1016/S0025-6196(11)60820-3.
Abstract/Text
OBJECTIVE: To determine the biochemical parameters of chylous pleural fluids and better inform current clinical practice in the diagnosis of chylothorax.
PATIENTS AND METHODS: We retrospectively reviewed 74 patients with chylothorax (defined by the presence of chylomicrons) who underwent evaluation during a 10-year period from January 1, 1997, through December 31, 2006. The biochemical parameters and appearance of the fluid assessed during diagnostic evaluation were analyzed.
RESULTS: The study consisted of 37 men (50%) and 37 women (50%), with a median age of 61.5 years (range, 20-93 years). Chylothorax was caused by surgical procedures in 51%. The chylous pleural fluid appeared milky in only 44%. Pleural effusion was exudative in 64 patients (86%) and transudative in 10 patients (14%). However, pleural fluid protein and lactate dehydrogenase levels varied widely. Transudative chylothorax was present in all 4 patients with cirrhosis but was also seen with other causes. The mean +/- SD triglyceride level was 728+/-797 mg/dL, and the mean +/- SD cholesterol value was 66+/-30 mg/dL. The pleural fluid triglyceride value was less than 110 mg/dL in 10 patients (14%) with chylothorax, 2 of whom had a triglyceride value lower than 50 mg/dL.
CONCLUSION: Chylothoraces may present with variable pleural fluid appearance and biochemical characteristics. Nonmilky appearance is common. Chylous effusions can be transudative, most commonly in patients with cirrhosis. Traditional triglyceride cutoff values used in excluding the presence of chylothorax may miss the diagnosis in fasting patients, particularly in the postoperative state.
Emmet E McGrath, Zoe Blades, Paul B Anderson
Chylothorax: aetiology, diagnosis and therapeutic options.
Respir Med. 2010 Jan;104(1):1-8. doi: 10.1016/j.rmed.2009.08.010. Epub 2009 Sep 18.
Abstract/Text
Chylothorax is a rare condition that results from thoracic duct damage with chyle leakage from the lymphatic system into the pleural space, usually on the right side. It has multiple aetiologies and is usually discovered after it manifests itself as a pleural effusion. Diagnosis involves cholesterol and triglyceride measurement in the pleural fluid. Complications include malnutrition, immunosuppression and respiratory distress. Treatment may be either conservative or aggressive depending on the clinical scenario. In this review, we discuss the aetiology, diagnosis and treatment of chylothorax. English language publications in MEDLINE and references from relevant articles from January 1, 1980 to February 28, 2008 were reviewed. Keywords searched were chylothorax, aetiology, diagnosis and treatment.
Copyright 2009 Elsevier Ltd. All rights reserved.
M A Sarsam, A N Rahman, A K Deiraniya
Postpneumonectomy chylothorax.
Ann Thorac Surg. 1994 Mar;57(3):689-90. doi: 10.1016/0003-4975(94)90568-1.
Abstract/Text
Over a period of 22 years, chylothorax developed in 9 of 1,800 patients who underwent pneumonectomy. Two groups were identified. In group I (n = 5), accelerated opacification of the pneumonectomy space was noted, but the mediastinum remained shifted to the pneumonectomy site. No hemodynamic problems developed and their course was no different from that of other patients who had undergone pneumonectomy. In the second group (group II; n = 4), rapid opacification of the pneumonectomy space was accompanied by mediastinal shift away from the pneumonectomy site and by major hemodynamic and respiratory embarrassment. All 4 patients required surgical intervention to control the chylous leak.
J I Ulíbarri, Y Sanz, C Fuentes, A Mancha, M Aramendia, S Sánchez
Reduction of lymphorrhagia from ruptured thoracic duct by somatostatin.
Lancet. 1990 Jul 28;336(8709):258.
Abstract/Text
P C Rimensberger, B Müller-Schenker, A Kalangos, M Beghetti
Treatment of a persistent postoperative chylothorax with somatostatin.
Ann Thorac Surg. 1998 Jul;66(1):253-4.
Abstract/Text
Chylothorax is a rare but potentially serious complication of pediatric cardiac operations. We report the case of a 4-month-old boy who underwent a Senning procedure for correction of D-transposition of the great vessels. A persistent postoperative chylothorax developed, necessitating continuous drainage, despite conservative treatment over 3 weeks. Thereafter, continuous somatostatin infusion for 14 days led to the reduction and finally cessation of chyle production. This treatment allowed early enteral feeding and avoided further surgical intervention.
R F Kelly, S J Shumway
Conservative management of postoperative chylothorax using somatostatin.
Ann Thorac Surg. 2000 Jun;69(6):1944-5.
Abstract/Text
Chylothorax is a rare but serious postoperative complication of thoracic surgical procedures. We report the case of a 77-year-old man who underwent a coronary artery bypass procedure using a left internal mammary artery pedicle graft. A permanent pacemaker was required postoperatively. A persistent postoperative chylothorax developed necessitating continuous drainage and conservative management. Somatostatin was instituted when after 1 week this management failed to resolve the chylothorax. This led to rapid cessation of chyle production. Enteral feeding was reinstituted without complication and surgical intervention was avoided.
黒田浩章, 川村雅文：術後乳糜胸への対応とその管理. 胸部外科2008; 61: 700-704.
Krishnan Sriram, Robert A Meguid, Michael M Meguid
Nutritional support in adults with chyle leaks.
Nutrition. 2016 Feb;32(2):281-6. doi: 10.1016/j.nut.2015.08.002. Epub 2015 Sep 1.
Abstract/Text
We provide a practical approach to the complex management problem of chyle leaks that occur after surgical procedures or trauma, or when they occur spontaneously in association with malignancies. The volume of chyle loss causes significant problems due to loss of fluid, electrolytes, proteins, and lymphocytes, causing deleterious effects on wound healing and immunity. Enteral feeding is not always possible as long chain fatty acids are absorbed through the intestinal lacteals, the original source of chyle. Regular diets increase the leak and delay healing. Nutritional support involves coordinated care between healthcare providers to provide a combination of various modalities, including nil by mouth, parenteral nutrition, enteral feeding with formula modifications, and oral diet.
Published by Elsevier Inc.
Sulaiman A Al-Zubairy, Abdulrazaq S Al-Jazairi
Octreotide as a therapeutic option for management of chylothorax.
Ann Pharmacother. 2003 May;37(5):679-82.
Abstract/Text
OBJECTIVE: To report a case of post-cardiac surgery-induced chylothorax treated with octreotide and review the literature on octreotide efficacy.
CASE SUMMARY: A 5-month-old boy with Down syndrome was admitted for atrioventricular canal repair. On admission, he was taking captopril and furosemide. On postoperative day 4, he exhibited signs of chest wheezing and crackles, but was without cough or fever. Chest X-ray revealed a moderate right-sided pleural effusion. Accordingly, a pleural catheter was inserted and drained an average of 7.14 mL/h of chylous fluid that day. Laboratory analysis of the pleural fluid revealed a triglyceride level of 89 mg/dL, without bacterial growth. Based on those findings, the diagnosis was chylothorax. Because of the continuous extensive tube drainage, octreotide 3.5 micro g/kg/h was begun. The average daily chyle drainage was reduced from 7.14 one day before octreotide initiation to 0.83 mL/h on day 4 of octreotide therapy. After 4 days of therapy (postoperative day 8), octreotide was discontinued because of the satisfactory response and the pleural catheter was removed.
