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Weinzierl A, Grünherz L, Puippe GD, Gnannt R, von Reibnitz D, Giovanoli P, Vetter D, Möhrlen U, Wildgruber M, Müller A, Pieper CC, Gutschow CA, Lindenblatt N. Microsurgical central lymphatic reconstruction-the role of thoracic duct lymphovenous anastomoses at different anatomical levels. Front Surg 2024; 11:1415010. [PMID: 38826811 PMCID: PMC11140048 DOI: 10.3389/fsurg.2024.1415010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Accepted: 05/09/2024] [Indexed: 06/04/2024] Open
Abstract
Introduction In recent years advances have been made in the microsurgical treatment of congenital or acquired central lymphatic lesions. While acquired lesions can result from any surgery or trauma of the central lymphatic system, congenital lymphatic lesions can have a variety of manifestations, ranging from singular thoracic duct abnormalities to complex multifocal malformations. Both conditions may cause recurrent chylous effusions and downstream lymphatic congestion depending on the anatomical location of the thoracic duct lesion and are associated with an increased mortality due to the permanent loss of protein and fluid. Methods We present a case series of eleven patients undergoing central lymphatic reconstruction, consisting of one patient with a cervical iatrogenic thoracic duct lesion and eleven patients with different congenital thoracic duct lesions or thrombotic occlusions. Results Anastomosis of the thoracic duct and a nearby vein was performed on different anatomical levels depending on the underlying central lymphatic pathology. Cervical (n = 4), thoracic (n = 1) or abdominal access (n = 5) was used for central lymphatic reconstruction with promising results. In 9 patients a postoperative benefit with varying degrees of symptom regression was reported. Conclusion The presented case series illustrates the current rapid advances in the field of central microsurgical reconstruction of lymphatic lesions alongside the relevant literature.
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Affiliation(s)
- Andrea Weinzierl
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich (USZ), Zurich, Switzerland
| | - Lisanne Grünherz
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich (USZ), Zurich, Switzerland
| | - Gilbert Dominique Puippe
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich (USZ), Zurich, Switzerland
| | - Ralph Gnannt
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich (USZ), Zurich, Switzerland
| | - Donata von Reibnitz
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich (USZ), Zurich, Switzerland
| | - Pietro Giovanoli
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich (USZ), Zurich, Switzerland
- Faculty of Medicine, University of Zurich (UZH), Zürich, Switzerland
| | - Diana Vetter
- Department of Visceral and Transplant Surgery, University Hospital Zurich (USZ), Zurich, Switzerland
| | - Ueli Möhrlen
- Faculty of Medicine, University of Zurich (UZH), Zürich, Switzerland
- Department of Pediatric Surgery, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Moritz Wildgruber
- Department of Radiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Andreas Müller
- Department of Neonatology and Pediatric Intensive Care, Children’s Hospital, University of Bonn, Bonn, Germany
| | | | | | - Nicole Lindenblatt
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich (USZ), Zurich, Switzerland
- Faculty of Medicine, University of Zurich (UZH), Zürich, Switzerland
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Tsuzaka S, Aiyama T, Kamachi H, Kakisaka T, Orimo T, Nagatsu A, Asahi Y, Maeda T, Kamiyama T, Taketomi A. Lymphaticovenous anastomosis for treatment of refractory chylous ascites: A case report. Microsurgery 2023; 43:606-610. [PMID: 37016794 DOI: 10.1002/micr.31042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 01/17/2023] [Accepted: 03/09/2023] [Indexed: 04/06/2023]
Abstract
Chylous ascites, the leakage of lymphatic fluid into the abdominal cavity caused by lymphatic fluid stasis or lymphatic vessel damage, can be treated by lymphaticovenous anastomosis (LVA). We report rarely performed abdominal LVA to treat a case of refractory ascites possibly caused by ligation of the thoracic duct and pleurodesis in a man aged 60 years requiring weekly ascites drainage. Ligation was abandoned because the leakage site was not determined. The greater omentum (GO) was generally edematous and showed lymphatic effusion by gross appearance, and was considered suitable for LVA. We performed once LVA in the lymphatic vessels and veins of the GO using common microsurgical instrumentation and lateral anastomosis. Lymphatic vessels in the omentum were dilated to 2-3 mm, and LVA was simple. After LVA, GO edema improved. Postoperatively, the patient developed paralytic ileus, which improved within a few days, and the patient was discharged without any increase in ascites after starting to diet. One year post-surgery, there was no recurrence of ascites. LVA at the GO may be effective for the treatment of refractory chylous ascites because of its absorptive lymphatic draining capabilities and large transverse vessels.
