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Respiratory Medicine Oct 2019A chylothorax, also known as chylous pleural effusion, is an uncommon cause of pleural effusion with a wide differential diagnosis characterized by the accumulation of... (Review)
Review
A chylothorax, also known as chylous pleural effusion, is an uncommon cause of pleural effusion with a wide differential diagnosis characterized by the accumulation of bacteriostatic chyle in the pleural space. The pleural fluid will have either or both triglycerides >110 mg/dL and the presence of chylomicrons. It may be encountered following a surgical intervention, usually in the chest, or underlying disease process. Management of a chylothorax requires a multidisciplinary approach employing medical therapy and possibly surgical intervention for post-operative patients and patients who have failed medical therapy. In this review, we aim to discuss the anatomy, fluid characteristics, etiology, and approach to the diagnosis of a chylothorax.
Topics: Antineoplastic Agents, Hormonal; Chylothorax; Diagnosis, Differential; Exudates and Transudates; Humans; Lymphography; Lymphoscintigraphy; Octreotide; Pleural Effusion; Postoperative Period; Radiography, Thoracic; Suction; Thoracentesis; Thoracic Duct; Tomography, X-Ray Computed; Triglycerides
PubMed: 31454675
DOI: 10.1016/j.rmed.2019.08.014 -
Asian Journal of Surgery Jul 2023
Topics: Humans; Thoracic Duct; Dilatation; Dilatation, Pathologic
PubMed: 37173246
DOI: 10.1016/j.asjsur.2023.03.194 -
The Journal of Thoracic and... Aug 2018
Topics: Lymphography; Thoracic Duct
PubMed: 29730121
DOI: 10.1016/j.jtcvs.2018.04.032 -
The Journal of Thoracic and... Feb 2018
Topics: Chylothorax; Humans; Laparoscopy; Ligation; Thoracic Duct
PubMed: 29106894
DOI: 10.1016/j.jtcvs.2017.09.111 -
Journal of Cardiovascular Magnetic... Jun 2023Lymphatic complications are common in patients with Fontan circulation. Three-dimensional balanced steady-state free precession (3D bSSFP) angiography by cardiovascular...
BACKGROUND
Lymphatic complications are common in patients with Fontan circulation. Three-dimensional balanced steady-state free precession (3D bSSFP) angiography by cardiovascular magnetic resonance (CMR) is widely used for cardiovascular anatomical assessment. We sought to determine the frequency of thoracic duct (TD) visualization using 3D bSSFP images and assess whether TD characteristics are associated with clinical outcomes.
METHODS
This was a retrospective, single-center study of patients with Fontan circulation who underwent CMR. Frequency matching of age at CMR was used to construct a comparison group of patients with repaired tetralogy of Fallot (rTOF). TD characteristics included maximum diameter and a qualitative assessment of tortuosity. Clinical outcomes included protein-losing enteropathy (PLE), plastic bronchitis, listing for heart transplantation, and death. A composite outcome was defined as presence of any of these events.
RESULTS
The study included 189 Fontan patients (median age 16.1 years, IQR 11.0-23.2 years) and 36 rTOF patients (median age 15.7 years, IQR 11.1-23.7 years). The TD diameter was larger (median 2.50 vs. 1.95 mm, p = 0.002) and more often well visualized (65% vs. 22%, p < 0.001) in Fontan patients vs. rTOF patients. TD dimension increased mildly with age in Fontan patients, R = 0.19, p = 0.01. In Fontan patients, the TD diameter was larger in those with PLE vs. without PLE (age-adjusted mean 4.11 vs. 2.72, p = 0.005), and was more tortuous in those with NYHA class ≥ II vs. class I (moderate or greater tortuosity 75% vs. 28.5%, p = 0.02). Larger TD diameter was associated with a lower ventricular ejection fraction that was independent of age (partial correlation = - 0.22, p = 0.02). More tortuous TDs had a higher end-systolic volume (mean 70.0 mL/m vs. 57.3 mL/m, p = 0.03), lower creatinine (mean 0.61 mg/dL vs. 0.70 mg/dL, p = 0.04), and a higher absolute lymphocyte count (mean 1.80 K cells/µL vs. 0.76 K cells/µL, p = 0.003). The composite outcome was present in 6% of Fontan patients and was not associated with TD diameter (p = 0.50) or tortuosity (p = 0.09).
