Pragmatic role of noncontrast magnetic resonance lymphangiography in postoperative chylothorax or cervical chylous leakage as a diagnostic and preprocedural planning tool.

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.

Canine idiopathic chylothorax: Anatomic characterization of the pre- and postoperative thoracic duct using computed tomography lymphography.

Surgical treatment has improved the prognosis of canine idiopathic chylothorax, although a recurrence of the disease occurs occasionally after the procedure. An improved understanding of possible causes for this recurrence would be helpful for prognosis and treatment planning in affected patients. In this retrospective case series study, we described the detailed pre- and postoperative computed tomographic lymphography (CTLG) imaging characteristics for a group of dogs with surgically confirmed idiopathic chylothorax. Preoperative CTLG was performed in 12 of 14 dogs diagnosed with idiopathic chylothorax. Thoracic ducts were present on the right side in 10 dogs, left side in one dog, and bilaterally in one dog. All the 14 dogs received a combination therapy of pericardiectomy and thoracic duct ligation (TDL) by video-assisted thoracoscopic surgery. One week after surgery, a postoperative CTLG was performed, and the thoracic ducts were apparent in seven of 14 dogs. Three dogs had an unchanged course of the thoracic duct, which could have resulted from a missed duct. Four dogs were identified as having a bypass formation: the oblique duct originated at the ligation site and connected to the duct on the other side. Our findings indicated that one of the possible causes for postoperative recurrence of chylothorax in dogs could be "invisible or sleeping" fine ducts that are collapsed and not visible in preoperative CTLG scans. After TDL causes a change in the pressure of lymphatic flow, these fine thoracic ducts may become apparent using postoperative CTLG.

Prophylactic fat-free diet in patients undergoing lobectomy for lung cancer does not decrease postoperative chylothorax: Results from a single-center retrospective study.

PURPOSE: Reliable measures to prevent chylothorax following lobectomy are lacking. Herein a case-control study was conducted to investigate the effect of prophylactic fat-free diet on the incidence of chylothorax after thoracoscopic lobectomy and systemic lymph node dissection (SLND) for lung cancer. METHODS: Between January 2015 and December 2017, the patients with primary non-small cell lung cancer who underwent lobectomy and SLND were retrospectively reviewed. Patients in the prophylactic group started fat-free diet one week before the surgery until removal of the chest tubes after the operation; while those in the control group took normal diet unless the onset of chylothorax. Logistic regression analysis was utilized to identify the predictive factors of chylothorax following lobectomy. RESULTS: The data of 110 patients in the control group and 115 cases in the prophylactic group were collected. The patients in prophylactic group showed less intraoperative blood loss [(79.9±48.7) mL vs. (100.9±55.6) mL, p=0.003], reduced postoperative drainage volume [(504.3±268.0) mL vs. (714.1±618.5) mL, p=0.001], and shorter chest tube duration [(3.6±1.7) days vs. (4.2±2.6) days, p=0.014]; however, a similar incidence of chylothorax [3 (2.6%) vs. 7 (6.4%), p=0.207] was recorded. Multivariate logistic regression analysis indicated that neoadjuvant therapy was an independent positive factor of chylothorax (odd ratio [OR] = 9.257; 95% confidence interval [CI] 1.434-59.773, p=0.019); whereas high-volume experience of the surgeon was an independent negative factor of this complication (OR = 0.129; 95% CI 0.017-0.982, p=0.048). CONCLUSION: Prophylactic fat-free diet does not decrease the incidence of chylothorax after lobectomy. Further well-designed trials are warranted to verify this occasional finding.

Management of visceral vascular anomalies.

Visceral vascular anomalies are common in patients with vascular malformations in other parts of the body and can include lymphatic, venous, and arteriovenous malformations. Depending on the organ or organs involved they may present differently and pose different treatment challenges. Defining the malformation and understanding its extent is paramount in devising management regimens. Medical, interventional, and surgical therapies are often required in combination to treat these complex lesions. There are new and promising advances in the development of therapeutic agents targeting the PI3K/AKT/mTOR pathway. Due to the complex nature of these lesions a coordinated, multi-disciplinary approach is necessary to manage and mitigate symptoms and complications of this diverse group of vascular malformations.