DISCUSSION: In our case and the other few cases reported, octreotide showed acceptable efficacy in the management of chylothorax. The mechanism by which octreotide decreases chyle production includes reducing the intestinal absorption of fats, mainly triglycerides, and increasing fecal fat excretion.
CONCLUSIONS: Octreotide may have reduced chyle production in our patient. Further reports and studies assessing octreotide efficacy in the management of chylothorax are warranted.
Ioannis Kalomenidis
Octreotide and chylothorax.
Curr Opin Pulm Med. 2006 Jul;12(4):264-7. doi: 10.1097/01.mcp.0000230629.73139.26.
Abstract/Text
PURPOSE OF REVIEW: This article reviews the current literature concerning the role of somatostatin and its synthetic analogue, octreotide, in the treatment of chylothorax.
RECENT FINDINGS: Management of chylothorax includes evacuation of the pleural cavity through a chest tube to alleviate dyspnoea, and dietary fat restriction aimed at reducing lymph flow. When these measures fail to control lymph flow, surgical interventions are employed to achieve definite closure of the thoracic duct leak. Several case reports and series have shown that octreotide is safe and probably effective in both children and adults with chylothorax of different origins. The property of somatostatin and octreotide to induce leak closure is attributed to a decelerating effect on lymph flow, although their exact mechanism of action is not well defined. In successful cases, a substantial reduction of lymph drainage through the chest tube is evident within the first few days of commencing the drug, and treatment lasts for 1-2 weeks. Treatment failure has been also reported, however.
SUMMARY: Accumulating evidence suggests that octreotide is a putative novel therapeutic intervention for chylothorax. It is imperative that randomized controlled studies are conducted in order to fully elucidate the efficacy and safety of this treatment.
Charles C Roehr, Andreas Jung, Hans Proquitté, Oliver Blankenstein, Hannes Hammer, Kokila Lakhoo, Roland R Wauer
Somatostatin or octreotide as treatment options for chylothorax in young children: a systematic review.
Intensive Care Med. 2006 May;32(5):650-7. doi: 10.1007/s00134-006-0114-9. Epub 2006 Mar 11.
Abstract/Text
OBJECTIVE: Chylothorax is a rare but life-threatening condition in children. To date, there is no commonly accepted treatment protocol. Somatostatin and octreotide have recently been used for treating chylothorax in children. We set out to summarise the evidence on the efficacy and safety of somatostatin and octreotide in treating young children with chylothorax.
DESIGN: Systematic review: literature search (Cochrane Library, EMBASE and PubMed databases) and literature hand search of peer reviewed articles on the use of somatostatin and octreotide in childhood chylothorax.
PATIENTS: Thirty-five children treated for primary or secondary chylothorax (10/somatostatin, 25/octreotide) were found.
RESULTS: Ten of the 35 children had been given somatostatin, as i.v. infusion at a median dose of 204 microg/kg/day, for a median duration of 9.5 days. The remaining 25 children had received octreotide, either as an i.v. infusion at a median dose of 68 microg/kg/day over a median 7 days, or s.c. at a median dose of 40 microg/kg/day and a median duration of 17 days. Side effects such as cutaneous flush, nausea, loose stools, transient hypothyroidism, elevated liver function tests and strangulation-ileus (in a child with asplenia syndrome) were reported for somatostatin; transient abdominal distension, temporary hyperglycaemia and necrotising enterocolitis (in a child with aortic coarctation) for octreotide.
CONCLUSIONS: A positive treatment effect was evident for both somatostatin and octreotide in the majority of reports. Minor side effects have been reported, however caution should be exercised in patients with an increased risk of vascular compromise as to avoid serious side effects. Systematic clinical research is needed to establish treatment efficacy and to develop a safe treatment protocol.
T Yamagami, T Masunami, T Kato, O Tanaka, T Hirota, T Nomoto, K Mikami, T Miki, T Nishimura
Spontaneous healing of chyle leakage after lymphangiography.
Br J Radiol. 2005 Sep;78(933):854-7. doi: 10.1259/bjr/61177542.
Abstract/Text
We report a 34-year-old man with the complication of chylous ascites after retroperitoneal lymphadenectomy that was refractory to various conservative therapies. Because surgical treatment for chylous ascites was considered, lymphangiography was performed to identify the area of leakage of chyle, after which the chylous ascites spontaneously healed.
T Matsumoto, T Yamagami, T Kato, T Hirota, R Yoshimatsu, T Masunami, T Nishimura
The effectiveness of lymphangiography as a treatment method for various chyle leakages.
Br J Radiol. 2009 Apr;82(976):286-90. doi: 10.1259/bjr/64849421. Epub 2008 Nov 24.
Abstract/Text
The purpose of this study was to assess the effectiveness of lymphangiography as a treatment for various chyle leakages. Pedal lymphangiography was performed in 9 patients (6 men and 3 women; mean age, 59 years) who were unlikely to be cured only by conservative treatment - a low-fat medium-chain triglyceride diet, total parenteral nutrition and insertion of a drainage tube - and in whom chylothorax (n = 5), chylous ascites (n = 2) and lymphatic fistulae (n = 2) were refractory to conservative treatment. In 7 of these 9 patients (78%), we could detect the chyle leakage sites. In 8 of the 9 patients (89%), lymphatic leakage was stopped after lymphangiography, and surgical re-intervention was avoided. No cases had a recurrence of chyle leakage during follow-up (range, 1-54 months). Lymphangiography is effective not only for diagnosis but also as treatment for various chyle leakages. Early lymphangiography is therefore recommended for patients with chyle leakages who are unlikely to be cured by conservative treatment only.
J G Selle, W H Snyder, J T Schreiber
Chylothorax: indications for surgery.
Ann Surg. 1973 Feb;177(2):245-9.
Abstract/Text
Teruhisa Takuwa, Junji Yoshida, Shotaro Ono, Tomoyuki Hishida, Mitsuyo Nishimura, Keiju Aokage, Kanji Nagai
Low-fat diet management strategy for chylothorax after pulmonary resection and lymph node dissection for primary lung cancer.
J Thorac Cardiovasc Surg. 2013 Sep;146(3):571-4. doi: 10.1016/j.jtcvs.2013.04.015. Epub 2013 Jun 12.
Abstract/Text
OBJECTIVE: We reviewed our experience of iatrogenic chylothorax after pulmonary resection for primary lung cancer to evaluate a low-fat diet management strategy.