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Affiliation(s)
- Shoichi Tsuzaka
- Department of Gastroenterological Surgery I, Hokkaido University Hospital, Kita-ku, Kita 15, Nishi 7, Sapporo, 060-8638, Hokkaido, Japan
| | - Takeshi Aiyama
- Department of Gastroenterological Surgery I, Hokkaido University Hospital, Kita-ku, Kita 15, Nishi 7, Sapporo, 060-8638, Hokkaido, Japan
| | - Hirofumi Kamachi
- Department of Gastroenterological Surgery I, Hokkaido University Hospital, Kita-ku, Kita 15, Nishi 7, Sapporo, 060-8638, Hokkaido, Japan
| | - Tatsuhiko Kakisaka
- Department of Gastroenterological Surgery I, Hokkaido University Hospital, Kita-ku, Kita 15, Nishi 7, Sapporo, 060-8638, Hokkaido, Japan
| | - Tatsuya Orimo
- Department of Gastroenterological Surgery I, Hokkaido University Hospital, Kita-ku, Kita 15, Nishi 7, Sapporo, 060-8638, Hokkaido, Japan
| | - Akihisa Nagatsu
- Department of Gastroenterological Surgery I, Hokkaido University Hospital, Kita-ku, Kita 15, Nishi 7, Sapporo, 060-8638, Hokkaido, Japan
| | - Yoh Asahi
- Department of Gastroenterological Surgery I, Hokkaido University Hospital, Kita-ku, Kita 15, Nishi 7, Sapporo, 060-8638, Hokkaido, Japan
| | - Taku Maeda
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine, Graduate School of Medicine, Hokkaido University Hospital, Kita-ku, Kita 15, Nishi 7, Sapporo, 060-8638, Hokkaido, Japan
| | - Toshiya Kamiyama
- Department of Gastroenterological Surgery I, Hokkaido University Hospital, Kita-ku, Kita 15, Nishi 7, Sapporo, 060-8638, Hokkaido, Japan
| | - Akinobu Taketomi
- Department of Gastroenterological Surgery I, Hokkaido University Hospital, Kita-ku, Kita 15, Nishi 7, Sapporo, 060-8638, Hokkaido, Japan
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Jun H, Hur S, Jeong YS, Kang CH, Lee H. Thoracic duct embolization in treating postoperative chylothorax: does bail-out retrograde access improve outcomes? Eur Radiol 2021; 32:377-383. [PMID: 34247305 DOI: 10.1007/s00330-021-08145-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 05/25/2021] [Accepted: 06/08/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To evaluate clinical outcomes of thoracic duct embolization (TDE) for the management of postoperative chylothorax with the aid of the bail-out retrograde approach for thoracic duct cannulation (TDC). MATERIALS AND METHODS Forty-five patients with postoperative chylothorax underwent Lipiodol lymphangiography (LLG) between February 2016 and November 2019. If targetable central lymphatic vessels were identified in LLG, TDC, a prerequisite for TDE, was attempted. While the conventional antegrade transabdominal approach was the standard TDC method, the retrograde approach was applied as a bail-out method. Embolization, the last step of TDE, was performed after confirming leakages in the trans-TDC catheter lymphangiography. Technical and clinical success rates were determined retrospectively. RESULTS TDC was attempted in 40 among 45 patients based on LLG findings. The technical success rate of TDC with the conventional antegrade approach was 78% (31/40). In addition, six more patients were cannulated using the bail-out retrograde approach, which raised the technical success rate to 93% (37/40). While 35 patients underwent embolization (TDE group), ten patients did not (non-TDE group) for the following reasons: (1) lack of targetable lymphatics for TDC in LLG (n = 5), (2) technical failure of TDC (n = 3), and (3) lack of discernible leakages in the transcatheter lymphangiography (n = 2). The clinical success of the TDE group was 89% (31/35), compared with 50% (5/10) of the non-TDE group. One major procedure-related complication was bile peritonitis caused by the needle passage of the distended gallbladder. CONCLUSIONS Bail-out retrograde approach for TDC could improve the overall technical success of TDC significantly. KEY POINTS • Bail-out retrograde thoracic duct access may improve the overall technical success of thoracic duct access, thus improving the clinical success of thoracic duct embolization.
