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Ladd B, Jones K, Polly D. Lymphatic Injury After Vertebral Column Resection from a Posterior Approach for Spinal Deformity Correction: A Case Report. JBJS Case Connect 2021; 11:01709767-202112000-00010. [PMID: 34648467 DOI: 10.2106/jbjs.cc.21.00145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE We describe a case of lymphatic injury that occurred during a 2-level vertebral column resection for spinal deformity correction from a posterior-only approach. Large surgical drain volume output with laboratory findings of high levels of triglycerides and lymphocytes prompted conservative treatment with an elastic wrap bandage and a "no fat" diet. The patient responded to the treatment with no sequelae noted. CONCLUSION Lymphatic complications are rare in spine surgery. All reported cases are associated with anterior approaches. The lymphatic injury presented here demonstrates the potential for this complication to occur during posterior-only approaches as well.
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Affiliation(s)
- Bryan Ladd
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota
| | - Kristen Jones
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota.,Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota
| | - David Polly
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota.,Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota
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Abstract
Isolated thoracic duct injury is an uncommon clinical event and is rare in the setting of trauma. We describe a case of an isolated thoracic duct injury resulting in the development of bilateral chylothorax following a motor vehicle collision in the absence of any other definable injury. We outline the initial patient presentation and diagnosis. After failing a trial of conservative management the patient underwent lymphangiography followed by thoracic duct ligation with pleurodesis. This case highlights the importance of recognizing thoracic duct injury following trauma.
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Affiliation(s)
- Shelby Champion
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | | | - Daniele Wiseman
- Department of Medical Imaging, London Health Science Centre, London, Ontario, Canada
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3
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Osman K, Wemyss-Holden S, Miller A. A Chylous Rupture. J R Soc Med 2017; 95:616-7. [PMID: 12461153 PMCID: PMC1279293 DOI: 10.1177/014107680209501213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- K Osman
- Department of Surgery, University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary, Leicester LE1 5WW, UK.
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Lizaola B, Bonder A, Trivedi HD, Tapper EB, Cardenas A. Review article: the diagnostic approach and current management of chylous ascites. Aliment Pharmacol Ther 2017; 46:816-824. [PMID: 28892178 DOI: 10.1111/apt.14284] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Revised: 07/15/2017] [Accepted: 08/11/2017] [Indexed: 01/19/2023]
Abstract
BACKGROUND Chylous ascites is rare, accounting for less than 1% of cases. An appropriate and stepwise approach to its diagnosis and management is of key importance. AIM To review the current diagnostic approach and management of chylous ascites. METHODS A literature search was conducted using PubMed using the key words 'chylous', 'ascites', 'cirrhosis', 'pathophysiology', 'nutritional therapy', 'paracentesis", "transjugular intrahepatic portosystemic shunt" and "TIPSS'. Only articles in English were included. RESULTS Chylous ascites is caused by the traumatic or obstructive disruption of the lymphatic system that leads to extravasation of thoracic or intestinal lymph into the abdominal space and the accumulation of a milky fluid rich in triglycerides. The most common causes are malignancy, cirrhosis and trauma after abdominal surgery. This condition can lead to chyle depletion, which results in nutritional, immunologic and metabolic deficiencies. An ascitic triglyceride concentration above 200 mg/dL is consistent with chylous ascites. Treatment is based on management of the underlying cause and nutritional support. CONCLUSIONS Chylous ascites is mostly due to malignancy and cirrhosis in adults, and congenital lymphatic disorders in children. Treatment with nutritional optimization and management of the underlying etiology are the cornerstones of therapy. When conservative measures fail, other interventions such as octreotide/somatostatin analogues, surgical ligation, embolization and transjugular intrahepatic portosystemic shunt in patients with cirrhosis can be considered.
