Treatment Of Post-Operative Chylothorax: The Role Of Intranodal Lymphangiography And Thoracic Duct Disruption.

Thoracic duct embolization has been increasingly adopted as a first-line therapy of chylothorax and this procedure includes lipiodol lymphangiography, thoracic duct access and embolization. Lymphangiography itself has a therapeutic role, with volume-dependent success rates of 37%-97% and even a reported 100% success rate in outputs of < 500 mL/day. We present a clinical case of a 48-years-old man diagnosed with esophageal squamous cell carcinoma, who underwent esophagectomy and presented with post-operative high-output (> 1L/day) chylothorax; thoracic duct embolization was proposed. Even though thoracic duct access and embolization were not achieved due to technical and anatomical factors, lipiodol lymphangiography and possibly thoracic duct maceration (after several punctures/attempts) contributed to the clinical success of the procedure, and this chylothorax with output values superior to those reported in the literature resolved within three days. As such, the therapeutic role of intranodal lymphangiography and thoracic duct disruption should be taken into account.

Lymphangiogenesis after nonvascularized lymph node transplantation: Lymphangiographic findings in mice and minipigs.

The establishment of new connections after NVLNT (non-vascularized lymph node transplantation) is still poorly understood. The purpose of this study was to investigate lymphatic connections after NVLNT using lymphangiography. In a mice model, 40 mice were allocated to undergo NVLNT or sham surgery. On day 21 after NVLNT, the lymphatic vessels were observed on near-infrared fluorescence imaging with indocyanine green. In a minipig model, 12 minipigs underwent NVLNT. On day 14 after NVLNT, the transplanted lymph node and donor site were checked by ultrasound, and minipigs with viable transplanted LNs were allocated to lipiodol lymphangiography or MR lymphangiography groups. Transplanted LN engraftment was examined with immunohistochemical staining. After NVLNT in mice, the signal intensities in the popliteal region at 3 minutes and 5 minutes were higher in the transplanted side than the control side (21.3 ± 8.1 vs. 11.0 ± 4.6 at 3 minutes, 26.7 ± 6.8 vs. 19.7 ± 5.9 at 5 minutes), while in the sham group, there were no significant differences between sides. In minipigs, lipiodol lymphangiography (n = 5) showed Lipiodol accumulation in transplanted LNs with innumerable newly formed lymphatic vessels and lymphovenous shunts. MR lymphangiography (n = 5) showed higher enhancement on the transplanted side compared to the control side. Histology showed successful engraftment of transplanted LNs in 16 out of 20 (80%) mice and 9 out of 12 (75%) minipigs. Omnidirectional lymphangiogenesis forming a dense lymphatic network and spontaneous formation of lymphovenous shunts were shown after NVLNT.

Inguinal intranodal lymphangiography reveals a high incidence of suprainguinal lymphatic disease in patients with leg edema undergoing stenting for symptomatic chronic iliofemoral venous obstruction.