Esophageal cancer surgery: review of complications and their management.

Esophagectomy, even with the progress in surgical technique and perioperative management, is a highly specialized surgery, associated with a high rate of complications. Early recognition and adequate treatment should be a standard of care for the most common postoperative complications: anastomotic leakage, pneumonia, atrial fibrillation, chylothorax, and recurrent laryngeal nerve palsy. Recent progress in endoscopy with vacuum and stent placement, or in radiology with embolization, has changed the management of these complications. The success of nonoperative treatments should be frequently reassessed and reoperation must be proposed in case of failure. We have summarized the clinical signs, diagnostic process, and management of the frequent complications after esophagectomy for esophageal cancer.

Unusual lung involvements of invasive mucinous adenocarcinoma with chylothorax.

A 77-year-old man who had a persistent productive cough for one month was admitted to our hospital. Chest computed tomography (CT) revealed subpleural nodular opacities, irregular pleural thickening with bilateral basal predominance, and a small right pleural effusion. Aspirated fluid was exudative and had the appearance of chylothorax without malignant cells. Surgical lung biopsy specimen showed focal proliferation of neoplastic epithelial cells with lepidic-predominant pattern and abundant mucus in the alveolar spaces, consistent with invasive mucinous adenocarcinoma (IMA). The results of PD-L1 expression and the EGFR, ALK, ROS1, and BRAF mutation status analyzed by next generation sequencer were all negative. IMA should be considered in the differential diagnosis of subpleural micronodular opacities accompanied by pleural effusion (chylothorax) on chest CT. KEY POINTS: Significant findings of the study This case showed subpleural micronodular opacities and chylothorax as unusual chest computed tomography (CT) patterns for invasive mucinous adenocarcinoma (IMA). What this study adds Invasive mucinous adenocarcinoma (IMA) should be considered in the differential diagnosis of subpleural micronodular opacities accompanied by pleural effusion on chest CT.

Hydrothorax in fetal cases of Opitz G/BBB diagnosis: Extending the phenotype?

We report two fetal cases carrying a de novo MID1 mutation and presenting with severe hydrothorax, suggesting the expansion of the phenotype of Opitz GBBB syndrome.

Computed tomographic lymphangiography via intra-metatarsal pad injection is feasible in dogs with chylothorax.

Lymphangiography can be useful for preoperative planning in chylothorax. Conventional ultrasound-guided intranodal injection can be difficult in some cases and is dependent upon operator skill. Alternative methods have been proposed to simplify the procedure, but their feasibility has not been sufficiently evaluated in clinical cases. The primary purpose of this multicenter, retrospective, descriptive study was to assess the feasibility and describe the clinical findings of CT lymphangiography by intrametatarsal pad injection in dogs with naturally occurring chylothorax. Twenty dogs were analyzed, and enhancement of thoracic ducts (TDs) was successful in 18 (90%) dogs within 5-14 min after initiating the injection, while successful enhancement of the lymphatic vessels cranial to the popliteal lymph nodes was seen in all dogs within 5 min after injection. The dose with good success to achieve TD enhancement was 1 mL/kg (concentration 350 mg I/kg). Only two dogs had mild discomfort after recovery from general anesthesia. Computed tomography lymphangiography by intrametatarsal pad injection is a feasible, easy, and safe procedure, which could provide adequate TD and cisterna chyli enhancement, identify TD number and cisterna chyli location and structure, and contribute to surgical planning.

Dasatinib-induced Chylothorax in Chronic Myelogenous Leukemia in Pediatric Patient: Report of a Case and Review of Literature.

Dasatinib is a second-generation potent and efficacious oral tyrosine kinase inhibitor frequently used for imatinib-resistant or intolerant BCR-ABL-positive chronic myeloid leukemia and for Philadelphia chromosome-positive acute lymphocytic leukemia. Dasatinib is known to cause adverse pulmonary events such as chylothorax and has been described in the adult literature but not pediatric literature. The authors present a pediatric case of dasatinib-related chylothorax, subsequent management, and a review of the literature of adult cases with dasatinib-related chylothorax.