METHODS: From October 2003 to March 2010, 1580 patients underwent lobectomy or greater resection and systematic mediastinal lymph node dissection for primary lung cancer at our institution. Chylothorax was diagnosed on the basis of chylous leakage from the chest tube and was confirmed by presence of triglycerides (>110 mg/dL) in the drainage fluid. We initially treated the patients with chylothorax conservatively with a low-fat diet (fat intake <10 g/day). If chest tube drainage produced >500 mL of chylous fluid during the first 24 hours after the initiation of the low-fat diet, surgical intervention was performed. If chest tube drainage produced >300 mL/day of chylous fluid after 3 days of a low-fat diet, we performed pleurodesis by injecting a preparation of OK-432, a penicillin-treated lyophilized preparation of a Streptococcus strain into the thoracic cavity through a chest tube.
RESULTS: Postoperative chylothorax developed in 37 patients (2.3%), 33 men and 4 women, with a median age of 69 years (range, 44-84). The initial procedures were pneumonectomy in 1 patient and lobectomy in 36 patients. In 23 patients (62%), their condition resolved with the low-fat diet only. A total of 10 patients underwent OK-432 pleurodesis, and 8 of these were cured with continuation of the low-fat diet. These 31 patients who responded to conservative treatment (84%) resumed a normal diet at a median of 10 days (range, 5-27) after the chylothorax diagnosis. The remaining 6 patients (16%) underwent reoperation and were discharged at a median of 18 days (range, 14-33) after the initial surgery.
CONCLUSIONS: A low-fat diet and OK-432 pleurodesis achieved positive results in >80% of patients with chylothorax after pulmonary resection with systematic mediastinal lymph node dissection within 4 weeks after the initial surgery. More than 500 mL of chylous fluid during the first 24 hours after the initiation of the low-fat diet was valid as an indication of the need for surgical intervention.
Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.
Brandon T Bacon, Wayne Mashas
Chylothorax caused by blunt trauma: Case review and management proposal.
Trauma Case Rep. 2020 Aug;28:100308. doi: 10.1016/j.tcr.2020.100308. Epub 2020 May 21.
Abstract/Text
Chylothorax is a potentially devastating complication of lymphatic trauma of the thorax. To date, no recommendations have provided decision making support for prompt definitive treatment. We present a 53 year old male involved in a motor vehicle collision sustaining 9 left rib fractures with flail segments. He was treated non-operatively with a chest tube and no fat diet. A Case report review was performed and a proposed guideline for managing blunt trauma chylothorax in adult patients was developed. In low-output chylothorax, effective initial treatment begins with a no fat diet and chest tube. We propose that a low output leak be defined as <500 mL of initial output or <500 mL/day and can be managed non-operatively in nearly 100% of patients. High output injuries of >1000 mL of initial output will require surgical intervention and should be considered for prompt definitive care.
© 2020 The Authors.
J Shimizu, Y Hayashi, M Oda, K Morita, Y Arano, S Nagao, S Murakami, H Urayama, Y Watanabe
Treatment of postoperative chylothorax by pleurodesis with the streptococcal preparation OK-432.
Thorac Cardiovasc Surg. 1994 Aug;42(4):233-6. doi: 10.1055/s-2007-1016494.
Abstract/Text
Of the 2877 patients who underwent chest surgery at our department during the 20-year period between 1973 and 1992, 9 (0.3%) developed postoperative chylothorax. The underlying disease included primary lung cancer in 5 patients, pulmonary metastasis in 1, invasive thymoma in 2, and neuroblastoma of the posterior mediastinum in 1. For the treatment of chylothorax, the thoracic duct was ligated in 2 patients with a high volume of chylous leakage. In 6 patients treated conservatively, early pleurodesis was attained by injecting 1 to 5 doses (mean: 2.2 doses) of the streptoccal preparation OK-432 intrathoracically; favorable results were achieved. In 1 patient, the diagnosis of chylothorax was delayed because of postoperative pyothorax. This patient developed nutritional deficiency, compromised immunity, and disseminated intravascular coagulation (DIC), which led to death before the chylothorax could be treated. In principle, postoperative chylothorax should be treated conservatively. Favorable results can be expected with the intrathoracic injection of OK-432 beginning at the early postoperative period to achieve pleurodesis, combined with the prevention of nutritional deficiency, electrolyte imbalance, and infection.
Gregory J Nadolski, Maxim Itkin
Feasibility of ultrasound-guided intranodal lymphangiogram for thoracic duct embolization.
J Vasc Interv Radiol. 2012 May;23(5):613-6. doi: 10.1016/j.jvir.2012.01.078. Epub 2012 Mar 21.
Abstract/Text
PURPOSE: To show the feasibility of opacifying the thoracic duct using ultrasound-guided intranodal lymphangiogram (IL) for thoracic duct embolization (TDE).
MATERIALS AND METHODS: Six patients (two women and four men, mean age, 59.2 y [range, 43-74 y]) underwent IL and TDE for chylothorax. Under ultrasound guidance, a needle was positioned in a groin lymph node, and lipiodol was injected. The thoracic duct was catheterized, and embolization was performed as indicated. Cumulative times from start of the procedure until initiation of the lymphangiogram, until identification of target lymphatic, until catheterization of the thoracic duct, and until completion of the procedure were collected. Times were compared with times of a control group of six patients (two women and four men, mean age, 66.7 y [range, 49-82 y]) who had undergone TDE using pedal lymphangiography (PL).
RESULTS: The procedure of opacification, catheterization, and embolization of the thoracic duct was successful in all cases. Cumulative times (mean ± standard deviation) in the IL and PL groups from start of the procedure until (i) initial lymphangiogram were 20.5 minutes ± 8.6 and 46.5 minutes ± 22.6, (ii) identification of a target lymphatic for catheterization were 60.5 minutes ± 18.2 and 110.5 minutes ± 31.6, (iii) catheterization of the thoracic duct were 79.0 minutes ± 28.9 and 128.2 minutes ± 37.0, and (iv) completion of procedure were 125.8 minutes ± 49.0 and 152.8 minutes ± 36.4.
CONCLUSIONS: IL is a feasible technique to visualize the thoracic duct for embolization. Using IL, the thoracic duct may be more quickly visualized and catheterized for TDE than with PL.
Copyright © 2012 SIR. Published by Elsevier Inc. All rights reserved.
井上政則，中塚誠之，中川基人, 陣崎雅弘: 胸部外科術後の難治性乳糜胸水に対する経皮的胸管塞栓術．Rad Fan 2015; 13: 57-61.
Mohammad Toliyat, Kanwar Singh, Robert C Sibley, Murthy Chamarthy, Sanjeeva P Kalva, Anil K Pillai
Interventional radiology in the management of thoracic duct injuries: Anatomy, techniques and results.
Clin Imaging. 2017 Mar - Apr;42:183-192. doi: 10.1016/j.clinimag.2016.12.012. Epub 2017 Jan 3.
Abstract/Text
Disruption of the thoracic duct can have devastating consequences and be associated with a high morbidity and mortality. Conservative therapies have been attempted to treat chylothorax without much success. Surgical management has traditionally been necessary to provide definitive treatment at the expense of increased morbidity. Lymphatic interventions have recently emerged as a new frontier for interventional radiologists to add value and provide minimally invasive therapies for debilitating conditions. The goal of this manuscript is to review the anatomy of the thoracic duct, describe various percutaneous techniques for accessing the duct, and briefly discuss outcomes as reported in the literature.