CONCLUSIONS
The TD is well visualized in two-thirds of patients with Fontan circulation on 3D-bSSFP images. Larger TD diameter is associated with PLE and increased TD tortuosity is associated with an NYHA class ≥ II.
Topics: Humans; Adolescent; Thoracic Duct; Fontan Procedure; Retrospective Studies; Predictive Value of Tests; Tetralogy of Fallot; Magnetic Resonance Spectroscopy
PubMed: 37303061
DOI: 10.1186/s12968-023-00937-w -
Emergency Medicine Journal : EMJ Feb 2007During a high-speed road traffic accident, a 26-year-old man suffered multiple fractures of his thoracic vertebrae and bilateral pneumothoraces. The day after admission...
During a high-speed road traffic accident, a 26-year-old man suffered multiple fractures of his thoracic vertebrae and bilateral pneumothoraces. The day after admission and commencement of nasogastric feeding, milky fluid was noted in his right chest drain. Feeding was stopped and a contrast oesophogram and oesophagoscopy were performed, which were normal. The chylothorax quickly resolved and both drains were removed on day 6. Initial treatment of chylothorax aims to decompress the pleural space and minimise chyle production by not feeding the patient via the enteral route. Most authors recommend conservative management for 2 weeks or more unless certain parameters are met: average daily chyle loss of > 1.5 l for a 5-day period, or imminent nutritional complications. In this case, surgical management of the chylothorax and spinal fractures was planned. However, conservative management was successful, highlighting the fact that early aggressive surgical intervention for chyle leaks in blunt trauma is not necessary.
Topics: Accidents, Traffic; Adult; Chest Tubes; Chylothorax; Humans; Male; Multiple Trauma; Pneumothorax; Spinal Fractures; Thoracic Duct; Thoracic Vertebrae; Wounds, Nonpenetrating
PubMed: 17251600
DOI: 10.1136/emj.2006.042028 -
British Medical Journal Feb 1964
Topics: Adolescent; Blood Protein Disorders; Child; Chyle; Fistula; Humans; Hyperplasia; Hypertrophy; Lymphatic System; Lymphedema; Lymphography; Prognosis; Protein Deficiency; Surgical Procedures, Operative; Thoracic Duct
PubMed: 14101998
DOI: 10.1136/bmj.1.5382.529 -
Diseases of the Esophagus : Official... Sep 2023Despite advances in multidisciplinary treatment, esophagectomy remains the main curative treatment for esophageal cancer. The advantages and disadvantages of thoracic...
Despite advances in multidisciplinary treatment, esophagectomy remains the main curative treatment for esophageal cancer. The advantages and disadvantages of thoracic duct (TD) resection have been controversial for decades. We have herein reviewed relevant published literature regarding 'thoracic duct,' 'esophageal cancer,' and 'esophagectomy' describing the anatomy and function of the TD, and incidence of thoracic duct lymph nodes (TDLN) and TDLN metastases, as well as the oncological and physiological effects of TD resection. The presence of lymph nodes around the TD, referred to as TDLN, has been reported previously. The delineation of TDLNs is clearly defined by a thin fascial structure covering the TD and the surrounding adipose tissue. Previous studies have examined the number of TDLNs and the percentage of patients with TDLN metastasis and revealed that each patient had approximately two TDLNs. The percentage of patients with TDLN metastasis was reported to be 6-15%. Several studies have been conducted to compare the survival after TD resection with that after TD preservation. However, no consensus has been reached because all studies were retrospective, precluding firm conclusions. Although the issue of whether the risk of postoperative complications is affected by TD resection is still unclear, resecting the TD has been shown to have a long-term impact on nutritional status after surgery. In summary, TDLNs are quite common and present in most patients, while metastasis in the TDLNs occurs in a minority. However, the oncological value of TD resection in esophageal cancer surgery remains controversial due to varying findings and methodological limitations of previous comparative studies. Considering the potential but unproven oncological benefits and possible physiological drawbacks of TD resection, including postoperative fluid retention and disadvantages in the long-term nutritional outcome, clinical stage, and nutritional status should be considered before deciding whether to perform TD resection or not.
