Lymphangiography and subsequent sclerotherapy can be easily applied by cannulation of the lymph duct with a catheter for the neonatal central vein

The bright future of nanotechnology in lymphatic system imaging and imaging-guided surgery

Lymphatic system is identified the second vascular system after the blood circulation in mammalian species, however the research on lymphatic system has long been hampered by the lack of comprehensive imaging modality. Nanomaterials have shown the potential to enhance the quality of lymphatic imaging due to the unparalleled advantages such as the specific passive targeting and efficient co-delivery of cocktail to peripheral lymphatic system, ease molecular engineering for precise active targeting and prolonged retention in the lymphatic system of interest. Multimodal lymphatic imaging based on nanotechnology provides a complementary means to understand the kinetics of lymphoid tissues and quantify its function. In this review, we introduce the established approaches of lymphatic imaging used in clinic and summarize their strengths and weaknesses, and list the critical influence factors on lymphatic imaging. Meanwhile, the recent developments in the field of pre-clinical lymphatic imaging are discussed to shed new lights on the design of new imaging agents, the improvement of delivery methods and imaging-guided surgery strategies.

Effectiveness of lymphatic cannulation in case of non-applicable intranodal lymphangiography

A 78-year-old man presented with lymphatic fluid collections in bilateral inguinal area after bilateral inguinal lymph node dissections. Because no inguinal or popliteal lymph nodes were observed under ultrasound examination, intranodal lymphangiography was not applicable. Although traditional pedal lymphangiography was required, it was difficult to perform this procedure owing to the decreasing frequency over the past 20 years and being unavailable in not only our institution, but also other in institutions. Therefore, we performed catheterization using the 29-guage Argyle PI catheter into the lymphatic duct in lower legs under a microscope and achieved successful percutaneous embolization using N-butyl cyanoacrylate for inguinal lymphatic leakage.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

KEY POINTS

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

CITATION FORMAT

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

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

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