Published by Elsevier Inc.
Bradley Bender, Vijayashree Murthy, Ronald S Chamberlain
The changing management of chylothorax in the modern era.
Eur J Cardiothorac Surg. 2016 Jan;49(1):18-24. doi: 10.1093/ejcts/ezv041. Epub 2015 Mar 1.
Abstract/Text
Initial conservative therapy is applied to all cases of chylothorax (CTx) with expected excellent outcomes. The indication for aggressive surgical treatment of early CTx remains uncertain and requires rigorous scientific scrutiny. Lymphangiography and lymphoscintigraphy are useful to localize the leak and assess thoracic duct patency as well as to differentiate partial from complete thoracic duct transection. The aetiology of the CTx, flow rate and patient condition dictate the preferred management. Octreotide/somatostatin and etilefrine therapy is highly efficacious in the conservative management of CTx. For patients in whom conservative management fails, those who are good surgical candidates, and those in whom the site of the leak is well identified, surgical repair and/or ligation using minimally invasive techniques is highly successful with limited adverse outcomes. Similarly, if the site of the chylous effusion cannot be well visualized, a thoracic duct ligation via video-assisted thoracic surgery is the gold standard approach. A pleuroperitoneal or less often a pleurovenous shunt is a final option and may be curative in some patients.
© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
Douglas Z Liou, Heather Warren, Dermot P Maher, Harmik J Soukiasian, Nicolas Melo, Ali Salim, Eric J Ley
Midodrine: a novel therapeutic for refractory chylothorax.
Chest. 2013 Sep;144(3):1055-1057. doi: 10.1378/chest.12-3081.
Abstract/Text
Thoracic duct injury is a rare but serious complication following surgery of the neck or chest that leads to uncontrolled chyle leak. Conventional management includes drainage, nutritional modification, or aggressive surgical interventions such as thoracic duct ligation, flap coverage, fibrin glue, or talc pleurodesis; few successful medical therapeutics are available. We report a case of a high-output chylothorax refractory to aggressive medical and surgical interventions. Chyle output decreased substantially after initiating midodrine, an α1-adrenergic agonist that causes vasoconstriction of the lymph system, reducing chyle flow. This case report suggests that midodrine may be a novel therapeutic for refractory chyle leaks.
Parthipan Sivakumar, Liju Ahmed
Use of an Alpha-1 Adrenoreceptor Agonist in the Management of Recurrent Refractory Idiopathic Chylothorax.
Chest. 2018 Jul;154(1):e1-e4. doi: 10.1016/j.chest.2018.02.005.
Abstract/Text
A 70-year-old woman presents with recurrent idiopathic chylothorax refractory to both medical and surgical treatment. To our knowledge, this is the first reported case where midodrine, an alpha-1 receptor agonist, was used as an adjunctive therapy for idiopathic chylothorax resulting in both a radiographic and clinical response.
Copyright © 2018 American College of Chest Physicians. All rights reserved.
石田 薫，森 昌造，鈴木俊輔，他：食道癌切除後の乳廉胸tetracyclineとOK－432による癒着療法．日消外会誌1984：17：1599-1602.
清水喜徳，安井 昭，西田佳昭，他：OK－432，minomycinの胸腔内注入で治癒した食道癌切除後乳康胸の1例．日第四医会誌1990；51：2451-2455.
山口秀樹，河野謙治，迎 寛，他：OK－432による胸膜癒着療法が奏効した特発性乳び胸の1例．日本胸部疾患学会雑誌1994：32：199-203.
松本英彦，三谷惟章，小川洋樹，他：OK－432の胸腔内注入が著効を奏した肺癌術後乳廉胸の1例．胸部外科1993；46：987-989.
大久保哲之，成田吉明，道家 充，他：脊椎前方固定術術後乳廉胸に対する外科治療の1例．胸部外科1998；51：521-525.
河内康憲，渡辺礼香，西原利男，他：9年間の寛解中に乳康胸を呈した悪性リンパ腫．臨床血液 1995；36：1311-1315.
清水谷尚宏，森迫隆久，宮尾桂子，他：悪性胸膜中皮腫に両側乳康胸を合併した1例．日本呼吸器学会雑誌 2002；40：832-836.
成田裕介，猶木克彦，檜田直也，他：ステロイド・免疫抑制剤無効の胸水を合併した全身性エリテマトーデスに発症した両側乳糜胸の1症例．日呼吸会誌 2008；46：120-125.
三輪真史，笠松紀雄，柴田雅彦，他: 乳糜胸水で発見された胃癌の1例. 日本呼吸器学会雑誌2002；40：832-836.
D C Mares, P N Mathur
Medical thoracoscopic talc pleurodesis for chylothorax due to lymphoma: a case series.
Chest. 1998 Sep;114(3):731-5.
Abstract/Text
STUDY OBJECTIVES: Recurrent chylothorax as a complication of lymphoma has had unsatisfactory outcomes. Serial thoracentesis, tube thoracostomy, and pleurodesis via chest tube have been ineffective and compromise the nutritional and immune status of the patient. Medical thoracoscopic talc pleurodesis has been safe and effective in the treatment of some other varieties of recurrent pleural effusions. Our objective was to investigate the safety and efficacy of medical thoracoscopic talc pleurodesis in the palliation of chylothorax related to lymphoma.
DESIGN: This is a report of 24 hemithoraces treated in 19 consecutive patients with lymphoma-related chylothorax, failing chemotherapy or radiation therapy. The average patient age was 55 years.
INTERVENTIONS: Medical thoracoscopy was performed under local anesthesia and conscious sedation in a bronchoscopy suite. Sedation included midazolam (mean dose, 6 mg; range, 2-14 mg) with either meperidine (mean dose, 94 mg; range 25-140 mg), or morphine (mean dose, 18 mg; range 4-40 mg). Pleurodesis was performed with insufflation of sterile asbestos-free talc, (4-8 g). After pleurodesis, chest tubes were placed, with the mean duration of chest tube placement being 4 days, range 3 to 10 days.
RESULTS: One patient died a few days after the procedure due to causes related to the primary disease process. Follow-up was for at least 90 days following the procedure. Patients were assessed at 30, 60, and 90 days following the procedure. At each of these endpoints, all patients remaining alive were without recurrence of pleural effusions, which was confirmed by chest radiography. Eight patients in the series died of the effects of their malignancy during the 90-day evaluation interval. Complications included medication reactions in two patients (8.3%) and ARDS in one patient (4.1%).
CONCLUSION: Many patients with lymphoma-related chylothorax are refractory to chemotherapy and/or radiation therapy. In this group, medical thoracoscopic talc pleurodesis has an acceptable complication rate and a 100% success rate in the prevention of recurrence of pleural effusions at 30, 60, and 90 days following the procedure.
Enrique Alejandre-Lafont, Christoph Krompiec, Wigbert S Rau, Gabriele A Krombach
Effectiveness of therapeutic lymphography on lymphatic leakage.
Acta Radiol. 2011 Apr 1;52(3):305-11. doi: 10.1258/ar.2010.090356.
