Quiste cervical del conducto torácico: reporte de un caso y revisión de la literatura / Cervical thoracic duct cyst: case report and review of the literatura

El quiste del conducto torácico en su porción cervical es una patología infrecuente con escasos casos reportados en la literatura mundial. Habitualmente, se presenta como un aumento de volumen blando e indoloro en la fosa supraclavicular izquierda, el cual puede generar sintomatología compresiva variable de las estructuras adyacentes. Presentamos el caso de una mujer de 76 años remitida a la consulta de otorrinolaringología por evidencia de una lesión quística en la fosa supraclavicular izquierda con estudio posterior concordante con quiste cervical del conducto torácico.

The cervical thoracic duct cyst is an infrequent entity, with only a few cases reported in the international literature. It usually presents as a painless swelling on the left supraclavicular fossa, that can generate symptoms due to compression of adjacent structures. We present the case of a 76-year-old women that was referred to otolaryngology due to a supraclavicular cyst, with subsequent diagnosis of cervical thoracic duct cyst.

Prophylactic thoracic duct obliteration and resection during esophagectomy: What is the impact on perioperative risks and long-term survival? A systematic review and meta-analysis.

There is no agreement whether prophylactic thoracic duct ligation (TDL), with or without resection, during esophagectomy for patients with cancer is beneficial. The effects of these procedures on postoperative complications and overall survival remain unclear. This systematic review included 16 articles. TDL did not influence short- and long-term outcomes. However, thoracic duct resection increased postoperative chylothorax and overall complications, with no improvement in survival.

Lymphovenous Anastomosis for the Treatment of Chylothorax in Infants: A Novel Microsurgical Approach to a Devastating Problem.

With the expanding horizon of microsurgical techniques, novel treatment strategies for lymphatic abnormalities are increasingly reported. Described in this article is the first reported use of lymphovenous anastomosis surgery to manage recalcitrant chylothoraces in infants. Chylothorax is an increasingly common postoperative complication after pediatric cardiac surgery, with a reported incidence of up to 9.2 percent in infants. Although conservative nutritional therapy has a reported 70 percent success rate in this patient population, failed conservative management leading to persistent chylothorax is associated with a significant risk of multisystem complications and mortality. Once conservative medical strategies are deemed unsuccessful, surgical or radiologic interventions, such as percutaneous thoracic duct embolization or ligation, are often attempted. However, these procedures lack high-level evidence in the infant population and remain a challenge, given the small size of the lymphatic vessels. As such, we report our experience with performing lymphovenous anastomoses in two infants who had developed refractory chylothoraces secondary to thoracic duct injury following cardiac surgery for congenital cardiac anomalies. In addition, this article reviews the relevant pathophysiology of chylothoraces, current treatment algorithm following failed conservative management, and potential role of the microsurgeon in the multidisciplinary management of this life-threatening problem. As part of the evolving microsurgery frontier, physiologic operations, such as lymphovenous anastomosis, may have a considerable role in the management of refractory pediatric chylothoraces. In our experience, lymphovenous anastomosis can restore normal lymphatic circulation within 1 to 2 weeks, liberate patients from mechanical ventilation, and enable expeditious return to enteral feeding. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

[Cervical thoracic duct cyst: An uncommon entity]. / Quiste cervical del conducto torácico: una rara entidad.

BACKGROUND: Cervical thoracic duct cysts are a rare anomaly. OBJECTIVE: To report a case of cervical thoracic duct cyst, and perform a literature review. CLINICAL CASE: A 78-year-old female, with a one-year history of a left-sided asymptomatic supraclavicular cystic mass. Computerized tomography revealed a cystic mass 42mm in diameter. We performed a fine needle aspiration puncture, obtaining a thick, milky, whitish liquid. The patient underwent surgery; finding a left-sided supraclavicular cystic mass, with some lymph vessels heading towards the jugulo subclavian venous junction. We performed a ligation of these lymph vessels and resection of the mass. The histopathologic study confirmed the diagnosis of thoracic duct cyst. CONCLUSION: Diagnosis of cervical thoracic duct cyst should be suspected with a cystic lesion in the left supraclavicular region, which when perforated exudes a very distinctive thick milky, whitish liquid with a high content of lymphocytes and triglycerides. Treatment should be complete removal with ligation of the lymphatic afferent vessels.

Computed Tomography-Guided Percutaneous Thoracic Duct Sclero-Embolization for Persistent Chylothorax.

Postoperative chylous leak is often a consequence of thoracic duct injury during surgical procedures. Persistent chylothorax can be an extremely morbid condition. The authors describe a case of a refractory and long-standing chylous leak after thoracotomy for mediastinal lymphangioma removal. The patient was treated with a computed tomography-guided percutaneous thoracic duct sclero-embolization after failure of the conventional therapies. The chest tube output abruptly decreased after the procedure and was removed at 13th day. Percutaneous thoracic duct sclero-embolization proved to be safe and effective in the treatment of a persistent chylothorax.