A Child with Early-Onset Gorham-Stout Disease Complicated by Chylothorax: Near-Complete Regression of Bone Lesions with Interferon and Bisphosphonate Treatment.

We report a case of Gorham-Stout disease (GSD) complicated by chylothorax and treated with a combination therapy with interferon and bisphosphonates. This treatment may be helpful in improving the usually unfavorable prognosis of GSD beginning with a chylothorax before 1 year of age, and in reducing bone lesions. Moreover, the use of bisphosphonates appears to be useful in treating pain.

Is there any role for thoracoscopy in the diagnosis of benign pleural effusions.

Thoracoscopy in the endoscopy suite, has a high diagnostic yield of undiagnosed pleural effusions with minimal and mild complications. Whereas relatively minimal invasive techniques, such as thoracentesis, image-guided pleural biopsy or blind pleural biopsy, can yield sufficient cell or tissue material to establish the diagnosis of the underlying condition, more definite invasive diagnostic and therapeutic procedure, such as thoracoscopy, may be required for accurate sampling and diagnosis, and further provide real-time treatment options in same procedure. If thoracoscopy is considered the gold standard for the diagnosis is a fact in case. The current review aims to provide informations on thoracoscopy indications in benign pleural diseases according to up to date publications.

Primary versus trauma-induced Gorham-Stout disease.

Gorham-Stout disease - also known as "disappearing bone disease" is currently considered a single entity with varying clinical manifestations. We reviewed the existent literature from the earliest historic description(Jackson in 1838) and Gorham and Stout's original series of patients, multiple case reports and series since. After analyzing 212 reported cases, we identified 76 cases with details that recorded either a history of multifocal disease or an identifiable history of preceding trauma. From this review, we have defined two distinct Gorham-Stout entities - those characteristically associated with lymphangiomatosis [a form of GLA (generalized lymphangiomatosis) questionably distinguishable by bone biopsy and radiologic appearance] with multifocal distributed bone lesions, and those others, usually self-limited, first appearing after a traumatic event and always confined to a single bone or closely adjacent one. Multifocal disease is more likely to have chylothorax as a complication. These two Gorham-Stout entities differ in their demographic distribution, clinical history and manifestations, and they follow divergent clinical courses. The prognosis differs, and so should approaches to monitoring as well as acute and long-term treatment. Further research should seek to identify and define the differences in pathology and molecular mechanisms.

Pseudochylothorax: An unusual mode of revelation of pleural metastasis from solid tumor.

INTRODUCTION: Pseudochylothorax is a rare cause of pleural effusion. Sometimes confounded with chylothorax, firm diagnosis relies on analysis of the pleural liquid: exudative liquid (protein >30 g/L, lactate dehydrogenase >200 UI/L) with a high level of cholesterol (usually >200 mg/dL), low level of triglyceride (usually <110 mg/dL), cholesterol total/triglyceride ratio >1, absence of chylomicron, and in some cases the presence of cholesterol crystals. Pseudochylothorax is secondary to tuberculosis and rheumatoid arthritis in nearly 90% of cases. Its oncologic etiologies are mainly represented by malignant hematologic disorders. METHODS: We report the first case of pseudochylothorax whose cause was the pleural metastasis of an extrathoracic solid tumor in a 61-year-old man with a medical history of oropharynx carcinoma. RESULTS: Computed tomography scan disclosed a left partitioned effusion of high abundance, responsible for a passive atelectasis of the left lower lobe and multiple bilateral pulmonary nodules. A drainage tube was inserted to allow the evacuation of serous liquid; biochemical examination revealed an exudative effusion with pseudochylothorax criteria. Because the daily chest drainage output remained greater than 1 L per day, videothoracoscopy pleural biopsies and talc pleurodesis were performed. Histopathologic examination of the pleural biopsies found a pleural localization of oropharynx carcinoma. CONCLUSION: Because its occurrence is probably underestimated, when pseudochylothorax is diagnosed, oncologic causes should be considered.

Risk Factors for Postoperative Chylothorax After Radical Subtotal Esophagectomy.