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Affiliation(s)
- B Lizaola
- Department of Medicine, St. Elizabeth Medical Center, Brighton, MA, USA
| | - A Bonder
- Liver Center, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - H D Trivedi
- Liver Center, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - E B Tapper
- Department of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - A Cardenas
- GI/Liver Unit, Institute of Digestive Diseases and Metabolism, University of Barcelona, Hospital Clinic and Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS), Barcelona, Spain
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Eren T, Demir M, Orman S, Leblebici M, Özemir İA, Alimoğlu O. Isolated chylous injury due to blunt abdominal trauma: Report of a case and a review of the literature. Turk J Surg 2015; 33:119-122. [PMID: 28740964 DOI: 10.5152/ucd.2015.2925] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 12/02/2014] [Indexed: 12/23/2022]
Abstract
The chyle duct (CD) lies close to the spine behind the right renal vein and vena cava. Forces capable of tearing the CD may also injure other adjacent structures or organs. Cases of isolated chylous injury are rarely reported in the literature. Our aim was to report a case of isolated chylous injury due to blunt abdominal trauma that was successfully treated non-operatively. A 54-year-old man was involved in a deceleration-type traffic accident. His physical examinations, radiologic evaluations, paracentesis, and laboratory findings revealed isolated chylous injury resulting from intra- and retroperitoneal chylous fluid collection. The patient was treated via percutaneous drainage and medical therapy. This condition is generally self-limited and resolves without the necessity of any surgical interventions. However, if medical treatment is unsuccessful, the decision of diagnostic laparoscopy or exploratory laparotomy becomes inevitable.
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Affiliation(s)
- Tunç Eren
- Department of General Surgery, İstanbul Medeniyet University, Göztepe Training and Research Hospital, İstanbul, Turkey
| | - Mustafa Demir
- Department of General Surgery, İstanbul Medeniyet University, Göztepe Training and Research Hospital, İstanbul, Turkey
| | - Süleyman Orman
- Department of General Surgery, İstanbul Medeniyet University, Göztepe Training and Research Hospital, İstanbul, Turkey
| | - Metin Leblebici
- Department of General Surgery, İstanbul Medeniyet University, Göztepe Training and Research Hospital, İstanbul, Turkey
| | - İbrahim Ali Özemir
- Department of General Surgery, İstanbul Medeniyet University, Göztepe Training and Research Hospital, İstanbul, Turkey
| | - Orhan Alimoğlu
- Department of General Surgery, İstanbul Medeniyet University, Göztepe Training and Research Hospital, İstanbul, Turkey
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Tewari N, Bhalla A, Iftikhar S. Chylous ascites: Why exercise is bad for you. Int J Surg Case Rep 2012; 4:118-20. [PMID: 23174523 DOI: 10.1016/j.ijscr.2012.10.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Revised: 10/15/2012] [Accepted: 10/22/2012] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION The development of chylous ascites is usually associated with trauma, iatrogenic or otherwise. Blunt abdominal trauma producing hyperextension or hyperflexion may cause disruption to lymphatic vessels causing chylous ascites. PRESENTATION OF CASE This report describes the case of a 38-year-old gentleman who presented to the emergency department with severe abdominal pain after completing a triathlon. As the patient was in severe pain, an abdominal CT was performed which demonstrated a possible mid gut volvulus. Subsequent laparotomy noted a significant volume of intra-abdominal chyle with no other abnormalities. DISCUSSION This is the first report of chylous ascites occurring without associated abdominal pathology after a period of strenuous exercise. CONCLUSION Chylous ascites can occur as a result of hyperreflexion and hyperextension injuries sustained during strenuous exercise.
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Affiliation(s)
- N Tewari
- Royal Derby Hospitals NHS Foundation Trust, United Kingdom.