OBJECTIVE: Recent studies have emphasized the important role lymphatics play in the drainage of interstitial fluid and edema prevention. Although the infrainguinal lymphatics have been studied in some depth, with patterns of pathology identified, such data above the groin are sparse, especially for patients with phlebolymphedema. The present study attempts to evaluate the status of lymphatic flow above the inguinal ligament in patients presenting with edema and undergoing stenting for symptomatic chronic iliofemoral venous obstruction (CIVO). METHODS: A total of 31 lower limbs that underwent pedal lymphoscintigraphy for leg edema and subsequent stenting for symptomatic CIVO formed the study cohort. Each limb underwent intranodal lymphangiography of an ipsilateral inferior inguinal lymph node (10 mL of lipiodol) at the time of stenting. Fluoroscopic visualization of lipiodol transit was performed at 20, 40, and 60 minutes and 3 hours after injection. Enumeration of the lymph nodes and lymphatic collector vessels from above the inguinal ligament to L1, visualization of the thoracic duct, the time delay to visualization of the thoracic duct, and pathologic changes to the thoracic duct when present were all evaluated. These anomalies were independently scored, with the scores combined to generate a total suprainguinal score (range, 0-3). This score was then compared to the limb's lymphoscintigraphically derived infrainguinal score (total infrainguinal score range, 0-3) using the t test and Spearman correlation. The clinical outcomes (grade of swelling, venous clinical severity score) after stenting were appraised. RESULTS: Of the 30 patients (31 limbs), 18 were women, with left laterality noted in 23 limbs. A nonthrombotic iliac vein lesion occurred in 9 limbs and post-thrombotic syndrome in 22 limbs. Of the 31 limbs, 24 (77%) had suprainguinal lymphatic disease (SLD), with 22 of the 24 limbs having severe SLD and 2, mild SLD. When SLD was compared with infrainguinal lymphatic disease, 6 limbs (19%) had the same degree of involvement above and below the groin (1 with normal and 5 with severe disease), 17 limbs (55%) had more severe SLD, and 8 limbs (26%) had more severe infrainguinal lymphatic disease. Three limbs with normal pedal lymphoscintigraphic findings had severe SLD. The Spearman correlation coefficient for the comparison of SLD and infrainguinal disease in the same limb was 0.1 (P = .69). At baseline, the limbs with severe SLD had the same degree of leg swelling and venous clinical severity score as the limbs with absent to mild SLD (P > .1) with similar improvements after stenting (P > .4). Seven limbs underwent complex decongestive therapy (all with severe SLD and concomitant severe infrainguinal disease in one) to treat significant residual leg edema, with improvement. CONCLUSIONS: SLD appears to be common in patients with leg edema undergoing stenting for symptomatic CIVO. Such disease appears to affect the thoracic duct more commonly. Although patients with persistent or residual leg edema after stenting can benefit from complex decongestive therapy, further workup in the form of inguinal intranodal lymphangiography and targeted intervention might need to be considered for those who do not benefit from such therapy. Further study is warranted.

Therapeutic lymphangiography with ethiodized oil for the management of lymphoceles and chylous ascites.

PURPOSE: The purpose of this study was to analyze the safety, technical success and clinical outcome of percutaneous intranodal ethiodized oil (Lipiodol®) based lymphangiography (L-LAG) for the management of refractory pelvic lymphoceles or chylous ascites using high doses of ethiodized oil. MATERIALS AND METHODS: Thirty-four patients presenting with symptomatic, refractory postoperative pelvic lymphocele or chylous ascites referred for theranostic, inguinal, intranodal L-LAG treatment between May 2018 and November 2021 were retrospectively included. There were 21 men and 13 women, with a mean age of 62.7 ± 16.2 (standard deviation) years (age range: 9-86 years), who underwent a total of 49 L-LAG for the management of lymphoceles (n = 14), chylous ascites (n = 18) or a combination of lymphocele and chylous ascites (n = 2). Clinical and radiological pre-interventional, procedural and follow-up data up to January 2022 were collected from patients' electronic medical records and imaging files. RESULTS: Technical success was obtained in 48 out of 49 L-LAG (98%). No complications related to L-LAG were noted. After one or more L-LAG, clinical success was obtained in 30 patients (88%) with a mean of 1.4 interventions per patient and mean intranodal injected volume of 29 mL of ethiodized oil per session. The remaining four patients (12%), with one or more failed L-LAG, underwent additional surgical intervention to definitively treat the postoperative lymphatic leakage. CONCLUSION: L-LAG using high doses of ethiodized oil is a minimally invasive, safe and effective treatment of postoperative pelvic lymphocele or chylous ascites. Multiple sessions may be needed to obtain a meaningful clinical result.

Intranodal Lymphangiography and Embolization for the Treatment of Early Postoperative Lymphatic Leaks after Pelvic Surgery.