Abstract/Text
BACKGROUND: The number of conventional lymphographies has declined markedly since the introduction of cross-sectional imaging techniques. Nevertheless, lymphography has a high potential as a reliable method to visualize and directly occlude lymphatic leaks. When used as a distinct radiological procedure with the intention to treat, this application can be described as therapeutic lymphography.
PURPOSE: To investigate if therapeutic lymphography is a reliable method to treat lymphatic leakage when conservative treatment fails and to investigate which parameters influence the success rate.
MATERIAL AND METHODS: Between August 1995 and January 2008, 50 patients with lymphatic leakage in form of chylothorax, chylous ascites, lymphocele, and lymphatic fistulas underwent conventional therapeutic lymphography after failure of conservative therapy. Of these 50 patients, seven could not be statistically evaluated in our retrospective study: one patient died of cancer 1 day after lymphography, and six were excluded due to various technical problems. The remaining 43 patients were evaluated. Therapeutic success was evaluated and correlated to the volume of lymphatic leakage (more or less than 500 mL/day), as assessed by drainage.
RESULTS: In nearly 79% of patients, the location of the leak could be detected, and surgical intervention could be planned when therapeutic lymphography failed. Due to the irrigating effect of the contrast medium (lipiodol), the lymphatic leak could be completely occluded in 70% of patients when the lymphatic drainage volume was less than 500 mL/day. Even when lymphatic drainage was higher than 500 mL/day, therapeutic lymphography was still successful in 35% of the patients. The overall success rate in patients with failed conservative treatment was 51%. Success did not depend on other factors such as age and sex, cause of lymph duct damage, or time elapsed between lymphatic injury and intervention.
CONCLUSION: Therapeutic lymphography is an effective method in the treatment of lymphatic leakage when conservative therapy fails. The volume of lymphatic drainage per day is a significant predictor of the therapeutical success rate.
Sebastian Kos, Harald Haueisen, Ulrich Lachmund, Thomas Roeren
Lymphangiography: forgotten tool or rising star in the diagnosis and therapy of postoperative lymphatic vessel leakage.
Cardiovasc Intervent Radiol. 2007 Sep-Oct;30(5):968-73. doi: 10.1007/s00270-007-9026-5.
Abstract/Text
Since the advent of computed tomography, numbers and expertise in Lymphangiography (LAG) have markedly dropped. The intention of our study was to demonstrate the persisting diagnostic and therapeutic impact of LAG on the postoperative patient with known or suspected lymphatic vessel leakage. Between May 1, 1999, and April 30, 2006, we investigated pedal lipiodol-LAGs (18 monopedal, 2 bipedal) on 22 patients (16 male, 6 female) with known or suspected postoperative chylothorax, chylaskos, lymphocele, or lymphatic fistula. Ages varied from 26 to 81 years. The spectrum of operative procedures was broad: 6 thoracic, 5 abdominal, and 11 peripheral operations were performed. In 20 patients who underwent mono- or bipedal LAG for lymphatic vessel injury, we were able to demonstrate the specific site of leakage in 15 cases (75%) and found signs of extravasation in 5 patients (25%). Furthermore, in 11 patients (55%) we were able to avoid surgery because of closure of the leak after LAG. As the conservative therapeutic approach usually takes 2-3 weeks to reveal its therapeutic effects, 73.3% (11/15) of the patients who were not reoperated before this hallmark was passed did not need any further operation. Our study clearly demonstrates that even in the decades of modern cross-sectional imaging, classic LAG is a powerful and highly reliable tool to visualize and even assist occlusion of the postoperatively damaged lymphatic vessel and may thereby avoid the need for reoperation.
花田 圭太, 畑 啓昭, 大谷 哲之, 成田 匡大, 山口 高史, 猪飼 伊和夫：鼠径リンパ節穿刺によるリンパ管造影が有用であった食道癌術後乳糜胸の1例. 日臨外会誌 2016; 77: 322-327.
Mitsuhiro Momose, Satoshi Kawakami, Tomonobu Koizumi, Kazuo Yoshida, Shintaro Kanda, Ryoichi Kondo, Masumi Kadoya
Lymphoscintigraphy using technetium-99m HSA-DTPA with SPECT/CT in chylothorax after childbirth.
Radiat Med. 2008 Oct;26(8):508-11. doi: 10.1007/s11604-008-0265-4. Epub 2008 Oct 31.
Abstract/Text
Technetium-99m human serum albumin diethylene-triaminepentaacetic acid (HSA-DTPA) lymphoscintigraphy with single photon emission computed tomography combined with integrated low-dose computed tomography (SPECT/CT) is useful for evaluating chylothorax. We report a case of chylothorax that occurred 2 months after childbirth in a 24-year-old woman. Lymphoscintigraphy with SPECT/CT showed abnormal tracer accumulation in the right plural effusion, and chylothorax was diagnosed. Collateral branches of the thoracic duct were found to be ruptured during video-assisted thoracoscopic surgery performed for ligation.
De-Xin Yu, Xiang-Xing Ma, Qing Wang, Yang Zhang, Chuan-Fu Li
Morphological changes of the thoracic duct and accessory lymphatic channels in patients with chylothorax: detection with unenhanced magnetic resonance imaging.
Eur Radiol. 2013 Mar;23(3):702-11. doi: 10.1007/s00330-012-2642-8. Epub 2012 Sep 14.
Abstract/Text
OBJECTIVES: To characterise the imaging findings of patients with chylothorax and to identify the leak site using unenhanced MRI.
METHODS: Seven patients with chylothorax and 30 healthy individuals (as the control group) underwent three-dimensional heavily and routine T2-weighted MRI. Morphological changes and diameters of the thoracic duct, chyloma display, and some dilated accessory lymph channels were evaluated and measured. The differences between patients and the control group were compared. The leak sites of the thoracic duct and parietal pleura were also identified.
RESULTS: The patients had a higher display rate of the entire thoracic duct and some accessory lymphatic channels, enlarged diameters and tortuous configuration of the thoracic duct, and existence of chylomas compared with the control group (P < 0.05). Seven leaks of the thoracic duct in five patients and five leaks of the parietal pleura in four patients were identified. Close relationships between the leak of thoracic duct and the chylomas or the meshworks of tiny lymphatics were found (P < 0.05).
CONCLUSION: Unenhanced MRI appears reliable in the detection of morphological changes of thoracic lymphatics and in the identification of chyloma and leak sites in patients with chylothorax, which helps appropriate treatment planning and follow-up.
Eun Young Kim, Hye Sun Hwang, Ho Yun Lee, Jong Ho Cho, Hong Kwan Kim, Kyung Soo Lee, Young Mog Shim, Jaeil Zo
Anatomic and Functional Evaluation of Central Lymphatics With Noninvasive Magnetic Resonance Lymphangiography.
Medicine (Baltimore). 2016 Mar;95(12):e3109. doi: 10.1097/MD.0000000000003109.
