Conventional Lymphangiography (CL) in the Management of Postoperative Lymphatic Leakage (PLL): A Systematic Review.

BACKGROUND: Postoperative lymphatic leakage (PLL) is usually managed by conservative and/or surgical treatments but these procedures can be challenging to perform and potentially clinically ineffective. Therefore, conventional lymphangiography (CL) has emerged as an important alternative. The aim of this review is to present the available outcome data on CL in the management of PLL. METHOD: A systematic literature search (PubMed) using the MeSH term "lymphangiography" was performed and the search was restricted to literature published between January 2007 and August 2019. Identification, screening, and assessment for eligibility and inclusion were conducted in accordance with PRISMA. RESULTS: From the initially obtained 1006 articles (identification), 28 articles with a total of 201 patients were finally included (inclusion). The methodological quality of all included articles corresponds to level 4 (Oxford Centre for Evidence-based Medicine - Levels of Evidence, March 2009). PLL occurs after oncological and non-oncological surgery in the form of chylothorax, chylous ascites, and cervical, thoracic, abdominal and peripheral lymph fistula and/or lymphocele. The technical success rate of CL is 75-100 %. Access for CL is transpedal (176 patients) or intranodal (25 patients). Lipiodol is used as the contrast material in all articles, with a maximum amount of 20 ml for transpedal CL and 30 ml for intranodal CL. The X-ray imaging modalities used for CL are fluoroscopy, radiography and/or CT. Two articles report CL-associated major complications and CL-associated morbidity and mortality. The PLL cure rate is 51-70 % for transpedal CL (time to PLL cure: 2-29 days) and 33-100 % for intranodal CL (time to PLL cure: 2-< 30 days). Bailout procedures in the case of clinically ineffective CL include a range of treatments. CONCLUSION: CL is feasible, safe, and effective in the management of PLL. Lipiodol as the contrast material is essential in CL because the highly viscous iodinated poppy-seed oil has not only diagnostic but therapeutic effects. Guidelines and randomized controlled trials are further steps towards defining the ultimate value of CL. KEY POINTS: · PLL is a difficult-to-treat and potentially life-threatening surgical complication.. · CL has emerged as an alternative to conservative/surgical treatment of PLL.. · CL is feasible, safe, and effective in the management of PLL. · Lipiodol-based CL can be regarded as a therapeutic procedure.. · Guidelines and randomized controlled trials are further important steps.. CITATION FORMAT: · Sommer CM, Pieper CC, Itkin M et al. Conventional Lymphangiography (CL) in the Management of Postoperative Lymphatic Leakage (PLL): A Systematic Review. Fortschr Röntgenstr 2020; 192: 1025 - 1035.

Back to the Future: Lipiodol in Lymphography-From Diagnostics to Theranostics.

Lipiodol is an iodinated poppy seed oil first synthesized in 1901. Originally developed for therapeutic purposes, it has mainly become a diagnostic contrast medium since the 1920s. At the end of the 20th century, Lipiodol underwent a transition back to a therapeutic agent, as exemplified by its increasing use in lymphangiography and lymphatic interventions. Nowadays, indications for lymphangiography include chylothorax, chylous ascites, chyluria, and peripheral lymphatic fistula or lymphoceles. In these indications, Lipiodol alone has a therapeutic effect with clinical success in 51% to 100% of cases. The 2 main access sites to the lymphatic system for lymphangiography are cannulation of lymphatic vessels in the foot (transpedal) and direct puncture of (mainly inguinal) lymph nodes (transnodal). In case of failure of lymphangiography alone to occlude the leaking lymphatic vessel as well as in indications such as protein-losing enteropathy, postoperative hepatic lymphorrhea, or plastic bronchitis, lymphatic vessels can also be embolized directly by injecting a mixture of Lipiodol and surgical glues (most commonly in thoracic duct embolization). The aim of this article is to review the historical role of Lipiodol and the evolution of its clinical application in lymphangiography over time until the current state-of-the-art lymphatic imaging techniques and interventions.

Nontraumatic Chylothorax: Diagnostic Algorithm and Treatment Options.

Nontraumatic chylothorax is a relatively rare condition in which the intestinal lymph (chyle) leaks into the pleural cavity. Nontraumatic chylothorax is more difficult to treat than the more common traumatic chylothorax because the site of chylous leak may occur in less predictable locations. In the past, patients with nontraumatic chylothoraces were offered traditional fluoroscopically guided lymphangiography and thoracic duct embolization similar to traumatic chylothorax. However, the observation that thoracic duct embolization outcomes for nontraumatic chylothorax differed based on the imaging findings during lymphangiography has led to the development of a treatment algorithm, which incorporates noninvasive diagnostic studies, such as magnetic resonance lymphangiography. The development of this systematic approach allows better delineation of the source of the chylous leak and selection of the appropriate method of embolization. In this article, we will review the etiologies of nontraumatic chylothorax, the diagnostic work-up for managing this condition, and the treatment algorithm to care for these patients.

Feasibility of ultrasound-guided intranodal lymphangiogram for thoracic duct embolization.

PURPOSE: To show the feasibility of opacifying the thoracic duct using ultrasound-guided intranodal lymphangiogram (IL) for thoracic duct embolization (TDE). MATERIALS AND METHODS: Six patients (two women and four men, mean age, 59.2 y [range, 43-74 y]) underwent IL and TDE for chylothorax. Under ultrasound guidance, a needle was positioned in a groin lymph node, and lipiodol was injected. The thoracic duct was catheterized, and embolization was performed as indicated. Cumulative times from start of the procedure until initiation of the lymphangiogram, until identification of target lymphatic, until catheterization of the thoracic duct, and until completion of the procedure were collected. Times were compared with times of a control group of six patients (two women and four men, mean age, 66.7 y [range, 49-82 y]) who had undergone TDE using pedal lymphangiography (PL). RESULTS: The procedure of opacification, catheterization, and embolization of the thoracic duct was successful in all cases. Cumulative times (mean ± standard deviation) in the IL and PL groups from start of the procedure until (i) initial lymphangiogram were 20.5 minutes ± 8.6 and 46.5 minutes ± 22.6, (ii) identification of a target lymphatic for catheterization were 60.5 minutes ± 18.2 and 110.5 minutes ± 31.6, (iii) catheterization of the thoracic duct were 79.0 minutes ± 28.9 and 128.2 minutes ± 37.0, and (iv) completion of procedure were 125.8 minutes ± 49.0 and 152.8 minutes ± 36.4. CONCLUSIONS: IL is a feasible technique to visualize the thoracic duct for embolization. Using IL, the thoracic duct may be more quickly visualized and catheterized for TDE than with PL.