PURPOSE: To assess outcome and predictors of outcome after lymphatic embolization (LE) for early postoperative lymphatic leak after pelvic surgery. MATERIAL AND METHODS: Lymphangiography (LG) procedures performed between May 2015 and February 2020 for postoperative intraperitoneal lymphatic leaks after pelvic surgery were reviewed. Treatment indication was lymphatic drainage of >500 mL/d persisting for >1 week. LE was performed by injecting glue into the iliac lymph node. Fisher exact and Wilcoxon rank-sum tests were used for comparative analysis, and logistic regression was used to assess predictors of outcome. RESULTS: LG was performed in 71 patients. A leak was demonstrated in 69 patients who underwent LE. The mean drainage was 1,329 mL/d ± 773. Catheters were removed in 49 (69.0%) patients after 1 procedure and in 69 (97.2%) patients after a mean of 1.3 procedures. The mean drainage at the time of catheter removal was 157 mL/d ± 100. Failure occurred in 12 (16.9%) cases, including 2 (2.8%) cases of unsuccessful catheter removal and 10 (14.1%) cases of catheter reinsertion owing to recurrent ascites (n = 3) and lymphoceles (n = 7). Older age and drainage of >1,500 mL/d were associated with failure (P = .004). Drainage of >1,500 mL/d was associated with a post-LE catheter dwell time of longer than 1 week (P = .024). Minor adverse events were noted in 4 (5.6%) patients who presented with transient leg swelling. CONCLUSIONS: LE was effective for treating pelvic surgery-related lymphatic leaks. Reintervention may be required. Drainage of >1,500 mL/d was associated with clinical failure and a post-LE catheter dwell time of longer than 1 week.

Invasive treatment of persistent postoperative chylothorax secondary to thoracic duct variation injury: Two case reports and literature review.

RATIONALE: Postoperative chylothorax is a rare complication after pulmonary resection. Thoracic duct variations may play a key role in postoperative chylothorax occurrence and make treatment difficult. No studies in the literature have reported the successful treatment of chylothorax second to thoracic duct variation by lipiodol-based lymphangiography. PATIENT CONCERNS: A 63-year-old male and a 28-year-old female with primary lung adenocarcinoma were treated by video-assisted thoracoscopic cancer resection, and suffered postoperative chylothorax. Conservative treatment was ineffective, including nil per os, persistent thoracic drainage, fatty food restriction, and somatostatin administration. DIAGNOSIS: Postoperative chylothorax. INTERVENTIONS: Patients received lipiodol-based lymphangiography under fluoroscopic guidance. Iatrogenic injuries were identified at thoracic duct variations, including an additional channel in case 1 and the lymphatic plexus instead of the thoracic duct in case 2. OUTCOMES: Thoracic duct variations were identified by lipiodol-based lymphangiography, and postoperative chylothorax was successfully treated by lipiodol embolizing effect. LESSONS: Thoracic duct variations should be considered after the failure of conservative treatment for postoperative chylothorax secondary to pulmonary resection. Lipiodol-based lymphangiography is valuable for identifying the thoracic duct variations and embolizing chylous leakage.

Thoracic Duct Lymphangiography via the Testicular Parenchyma in a Rabbit Model.

This study aimed to establish an animal model for thoracic duct lymphangiography using ethiodized oil. Thoracic duct lymphangiography was performed via the testes in 21 Japanese white rabbits. The testicular parenchyma was punctured by palpation using a 30-gauge, 0.5-inch needle. Ethiodized oil was injected at a rate of 11.41 mL/h until the testicular efferent lymphatic vessels were delineated and then at a rate of 2.85 mL/h until the entire thoracic duct was delineated. Thoracic duct delineation was 100% successful and showed good depiction based on visual scores. The mean ethiodized oil dose administered was 4.59 mL ± 1.41, and the mean time to visualize the entire thoracic duct was 43.7 minutes ± 14.1. The presented model may serve as a method for future preclinical investigation of the thoracic duct anatomy and for thoracic duct interventions.

Intranodal lipiodol injection for the treatment of chyle leak in children - a preliminary experience.