Abstract/Text
Accurate assessment of the lymphatic system has been limited due to the lack of optimal diagnostic methods. Recently, we adopted noncontrast magnetic resonance (MR) lymphangiography to evaluate the central lymphatic channel. We aimed to investigate the feasibility and the clinical usefulness of noninvasive MR lymphangiography for determining lymphatic disease.Ten patients (age range 42-72 years) with suspected chylothorax (n = 7) or lymphangioma (n = 3) who underwent MR lymphangiography were included in this prospective study. The thoracic duct was evaluated using coronal and axial images of heavily T2-weighted sequences, and reconstructed maximum intensity projection. Two radiologists documented visualization of the thoracic duct from the level of the diaphragm to the thoracic duct outlet, and also an area of dispersion around the chyloma or direct continuity between the thoracic duct and mediastinal cystic mass.The entire thoracic duct was successfully delineated in all patients. Lymphangiographic findings played a critical role in identifying leakage sites in cases of postoperative chylothorax, and contributed to differential diagnosis and confirmation of continuity with the thoracic duct in cases of lymphangioma, and also in diagnosing Gorham disease, which is a rare disorder. In patients who underwent surgery, intraoperative findings were matched with lymphangiographic imaging findings.Nonenhanced MR lymphangiography is a safe and effective method for imaging the central lymphatic system, and can contribute to differential diagnosis and appropriate preoperative evaluation of pathologic lymphatic problems.
Saebeom Hur, Jinoo Kim, Lakshmi Ratnam, Maxim Itkin
Lymphatic Intervention, the Frontline of Modern Lymphatic Medicine: Part I. History, Anatomy, Physiology, and Diagnostic Imaging of the Lymphatic System.
Korean J Radiol. 2023 Feb;24(2):95-108. doi: 10.3348/kjr.2022.0688.
Abstract/Text
Recent advances in lymphatic imaging have provided novel insights into the lymphatic system. Interventional radiology has played a significant role in the development of lymphatic imaging techniques and modalities. Radiologists should be familiar with the basic physiology and anatomy of the lymphatic system to understand the imaging features of lymphatic disorders, which reflect their pathophysiology. This study comprehensively reviews the physiological and anatomical aspects of the human lymphatic system as well as the latest lymphatic imaging techniques.
Copyright © 2023 The Korean Society of Radiology.
A C Havard, D J Collins, R L Guy, J E Husband
Magnetic resonance behaviour of lipiodol.
Clin Radiol. 1992 Mar;45(3):198-200. doi: 10.1016/s0009-9260(05)80642-7.
Abstract/Text
Lipiodol is a frequently used contrast agent for lymphangiography and more recently has been used in the investigation of hepatoma. We describe the magnetic resonance characteristics of lipiodol using a Siemens 1.5 T Magnetom with reference to the appearance and behaviour of lipiodol in abdominal lymphadenopathy. The characteristics described differ from previously published reports.
Vishwan Pamarthi, Waleska M Pabon-Ramos, Vincent Marnell, Lynne M Hurwitz
MRI of the Central Lymphatic System: Indications, Imaging Technique, and Pre-Procedural Planning.
Top Magn Reson Imaging. 2017 Aug;26(4):175-180. doi: 10.1097/RMR.0000000000000130.
Abstract/Text
Magnetic resonance imaging is increasingly being used to evaluate the lymphatic system. Advances in magnetic resonance (MR) software and hardware allow improved visualization of lymph nodes and lymphatic vessels. We describe how MR lymphangiography can be used to diagnose central lymphatic system anatomy and pathology, which can be used for diagnostic purposes or for pre-procedural planning.
Dongho Hyun, Ho Yun Lee, Jong Ho Cho, Hong Kwan Kim, Yong Soo Choi, Jhingook Kim, Jae Ill Zo, Young Mog Shim
Pragmatic role of noncontrast magnetic resonance lymphangiography in postoperative chylothorax or cervical chylous leakage as a diagnostic and preprocedural planning tool.
Eur Radiol. 2022 Apr;32(4):2149-2157. doi: 10.1007/s00330-021-08342-6. Epub 2021 Oct 26.
Abstract/Text
OBJECTIVES: To define the roles of noncontrast magnetic resonance lymphangiography (MRL) in the management of postoperative chylothorax or cervical chylous leakage.
METHODS: A total of 50 consecutive patients underwent noncontrast MRL, intranodal lymphangiography, and thoracic duct embolization between May 2016 and April 2020. Their mean age was 62.6 years ± 10.3 (SD) years, and 35 of the participants were men. Conventional lymphangiographic images were sufficient in quality as a reference for the evaluation of diagnostic accuracy of leakage and location in 35 patients (70%) and for evaluation of anatomic details of the thoracic duct and jugulovenous junction in 34 patients (68%).
RESULTS: MRL showed that the sensitivity, specificity, and positive and negative predictive values for leakage detection were 100%, 97.1%, 100%, and 100%, respectively, and the concordance rate was 97.14% (95% confidence interval [CI], 85.08-99.93%; p < .001). Leakage location was concordant between MRL and conventional lymphangiography in 27 patients (77.1%, 27/35). Regarding anatomical details of the thoracic duct, variation of the thoracic duct was missed in 11.7% of patients (4/34). The jugulovenous junction was observed in 91.1% (31/34), and its opening into the central vein was depicted in 76.4% (26/34). The concordance rate was between 76.47 and 91.18.
CONCLUSIONS: Noncontrast MRL has a high sensitivity for the detection of postoperative thoracic and cervical chylous leakage but is suboptimal for the localization of the leak and depiction of anatomical details of the thoracic duct. This method is worthy of consideration as either a decision-making or planning tool for subsequent interventions.
KEY POINTS: • Noncontrast MRL provides limited resolution images of CLS but has a high sensitivity for the detection of postoperative chylous leakage in the thoracic and neck regions. • Noncontrast MRL is suboptimal for depicting anatomic details in the thoracic duct and jugulovenous junction but can play a role as a decision-making and a planning tool for subsequent lymphatic interventions.
© 2021. European Society of Radiology.
Govind B Chavhan, Christopher Z Lam, Mary-Louise C Greer, Michael Temple, Joao Amaral, Lars Grosse-Wortmann
Magnetic Resonance Lymphangiography.
Radiol Clin North Am. 2020 Jul;58(4):693-706. doi: 10.1016/j.rcl.2020.02.002. Epub 2020 May 6.
Abstract/Text
Dynamic contrast-enhanced magnetic resonance lymphangiography is a novel technique to image central conducting lymphatics. It is performed by injecting contrast into groin lymph nodes and following passage of contrast through lymphatic system using T1-weighted MR images. Currently, it has been successfully applied to image and plan treatment of thoracic duct pathologies, lymphatic leaks, and other lymphatic abnormalities such as plastic bronchitis. It is useful in the assessment of chylothorax and chyloperitoneum. Its role in other areas such as intestinal lymphangiectasia and a variety of lymphatic anomalies is likely to increase.
Copyright © 2020 Elsevier Inc. All rights reserved.
棚橋裕吉, 森崇, 松尾政之, 五島聡：【Step up MRI 2020 最新技術が広げるMRIの可能性:基礎から臨床の最前線まで】最新MRI技術の可能性 基礎編 MR lymphangiographyの有用性. INNERVISION 2020：35(9): 4-6.