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Steinemann DC, Dindo D, Clavien PA, Nocito A. Atraumatic chylous ascites: systematic review on symptoms and causes. J Am Coll Surg 2011; 212:899-905.e1-4. [PMID: 21398159 DOI: 10.1016/j.jamcollsurg.2011.01.010] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Revised: 01/10/2011] [Accepted: 01/11/2011] [Indexed: 12/14/2022]
Affiliation(s)
- Daniel C Steinemann
- Department of Visceral and Transplantation Surgery, University Hospital Zurich, Zurich, Switzerland
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Abstract
The objective of this study was to evaluate incidence of chylous injury in blunt trauma using a retrospective chart review. We present two patients who sustained chyle duct injury after blunt trauma. The first patient is a pedestrian struck by car. Abdominal CT scan revealed duodenal thickening and a moderate amount of paraduodenal fluid, which prompted surgical exploration. At laparotomy, the patient was found to have a disruption of his lymphatics at the level of the inferior vena cava (IVC) without duodenal injury treated with hemoclips, fibrin sealant and elemental gastrojejunal feeds. The second patient was involved in a high speed motor vehicle collision (MVC) resulting in transection of the mesentery of the transverse colon. Disrupted lacteals were treated intra-operatively with hemoclips and fibrin sealant decreasing the lymph leak. In both cases, the leak completely resolved with use of tube feedings with medium chain triglycerides. On literature review, six prior patients with spontaneous chylous retroperitoneum were described undergoing similar operative management. Chylous leakage due to blunt trauma is a rare finding. Mechanism of injury includes hyperextension or flexion resulting in stretching and shearing of the tethered lymphatics. Open ligation or clipping of the injured ducts seems effective. Tube feeds with medium chain triglycerides may enhance efficacy of operative treatment.
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Affiliation(s)
- James M. Haan
- University of Maryland, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | | | - Timothy J. Novosel
- University of Maryland, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Deborah M. Stein
- University of Maryland, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
| | - Thomas M. Scalea
- University of Maryland, R Adams Cowley Shock Trauma Center, Baltimore, Maryland
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Abstract
Chylous ascites is a rare and challenging clinical condition that occurs as a result of disruption of the abdominal lymphatics. We include a review of the literature describing the etiology, diagnosis, and therapy of chylous ascites.
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Affiliation(s)
- Tony Almakdisi
- Temple University/Conemaugh Memorial Hospital, Department of Medicine, Johnstown, Pennsylvania 15905, USA.
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Osman K, Wemyss-Holden S, Miller A. A chylous rupture. J R Soc Med 2002. [PMID: 12461153 PMCID: PMC1279293 DOI: 10.1258/jrsm.95.12.616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- K Osman
- Department of Surgery, University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary, Leicester LE1 5WW, UK.
| | - S Wemyss-Holden
- Department of Surgery, University Hospitals of Leicester NHS Trust,
Leicester Royal Infirmary, Leicester LE1 5WW, UK
| | - A Miller
- Department of Surgery, University Hospitals of Leicester NHS Trust,
Leicester Royal Infirmary, Leicester LE1 5WW, UK
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Affiliation(s)
- Andrés Cárdenas
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts 02215, USA
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Resende Neto JBD, Pinto DM, Abrantes WL. Ascite quilosa traumática. Rev Col Bras Cir 2002. [DOI: 10.1590/s0100-69912002000100013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Affiliation(s)
- O O Aalami
- Department of Surgery, University of California, Davis-East Bay, Oakland, Calif, 94602, USA
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Abstract
An 8-year-old boy was evaluated for blunt abdominal trauma after a motor vehicle crash. In the course of his workup, a computed tomography (CT) scan of the abdomen was suspicious for a duodenal injury. At surgery, the duodenum was found to be normal; however, a rupture of the cisterna chyli was identified. This injury was repaired, and the boy made an uneventful recovery. This report is one of few in the literature describing isolated injury to the cisterna chyli after blunt abdominal trauma.
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Affiliation(s)
- C M Calkins
- Department of Surgery, Denver Health Medical Center, University of Colorado Health Sciences Center, 80204, USA
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Affiliation(s)
- R M Patten
- Department of Radiology, Denver Health Medical Center, CO 80204, USA
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