OBJECTIVE: To assess the effectiveness of intranodal lymphangiography using ethiodised oil (Lipiodol; Guerbet Japan, Tokyo, Japan) for the treatment of refractory cases of chylothorax and chylous ascites in the paediatric population. METHODS: Between 2016 and 2020, eight children having chyle leak resistant to conservative management underwent intranodal lymphangiography using lipiodol injection. After ethical approval by the Institutional Review Board, these patients' data were retrospectively analysed. Technical success was defined by opacification of inguinal and retroperitoneal lymphatics while injection on fluoroscopy. Clinical success was defined as progressively decreasing drain output and eventual cessation of output within a week after the procedure. Long-term follow up was done as feasible. RESULTS: Technical success was achieved in all the patients. Complete cessation of drain output was noted within 1 week of procedure in all patients indicating clinical success. One patient had recurrence of chylous leakage after an interval of 1 month and intranodal lymphangiography was repeated for that patient. The child had technical as well as clinical success after the repeat procedure. Hence a total of 9 procedures were performed in 8 patients. CONCLUSION: Intranodal lymphangiography may prove to be a valuable minimally invasive therapeutic tool in cases of refractory chylous leakage in paediatric patients with minimal risk of complications. ADVANCES IN KNOWLEDGE: Intranodal lymphangiography using lipiodol may prove to be a minimally invasive alternative in paediatric patients with refractory lymphatic leaks.

Treatment of Postoperative Lymphatic Leakage Applying Transpedal Lymphangiography - Experience in 355 Consecutive Patients.

PURPOSE: Report of experience from a single institution in treating postoperative lymphatic leakage (PLL) applying conventional transpedal lymphangiography (TL). MATERIALS AND METHODS: 453 patients with the initial diagnosis of PLL receiving TL between 03/1993 and 09/2018 were identified in the database. Only patients with confirmed PLL were included in the study. The technical success, safety, and treatment success of TL were evaluated. Independent predictors of TL treatment failure were examined using univariate and multivariate logistic regression analysis. RESULTS: 355 consecutive patients (218 men, 137 women; median age of 62 years) who underwent TL for PLL (e. g., chylothorax) after ineffective conservative treatment were included. The median time between causal surgery and TL was 27 days. The median technical success rate of TL was 88.5 %, with a median volume of Lipiodol of 10.0 ml. No complication of TL was recorded. Three groups were defined according to the different clinical courses: group A (41/355, 11.5 %) - TL with technical failure; group B (258/355, 72.7 %) - "therapeutic" TL alone with technical success; and group C (56/355, 15.8 %) - "diagnostic" TL with simultaneously invasive treatment (incl. surgical revision and percutaneous sclerotherapy). Treatment success rate and median time to treatment success were higher in group C than in group B, but without significant differences (64.3 % vs. 61.6 %, p = 0.710; six vs. five days, p = 0.065). Univariate and multivariate logistic regression analyses for group B confirmed drainage volume (> 500 ml/d) and Lipiodol extravasation as independent predictors of TL clinical failure (odds ratios [ORs] of 2.128 and 2.372 [p = 0.005 and p = 0.003, respectively]). CONCLUSION: TL is technically reliable, safe, and effective in treating PLL. When conservative treatment fails, TL can be regarded as the next treatment option. KEY POINTS: · TL is technically reliable, safe, and effective for treating PLL.. · When conservative treatment fails, TL can be regarded as the next treatment option.. · Drainage volume > 500 ml/day is an independent predictor of clinical failure after TL.. · Lipiodol extravasation is an independent predictor of clinical failure after TL.. CITATION FORMAT: · Pan F, Richter GM, Do TD et al. Treatment of Postoperative Lymphatic Leakage Applying Transpedal Lymphangiography - Experience in 355 Consecutive Patients. Fortschr Röntgenstr 2022; 194: 634 - 643.

Lymphatic-venous anastomosis for the treatment of refractory lymphatic ascites following radiation therapy: A case report.