Constantin Cope, Larry R Kaiser
Management of unremitting chylothorax by percutaneous embolization and blockage of retroperitoneal lymphatic vessels in 42 patients.
J Vasc Interv Radiol. 2002 Nov;13(11):1139-48.
Abstract/Text
PURPOSE: To demonstrate the applicability, technique, and efficacy of percutaneous transabdominal catheter embolization or needle disruption of retroperitoneal lymphatic vessels in the treatment of high-output or unremitting chylothorax.
MATERIALS AND METHODS: Forty-two patients (21 men, 21 women; mean age, 56 y; range, 19-80 y) who had chylothorax with various etiologies were referred from the thoracic surgery department for treatment as soon as chylothorax was documented. The thoracic duct was punctured and catheterized via a peritoneal cannula to facilitate embolization with use of microcoils, particles, or glue; if there were no lymph trunks that could be catheterized, attempts were made to disrupt lymph collaterals with use of needles.
RESULTS: The thoracic duct was catheterized in 29 patients and embolized in 26 patients. In patients with lymph trunks that could be catheterized, treatment resulted in cure within 7 days in 16 patients and partial response with cure within 3 weeks in six patients. In the patients with lymph trunks that could not be catheterized (n = 16), disruption with use of needles resulted in cure in five patients and partial response in two patients. Cure and partial response rates after thoracic duct embolization and needle disruption were 73.8%, with no morbidity. Surgical thoracic duct ligation was performed in seven patients. The nonprocedural mortality rate was 19%. Follow-up was 3 months or longer.
CONCLUSIONS: Effective percutaneous treatment of high-output or medically uncontrollable chylothorax was performed promptly and safely in more than 70% of referred cases. This procedure should be attempted, especially if patients are very ill, before riskier surgical thoracic duct ligation is considered.
Maxim Itkin, John C Kucharczuk, Andrew Kwak, Scott O Trerotola, Larry R Kaiser
Nonoperative thoracic duct embolization for traumatic thoracic duct leak: experience in 109 patients.
J Thorac Cardiovasc Surg. 2010 Mar;139(3):584-89; discussion 589-90. doi: 10.1016/j.jtcvs.2009.11.025. Epub 2009 Dec 29.
Abstract/Text
OBJECTIVE: To demonstrate the efficacy of a minimally invasive, nonoperative, catheter-based approach to the treatment of traumatic chyle leak.
METHODS: A retrospective review of 109 patients was conducted to assess the efficacy of thoracic duct embolization or interruption for the treatment of high-output chyle leak caused by injury to the thoracic duct.
RESULTS: A total of 106 patients presented with chylothorax, 1 patient presented with chylopericardium, and 2 patients presented with cervical lymphocele. Twenty patients (18%) had previous failed thoracic duct ligation. In 108 of 109 patients, a lymphangiogram was successful. Catheterization of the thoracic duct was achieved in 73 patients (67%). In 71 of these 73 patients, embolization of the thoracic duct was performed. Endovascular coils or liquid embolic agent was used to occlude the thoracic duct. In 18 of 33 cases of unsuccessful catheterization, thoracic duct needle interruption was attempted below the diaphragm. Resolution of the chyle leak was observed in 64 of 71 patients (90%) post-embolization. Needle interruption of the thoracic duct was successful in 13 of 18 patients (72%). In 17 of the 20 patients who had previous attempts at thoracic duct ligation, embolization or interruption was attempted and successful in 15 (88%). The overall success rate for the entire series was 71% (77/109). There were 3 (3%) minor complications.
CONCLUSION: Catheter embolization or needle interruption of the thoracic duct is safe, feasible, and successful in eliminating a high-output chyle leak in the majority (71%) of patients. This minimally invasive, although technically challenging, procedure should be the initial approach for the treatment of a traumatic chylothorax.
Published by Mosby, Inc.
Stuart Lyon, Nigel Mott, Jim Koukounaras, Jen Shoobridge, Patricio Vargas Hudson
Role of interventional radiology in the management of chylothorax: a review of the current management of high output chylothorax.
Cardiovasc Intervent Radiol. 2013 Jun;36(3):599-607. doi: 10.1007/s00270-013-0605-3. Epub 2013 Apr 12.
Abstract/Text
Chylothorax is an uncommon type of pleural effusion whose etiology may be classified as traumatic or nontraumatic. Low-output chylothoraces usually respond well to conservative management, whereas high-output chylothoraces are more likely to require surgical or interventional treatment. Conservative management focuses on alleviation of symptoms, replacement of fluid and nutrient losses, and reduction of chyle output to facilitate spontaneous healing. Surgical management can be technically difficult due to the high incidence of variant anatomy and the high-risk patient population. Percutaneous treatments have rapidly developed and evolved during the past 14 years to represent a minimally invasive treatment compared with the more invasive nature of surgery. Percutaneous therapies provide a range of treatment options despite difficult or variant anatomy, with a reported high success rate coupled with low morbidity and mortality. This article is a review of etiology, diagnosis, and treatment of chylothorax, with a focus on interventional management techniques.
David Laslett, Scott O Trerotola, Maxim Itkin
Delayed complications following technically successful thoracic duct embolization.
J Vasc Interv Radiol. 2012 Jan;23(1):76-9. doi: 10.1016/j.jvir.2011.10.008. Epub 2011 Nov 23.
Abstract/Text
PURPOSE: Thoracic duct (TD) embolization (TDE) has become a universally accepted treatment of chylous pleural effusion. However, the long-term sequelae of occlusion of the TD are unknown. The objective of the present study was to determine the rate of delayed complications after technically successful TDE.
MATERIALS AND METHODS: A total of 169 patients underwent TDE for symptomatic chylous effusion between January 1, 1994, and June 11, 2010. In 106 of 169 cases (63%), TDE embolization was technically successful. Retrospective review of these charts was performed, and patients were interviewed to determine the development of lower-extremity edema, diarrhea, abdominal swelling, and other symptoms.
RESULTS: Follow-up information was available in 78 of 106 patients (73.6%). Mean length of follow-up was 34 months. During follow-up, 32 patients (41%) died of causes unrelated to TDE, and 46 (59%) were alive at the end of follow-up. The families of three deceased patients were available for interview. Four of 49 patients (8%) had chronic leg swelling that was probably related to the procedure, three (6%) had abdominal swelling, and six (12%) had chronic diarrhea. In four of these six cases, diarrhea was considered "probably related" to the procedure. Overall, a 14.3% rate of probably-related long-term complications after TDE was recorded.
CONCLUSIONS: Chronic diarrhea and lower-extremity swelling may be related to TDE and should be part of informed consent before the procedure. A prospective follow-up study is needed to further establish these relationships.
Copyright © 2012 SIR. Published by Elsevier Inc. All rights reserved.
Pyeong Hwa Kim, Jiaywei Tsauo, Ji Hoon Shin
Lymphatic Interventions for Chylothorax: A Systematic Review and Meta-Analysis.