Topics: Humans; Thoracic Duct; Lymph Node Excision; Retrospective Studies; Esophageal Neoplasms; Lymph Nodes; Postoperative Complications; Lymphatic Metastasis; Esophagectomy
PubMed: 36950928
DOI: 10.1093/dote/doad015 -
Journal of the American Veterinary... Dec 2022To document outcomes of thoracoscopic treatment of idiopathic chylothorax (IC) in dogs with and without constrictive pericardial physiology (CPP) and evaluate patterns...
OBJECTIVE
To document outcomes of thoracoscopic treatment of idiopathic chylothorax (IC) in dogs with and without constrictive pericardial physiology (CPP) and evaluate patterns of chyle flow redistribution after thoracic duct ligation (TDL).
ANIMALS
26 client-owned dogs.
PROCEDURES
In this prospective cohort study, echocardiography and cardiac catheterization were performed to document CPP in dogs with IC. Thoracoscopic TDL with pericardiectomy was performed if CPP was present (TDL/P group). Dogs without evidence of CPP underwent thoracoscopic TDL alone (TDL group). Dogs underwent preoperative, immediate postoperative, and 3-month postoperative CT lymphangiography studies when possible. Perioperative morbidity, resolution and late recurrence rates, and long-term outcome were recorded.
RESULTS
17 dogs underwent TDL, and 9 underwent TDL/P. Twenty-five of 26 (96%) survived the perioperative period. One dog died from ventricular fibrillation during pericardiectomy. Resolution rates for TDL and TDL/P were 94% and 88%, respectively (P = .55), with 1 late recurrence occurring in the TDL group in a median follow-up of 25 months (range, 4 to 60 months). On 3-month postoperative CT lymphangiography studies, ongoing chyle flow past the ligation site was demonstrated in 5 of 17 dogs, of which 1 dog developed recurrence at 13 months postoperatively. In 15 of 17 dogs, chylous redistribution after TDL was principally by retrograde flow to the lumbar lymphatic plexus.
CLINICAL RELEVANCE
In dogs without evidence of CPP, TDL alone was associated with a very good prognosis for treatment of IC. In the absence of CPP, the additional benefit of pericardiectomy in the treatment of IC is questionable.
Topics: Dogs; Animals; Chylothorax; Pericardiectomy; Thoracic Duct; Prospective Studies; Chyle; Treatment Outcome; Retrospective Studies; Ligation; Dog Diseases
PubMed: 36563067
DOI: 10.2460/javma.22.08.0381 -
Korean Journal of Radiology Mar 2020To evaluate the technical feasibility of intranodal lymphangiography and thoracic duct (TD) access in a canine model.
OBJECTIVE
To evaluate the technical feasibility of intranodal lymphangiography and thoracic duct (TD) access in a canine model.
MATERIALS AND METHODS
Five male mongrel dogs were studied. The dog was placed in the supine position, and the most prominent lymph node in the groin was accessed using a 26-gauge spinal needle under ultrasonography (US) guidance. If the cisterna chyli (CC) was not opacified by bilateral lymphangiography, the medial iliac lymph nodes were directly punctured and Lipiodol was injected. After opacification, the CC was directly punctured with a 22-gauge needle. A 0.018-in microguidewire was advanced through the CC and TD. A 4-Fr introducer and dilator were then advanced over the wire. The microguidewire was changed to a 0.035-in guidewire, and this was advanced into the left subclavian vein through the terminal valve of the TD. Retrograde TD access was performed using a snare kit.
RESULTS
US-guided lymphangiography (including intranodal injection of Lipiodol [Guerbet]) was successful in all five dogs. However, in three of the five dogs (60%), the medial iliac lymph nodes were not fully opacified due to overt Lipiodol extravasation at the initial injection site. In these dogs, contralateral superficial inguinal intranodal injection was performed. However, two of these three dogs subsequently underwent direct medial iliac lymph node puncture under fluoroscopy guidance to deliver additional Lipiodol into the lymphatic system. Transabdominal CC puncture and cannulation with a 4-Fr introducer was successful in all five dogs. Transvenous retrograde catheterization of the TD (performed using a snare kit) was also successful in all five dogs.
CONCLUSION
A canine model may be appropriate for intranodal lymphangiography and TD access. Most lymphatic intervention techniques can be performed in a canine using the same instruments that are employed in a clinical setting.
Topics: Animals; Dogs; Ethiodized Oil; Lymph Nodes; Lymphography; Male; Models, Animal; Thoracic Duct; Tomography, X-Ray Computed
PubMed: 32090522
DOI: 10.3348/kjr.2019.0313