Radical treatments for intra-abdominal malignancies disturb physiological lymphatic drainage and predispose the patients to lymphatic complications such as lymphatic ascites. Despite its infrequent occurrence, lymphatic ascites is a morbid complication, and a definitive treatment protocol for refractory cases has not been established. Surgical treatments are opted depending on the etiology, symptoms, and facility equipment. Lymphatic-venous anastomosis (LVA) bypasses the proximal lymphatic blockages and provides an alternative route for lymphatic fluid recirculation into the venous system, thereby improving the lymphatic congestion. Herein, we report the utility of LVA surgery in the treatment of refractory serous lymphatic ascites that developed after radiation therapy for cervical cancer in a 77-year-old woman. The patient had massive ascites and suffered from abdominal distention and anorexia for 1 year. The ascites was unresponsive to conservative treatment. Under local anesthesia, eight incisions were made in the lower extremities just above the lymphatic channels that were identified by indocyanine green lymphography, and a total of 14 LVAs were created. The postoperative course was uneventful, and the ascites improved significantly. The patient remained free from the recurrence of ascites during 3.5 years of postoperative follow-up. LVA surgery was effective for the improvement and long-term control of lymphatic ascites. This procedure may be a viable option for the management of lymphatic ascites.

Cerebral lipiodol embolisation.

Cerebral lipiodol embolisation is a rare but serious complication of lymphangiography. A man in his seventies had undergone lymphangiography for a refractory chyle leak following oesophagectomy. The day after lymphangiography, his conscious level dropped with bilaterally miotic pupils, increased muscle tone and double incontinence. CT scan of the head showed patchy high density throughout basal ganglia, cortex and cerebellum but no infarct, in keeping with lipiodol embolisation. He was managed initially in intensive care and subsequently underwent thoracoscopy with clipping and suturing of the left thoracic duct, and later a talc pleurodesis. At 3 months, he had some cognitive limitations and was walking with a stick.

[A case of acute chylous peritonitis treated with ultrasound-guided intranodal lymphangiography].

An 80-year-old woman presented with acute abdominal pain and distention. A diagnosis of acute chylous peritonitis was made via contrast-enhanced computed tomography and abdominal paracentesis. She underwent ultrasound-guided intranodal lymphangiography with Lipiodol® (IL with Lipiodol), and her persistent abdominal pain was significantly reduced within a day. Moreover, her ascitic fluid showed marked improvement and paracentesis was no longer needed. Based on the findings of the study, IL with Lipiodol could be a promising minimally invasive approach in the treatment of acute chylous peritonitis.

[Diffuse large B-cell lymphoma with markedly improved chylothorax by lymphangiography].

Chylothorax is a rare clinical sign in patients with diffuse large B-cell lymphoma (DLBCL), which is often challenging to manage and has a poor prognosis. We report the case of a 59-year-old woman who presented with right pleural effusion at the time of DLBCL diagnosis. Lymphadenopathy rapidly improved in response to chemotherapy. However, the pleural effusion progressed and was identified as chylothorax by thoracentesis. Because attempts to manage the condition with fasting and central venous nutrition were unsuccessful, we performed ultrasound-guided intranodal lipiodol lymphangiography from the inguinal lymph node. Although leak sites were not detected, the pleural effusion markedly improved on the day after the examination and resolved after 2 months. Lymphangiography is a minimally invasive examination with few complications. It contributes not only to the identification of leak sites but also to the improvement and resolution of chylothorax. Therefore, lymphangiography should be considered for refractory chylothorax that is unresponsive to chemotherapy or nutritional management.

Lipiodol lymphangiography as a treatment for refractory postoperative chylothorax: a case report.

Postoperative chylothorax is the most frequent cause of traumatic thoracic chyle leakage. Conservative treatment is primarily used to treat low flow rate chylothoraces and should be initiated as soon as the diagnosis has been made. In case of high flow rate chylothorax or failure of initial treatment, surgery and radiological treatment are indicated. Despite this fact, there is a lack of consensus regarding the best therapeutic option to choose. In the case reported herein, a postoperative chylothorax with a low flow chyle leakage which didn't respond to conservative treatment is demonstrated. We used lipiodol lymphangiography to determine the site of chyle leakage and to successfully treat our patient. Risk factors for non-response to conservative treatment are also discussed.

Intranodal Lymphangiography With High-Dose Ethiodized Oil Shows Efficient Results in Patients With Refractory, High-Output Postsurgical Chylothorax: A Retrospective Study.