BACKGROUND: Chylothorax is one of the complications of esophagectomy for esophageal cancer. The treatment of this condition has been well discussed, but the risk factors for postoperative chylothorax remain unclear. METHODS: A retrospective review of 294 patients who underwent esophagectomy for esophageal cancer was conducted. These were patients with squamous cell carcinoma or adenocarcinoma of the esophagus including Siewert type I tumor of the esophagogastric junction who underwent subtotal esophagectomy with two-field or three-field lymphadenectomy. Of these, 24 patients who were diagnosed with chylothorax as a postoperative complication were allocated to the chylothorax group and the other 270 patients were allocated to the nonchylothorax group. RESULTS: Univariate analysis showed a significant difference in three factors: resection of thoracic duct, post-chemoradiotherapy, and high intraoperative fluid balance. Multivariate analysis revealed that post-chemoradiotherapy [hazard ratio (HR) = 3.430; 95% confidence interval (CI) 1.364-8.625] and high intraoperative fluid balance (HR = 1.569; 95% CI 1.2.7-2.039) were independent factors predicting chylothorax. In addition, resection of the thoracic duct may be a predictor of chylothorax after esophagectomy (HR = 3.389; 95% CI 0.941-12.201, p = 0.062). Receiver operating characteristic curve analysis of intraoperative fluid revealed that the sensitivity was 62.5%, specificity was 74.1%, and the cutoff value was 6.55 mL/kg/h. CONCLUSIONS: This study revealed that post-chemoradiotherapy and high intraoperative fluid balance are predictors of chylothorax after esophagectomy. The elucidation of clinicopathological factors that can predict the incidence of chylothorax will help to establish more effective perioperative management for esophageal cancer patients.

The anatomy of the thoracic duct at the level of the diaphragm: A cadaver study.

BACKGROUND: Injury and subsequent leakage of unrecognized thoracic duct tributaries during transthoracic esophagectomy may lead to chylothorax. Therefore, we hypothesized that thoracic duct anatomy at the diaphragm is more complex than currently recognized and aimed to provide a detailed description of the anatomy of the thoracic duct at the diaphragm. BASIC PROCEDURES: The thoracic duct and its tributaries were dissected in 7 (2 male and 5 female) embalmed human cadavers. The level of origin of the thoracic duct and the points where tributaries entered the thoracic duct were measured using landmarks easily identified during surgery: the aortic and esophageal hiatus and the arch of the azygos vein. MAIN FINDINGS: The thoracic duct was formed in the thoracic cavity by the union of multiple abdominal tributaries in 6 cadavers. In 3 cadavers partially duplicated systems were present that communicated with interductal branches. The thoracic duct was formed by a median of 3 (IQR: 3-5) abdominal tributaries merging 8.3cm (IQR: 7.3-9.3cm) above the aortic hiatus, 1.8cm (IQR: -0.4 to 2.4cm) above the esophageal hiatus, and 12.3cm (IQR: 14.0 to -11.0cm) below the arch of the azygos vein. CONCLUSION: This study challenges the paradigm that abdominal lymphatics join in the abdomen to pass the diaphragm as a single thoracic duct. In this study, this occurred in 1/7 cadavers. Although small, the results of this series suggest that the formation of the thoracic duct above the diaphragm is more common than previously thought. This knowledge may be vital to prevent and treat post-operative chyle leakage.

Rare case of massive bilateral chylothorax.

We present a case of a 48-year-old woman who was referred from an outside hospital. There, she had initially underwent hysterectomy and left salpingo-oophorectomy for tubo-ovarian abscess. She later developed a colovaginal fistula and perforation of sigmoid colon and underwent Hartmann's procedure along with drainage of a left subphrenic abscess. Subsequently, she had to be intubated for acute respiratory failure and was transferred to our hospital. At our hospital, she was found to have massive bilateral pleural effusions. Bilateral small-bore chest tubes were inserted that drained milky fluid. Pleural fluid analysis was consistent with bilateral chylothorax. Thereafter, patient's respiratory status improved and she was extubated. The mechanism of chylothorax was thought be either secondary to the multiple abdominal procedures or alternatively as a complication of the right subclavian catheter that was placed at the outside hospital. Her chest tubes were removed eventually, and she had a slow but definite recovery.