J Vasc Interv Radiol. 2018 Feb;29(2):194-202.e4. doi: 10.1016/j.jvir.2017.10.006. Epub 2017 Dec 27.
Abstract/Text
PURPOSE: To perform a systematic review and meta-analysis of published studies to evaluate the efficacy of lymphatic interventions for chylothorax.
MATERIALS AND METHODS: The MEDLINE, EMBASE, and Cochrane databases were searched for English-language studies until March 2017 that included patients with chylothorax treated with lymphangiography (LAG), thoracic duct embolization (TDE), or thoracic duct disruption (TDD). Exclusion criteria were as follows: a sample size of less than 10 patients, no extractable data, or data included in subsequent articles or duplicate reports.
RESULTS: The cases of 407 patients from 9 studies were evaluated. The pooled technical success rates of LAG and TDE were 94.2% (95% confidence interval [CI], 88.4%-97.2%; I2 = 46.7%) and 63.1% (95% CI, 55.4%-70.2%; I2 = 37.3%), respectively. The pooled clinical success rates of LAG, TDE, and TDD, on a per-protocol basis, were 56.6% (95% CI, 45.4%-67.2%; I2 = 5.4%), 79.4% (95% CI, 64.8%-89.0%; I2 = 68.1%), and 60.8% (95% CI, 49.4%-71.2%; I2 = 0%), respectively. The pooled major complication rate of LAG and TDE was 1.9% (95% CI, 0.8%-4.3%; I2 = 0%) and 2.4% (95% CI, 0.9%-6.6%; I2 = 26.4%), respectively. The pooled overall clinical success rate of lymphatic interventions, on an intention-to-treat basis, was 60.1% (95% CI, 52.1%-67.7%; I2 = 54.3%). Etiology of chylothorax was identified as a significant source of heterogeneity for the pooled clinical success rate of TDE and overall clinical success rate.
CONCLUSIONS: Lymphatic interventions have a respectable efficacy for the treatment of chylothorax.
Copyright © 2017 SIR. Published by Elsevier Inc. All rights reserved.
Derek Mittleider, Thomas A Dykes, Kenneth P Cicuto, Steven M Amberson, Charles R Leusner
Retrograde cannulation of the thoracic duct and embolization of the cisterna chyli in the treatment of chylous ascites.
J Vasc Interv Radiol. 2008 Feb;19(2 Pt 1):285-90. doi: 10.1016/j.jvir.2007.10.025.
Abstract/Text
The authors offer a previously undescribed technique for cisterna chyli embolization in the treatment of chylous ascites. After the failure of conventional percutaneous direct cisterna chyli cannulation, the authors accessed the thoracic duct directly from the subclavian vein. Retrograde microcatheter access through the thoracic duct enabled embolization of the cisterna chyli. Embolization materials included fibered endovascular coils, gelatin sponge, and doxycycline. The patient's symptoms returned 10 days after embolization. This technique provided short-term success in the treatment of the patient's chylous ascites.
Shuji Kariya, Miyuki Nakatani, Yutaka Ueno, Asami Yoshida, Yasuyuki Ono, Takuji Maruyama, Atsushi Komemushi, Noboru Tanigawa
Transvenous Retrograde Thoracic Ductography: Initial Experience with 13 Consecutive Cases.
Cardiovasc Intervent Radiol. 2018 Mar;41(3):406-414. doi: 10.1007/s00270-017-1814-y. Epub 2017 Oct 24.
Abstract/Text
PURPOSE: To report the feasibility and findings of transvenous retrograde thoracic duct cannulation.
MATERIALS AND METHODS: The subjects were 13 patients who had undergone retrograde transvenous thoracic ductography. Despite conservative treatment, all required drainage for chylothorax, chylous ascites, or a chylous pericardial effusion. Lymphangiography was performed, and the junction of the thoracic duct with the vein was identified. A microcatheter was inserted into the thoracic duct retrogradely via the junction with the vein.
RESULTS: The catheter could be inserted to the cervical part, thoracic part, and cisterna chyli in 12 (92.3%), nine (69.2%), and six (46.2%) patients, respectively. Successful transvenous thoracic ductography was performed in eight patients (61.5%). The cervical part of the thoracic duct was branched into a plexiform configuration beyond which the microcatheter could not be advanced to reach the thoracic part in three unsuccessful cases. The success rate of transvenous thoracic ductography was significantly higher with the simple type (80%) than with the plexiform type (0%; p = 0.035). No extravasation of contrast agent was seen in the eight patients with successful thoracic ductography. Thoracic duct embolization was performed in one patient with a chylous pericardial effusion in whom myriad lymph ducts connecting to the hilar and pericardial regions from the thoracic duct were found, and drainage was unnecessary.
CONCLUSION: Transvenous retrograde thoracic ductography was successful in only eight of 13 patients (61.5%), but when the cervical part was the simple type, it was successful in eight of 10 patients (80%).
Philippe Guillem, Ioannis Papachristos, Christophe Peillon, Jean-Pierre Triboulet
Etilefrine use in the management of post-operative chyle leaks in thoracic surgery.
Interact Cardiovasc Thorac Surg. 2004 Mar;3(1):156-60. doi: 10.1016/S1569-9293(03)00263-9.
Abstract/Text
Etilefrine, a sympathomimetic drug, was used 11 times in 10 patients with thoracic (n=8) or abdominal (n=2) chyle leak occurring after thoracic surgical procedures. It was given as a 4.2-5 mg/h intravenous infusion. During the 11 etilefrine administrations, three patients had total parenteral nutrition, three had enteral nutrition, three had oral fat-free diet and medium-chain triglyceride supplementation, and two were fed orally without restriction. Daily chyle flow output decreased in all but one patient who was reoperated. Chyle flow output did not decrease relevantly in one patient who was reoperated. Chylothorax recurred after reoperation and etilefrine then induced significant output decrease. In another patient, etilefrine was stopped despite significant output reduction because of interactions with other sympathomimetic drugs used for heart failure. The mean etilefrine treatment duration was 6.4 days (range 4-7). The mean daily output was from 740 ml before etilefrine infusion to 183 ml on the seventh day of etilefrine use. By inducing contraction of the smooth muscle fibres present in the wall of the main thoracic chyle ducts, etilefrine can be considered as a useful adjunct in the management of post-operative chyle leak.
波多豪, 川西賢秀, 永井健一, 畑泰司, 森田俊治, 藤田淳也, 岩澤卓, 赤木謙三, 堂野恵三, 北田昌之: Etilefrin投与が有効であった食道癌術後難治性乳縻胸の1例. 日本消化器外科学会雑誌 2013; 46: 79-84.
尾島敏康, 中森幹人, 中村公紀, 岩橋誠, 勝田将裕, 山上裕機: Octreotide/etilefrine/OK-432併用療法にて治癒した食道癌術後乳糜胸の1例 日本臨床外科学会雑誌2014; 75: 1547-1550.
高橋一臣, 水野豊, 原田ジェームス統, 成田知宏, 阿佐美健吾, 鳩山恵一: Etilefrine投与が有用であった食道癌術後乳糜胸の1例. 日本臨床外科学会雑誌2016; 77: 804-808.