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Affiliation(s)
- Hoyong Jun
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Saebeom Hur
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
- Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
| | - Yun Soo Jeong
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Chang Hyun Kang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Hyukjoon Lee
- Department of Radiology, Christchurch Hospital, Christchurch, New Zealand
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Srinivasa RN, Chick JFB, Hage AN, Gemmete JJ, Murrey DC, Srinivasa RN. Endolymphatic Thoracic Duct Stent-Graft Reconstruction for Chylothorax: Approach, Technical Success, Safety, and Short-term Outcomes. Ann Vasc Surg 2017; 48:97-103. [PMID: 29217436 DOI: 10.1016/j.avsg.2017.11.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 11/21/2017] [Accepted: 11/21/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND To report approach, technical success, safety, and short-term outcomes of thoracic duct stent-graft reconstruction for the treatment of chylothorax. METHODS Two patients, 1 (50%) male and 1 (50%) female, with mean age of 38 years (range: 16-59 years) underwent endolymphatic thoracic duct stent-graft reconstruction between September 2016 and July 2017. Patients had radiographic left-sided chylothoraces (n = 2) from idiopathic causes (n = 1) and heart transplantation (n = 1). In both (100%) patients, antegrade lymphatic access was used to opacify the thoracic duct after which retrograde access was used for thoracic duct stent-graft placement. Pelvic lymphangiography technical success, antegrade cisterna chyli cannulation technical success, thoracic duct opacification technical success, retrograde thoracic duct access technical success, thoracic duct stent-graft reconstruction technical success, ethiodized oil volume, contrast volume, estimated blood loss, procedure time, fluoroscopy time, radiation dose, clinical success, complications, deaths, and follow-up were recorded. RESULTS Pelvic lymphangiography, antegrade cisterna chyli cannulation, thoracic duct opacification, retrograde thoracic duct access, and thoracic duct stent-graft reconstruction were technically successful in both (100%) patients. Mean ethiodized oil volume was 8 mL (range: 5-10 mL). Mean contrast volume was 13 mL (range: 5-20 mL). Mean estimated blood loss was 13 mL (range: 10-15 mL). Mean fluoroscopy time was 50.4 min (range: 31.2-69.7 min). Mean dose area product and reference air kerma were 954.4 μGmy2 (range: 701-1,208 μGmy2) and 83.5 mGy (range: 59-108 mGy), respectively. Chylothorax resolved in both (100%) patients. There were no minor or major complications directly related to the procedure. CONCLUSIONS Thoracic duct stent-graft reconstruction may be a technically successful and safe alternative to thoracic duct embolization, disruption, and surgical ligation for the treatment of chylothorax. Additional studies are warranted.
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Affiliation(s)
- Rajiv N Srinivasa
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Michigan Health System, Ann Arbor, MI
| | - Jeffrey Forris Beecham Chick
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Michigan Health System, Ann Arbor, MI.
| | - Anthony N Hage
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Michigan Health System, Ann Arbor, MI
| | - Joseph J Gemmete
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Michigan Health System, Ann Arbor, MI
| | - Douglas C Murrey
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Michigan Health System, Ann Arbor, MI
| | - Ravi N Srinivasa
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Michigan Health System, Ann Arbor, MI
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Interventional radiology in the management of thoracic duct injuries: Anatomy, techniques and results. Clin Imaging 2017; 42:183-192. [DOI: 10.1016/j.clinimag.2016.12.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 12/11/2016] [Accepted: 12/24/2016] [Indexed: 01/30/2023]
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Abstract
PURPOSE OF REVIEW The present review is focused on the management of lymphatic, chylous, and thoracic duct lesions following head and neck surgery, with particular attention to these complications after neck dissection. Postoperative scenarios may include chylous fistula, chylothorax, chylomediastinum, chylopericardium, lymphocele, persistent lymphorrhea, and secondary lymphedema. RECENT FINDINGS There is a paucity of literature on the treatment of lymphatic, chylous, and thoracic duct injuries following head and neck surgery; however, this review suggests that the most appropriate treatment should include both conservative and surgical approaches. Nonsurgical options consist of low-fat diet with medium-chain triglycerides, total parenteral nutrition, careful monitoring of fluid and electrolytes, drainage of the leakage, somatostatin analogs such as octreotide, and negative-pressure wound therapy. On the other hand, surgical management includes therapeutic percutaneous lymphography-guided thoracic duct cannulation and embolization, thoracic duct ligation, excision and imbrication of leaking lymphatics, chylous fistula surgical/microsurgical repair, fistula closure by locoregional flaps, video-assisted thoracoscopic surgery, thoracotomy, pleurodesis and decortication, pericardial 'window', and pleura-venous/pleura-peritoneal shunts. In addition, single or, preferably, multiple lymphovenous anastomoses may be taken into account. SUMMARY The various possible clinical presentations of such challenging lymphatic, chylous, and thoracic duct injuries require an appropriate multidisciplinary approach by experienced teams. Primary prevention of these complications can be achieved through adequate surgical planning to minimize lesions, including structured and thorough patient assessment, and centralization of resources and teams.
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Laslett D, Trerotola SO, Itkin M. Delayed Complications following Technically Successful Thoracic Duct Embolization. J Vasc Interv Radiol 2012; 23:76-9. [DOI: 10.1016/j.jvir.2011.10.008] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2011] [Revised: 10/14/2011] [Accepted: 10/18/2011] [Indexed: 12/11/2022] Open
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