OBJECTIVE. The purpose of this study is to evaluate the safety and efficacy of intranodal lymphangiography (INL) with high-dose ethiodized oil in patients with postoperative refractory chylothorax. MATERIALS AND METHODS. A retrospective review of a cohort of 18 patients with refractory postoperative chylothorax seen between May 2015 and March 2019 was conducted. All patients underwent intranodal lymphangiography with high doses of ethiodized oil (mean, 75 mL; range, 40-140 mL). The following information was gathered from the institutional database: patient demographics, type of surgery, output volumes, interval between surgery and lymphangiography, imaging results, amount of ethiodized oil injected, clinical success, and time to resolution. RESULTS. Of the 18 patients, 11 (61%) had previously undergone thoracic duct ligation, and seven (39%) had not. A lymphatic leak was confirmed by lymphangiography in 12 of 18 patients (67%). A total of five patients underwent a second session of INL, which was successful in three of the patients (60%). Removal of all chest tubes was possible in 15 of 18 patients (83%) after a mean of 12 days (range, 1-25 days). Two patients had an anastomotic leak develop after esophagectomy and died with their chest tubes in situ. One patient underwent thoracic duct ligation after two failed INL procedures. No complications were recorded. CONCLUSION. INL with a high dose of injected ethiodized oil is a safe and effective procedure for the management of postsurgical refractory chylothorax, with chest tube removal in 83% of patients.

Radiological management of postoperative lymphorrhea.

PURPOSE: Postoperative lymphorrhea can occur after different surgical procedures and may prolong the hospital stay due to the need for specific treatment. In this work, the therapeutic significance of the radiological management of postoperative lymphorrhea was assessed and illustrated. METHOD: A standardized search of the literature was performed in PubMed applying the Medical Subject Headings (MeSH) term "lymphangiography." For the review, the inclusion criterion was "studies with original data on Lipiodol-based Conventional Lymphangiography (CL) with subsequent Percutaneous Lymphatic Intervention (PLI)." Different exclusion criteria were defined (e.g., studies with <15 patients). The collected data comprised of clinical background and indications, procedural aspects and types of PLI, and outcomes. In the form of a pictorial essay, each author illustrated a clinical case with CL and/or PLI. RESULTS: Seven studies (corresponding to evidence level 4 [Oxford Centre for Evidence-Based Medicine]) accounting for 196 patients were included in the synthesis and analysis of data. Preceding surgery resulting in postoperative lymphorrhea included different surgical procedures such as extended oncologic surgery or vascular surgery. Central (e.g., chylothorax) and peripheral (e.g., lymphocele) types of postoperative lymphorrhea with a drainage volume of 100-4000 ml/day underwent CL with subsequent PLI. The intervals between "preceding surgery and CL" and between "CL and PLI" were 2-330 days and 0-5 days, respectively. CL was performed before PLI to visualize the lymphatic pathology (e.g., leakage point or inflow lymph ducts), applying fluoroscopy, radiography, and/or computed tomography (CT). In total, seven different types of PLI were identified: (1) thoracic duct (or thoracic inflow lymph duct) embolization, (2) thoracic duct (or thoracic inflow lymph duct) maceration, (3) leakage point direct embolization, (4) inflow lymph node interstitial embolization, (5) inflow lymph duct (other than thoracic) embolization, (6) inflow lymph duct (other than thoracic) maceration, and (7) transvenous retrograde lymph duct embolization. CL-associated and PLI-associated technical success rates were 97-100% and 89-100%, respectively. The clinical success rate of CL and PLI was 73-95%. CL-associated and PLI-associated major complication rates were 0-3% and 0-5%, respectively. The combined CL- and PLI-associated 30-day mortality rate was 0%, and the overall mortality rate was 3% (corresponding to six patients). In the pictorial essay, the spectrum of CL and/or PLI was illustrated. CONCLUSION: The radiological management of postoperative lymphorrhea is feasible, safe, and effective. Standardized radiological treatments embedded in an interdisciplinary concept are a step towards improving outcomes.