[Minimally invasive treatment for traumatic chylopericardium. Paediatric case report]. / Tratamiento por mínima invasión del quilopericardio traumático. Reporte de un caso pediátrico.

BACKGROUND: Chylopericardium is a rare occurrence in children. The most common causes are associated with cardiac surgery, malformations of the lymphatic system, idiopathic reasons, among others. OBJECTIVE: The case is presented of a patient with traumatic chylopericardium, the diagnostic methodology, and in particular, its successful resolution by surgical means. CLINICAL CASE: Male patient of 6 years old, previous accident of fall from patient's height. Chest x-ray showed evidence of cardiomegaly. An echocardiogram with pericardial effusion was performed. Pericardial puncture was performed with drainage of milky material, confirming chylous liquid. Treatment included pericardial catheterisation, total parenteral nutrition, octreotide, and diet with medium chain triglycerides, with persistent increased pericardial fluid. Lymphatic abnormalities were ruled out by MRI. He underwent surgical treatment due to failure of prior treatment. A thoracoscopic approach was adopted with a favourable outcome. CONCLUSIONS: Chylopericardium occurs in children in most cases after cardiovascular surgery. The case presented here was classified as idiopathic. Patients with this condition may present with severe symptoms, such as tamponade, or can be asymptomatic as in the case presented. If medical treatment fails, it should be resolved by surgery; the best choice is minimally invasive treatment with its well-known advantages.

Influence of thoracic duct ligation on the lipid metabolism of patients with esophageal carcinoma after esophagectomy.

The aim of this study was to determine the influence of thoracic duct ligation on the lipid metabolism of patients with esophageal carcinoma after esophagectomy. A total of 74 patients with esophageal carcinoma who underwent esophagectomy were divided into 2 groups according to whether or not their thoracic duct was ligated. Thirty-nine patients were in the thoracic duct ligation group and the other 35 assigned to the control group. Enteral feeding was through a nasojejunal tube from the 1st day to the 8th day after operation, and liquid diet was provided starting on the 6th day. We compared the plasma concentrations of cholesterol (CHOL), triglycerides (TG), high-density lipoprotein (HDL), and low-density lipoprotein (LDL) at different time points. There were no statistically significant differences between the two groups in CHOL, TG and HDL levels at different times. However, LDL levels in the thoracic duct ligation group were significantly lower at different times compared to the other group (P < 0.05), where they were the lowest at the end of the 1st month and then gradually recovered 3 months later. Thoracic duct ligation can effectively prevent chylomicrons from being transferred to the blood, reducing the generation of LDL. The establishment of collateral circulation was slow after the ligation of the thoracic duct, which had a negative effect on early postoperative nutrition of patients.

Thoracoamniotic shunts for the management of fetal lung lesions and pleural effusions: a single-institution review and predictors of survival in 75 cases.

PURPOSE: Hydrops and pulmonary hypoplasia are associated with significant morbidity and mortality in the setting of a congenital lung lesion or pleural effusion (PE). We reviewed our experience using in utero thoracoamniotic shunts (TA) to manage fetuses with these diagnoses. METHODS: A retrospective review of fetuses diagnosed with a congenital lung lesion or pleural effusion who underwent TA shunt placement from 1998-2013 was performed. RESULTS: Ninety-seven shunts were placed in 75 fetuses. Average gestational age (±SD) at shunt placement and birth was 25±3 and 34±5 weeks. Shunt placement resulted in a 55±21% decrease in macrocystic lung lesion volume and complete or partial drainage of the PE in 29% and 71% of fetuses. 69% of fetuses presented with hydrops, which resolved following shunt placement in 83%. Survival was 68%, which correlated with GA at birth, % reduction in lesion size, unilateral pleural effusions, and hydrops resolution. Surviving infants had prolonged NICU courses and often required either surgical resection or tube thoracostomy in the perinatal period. CONCLUSION: TA shunts provide a therapeutic option for select fetuses with large macrocystic lung lesions or PEs at risk for hydrops and/or pulmonary hypoplasia. Survival following shunting depends on GA at birth, reduction in mass size, and hydrops resolution.

Transabdominal ligation of the thoracic duct with pericardial-peritoneal shunting in a case of primary idiopathic chylous pericardial effusion.

Primary chylous pericardial effusion is a rare entity with few cases reported so far. We report a case of idiopathic etiology in a previously healthy 16-year-old boy. The patient presented with intermittent chest pain and dizziness caused by a chronic pericardial effusion. An echocardiogram revealing a pericardial effusion and open pericardiocentesis with a drainage of approximately of 500 ml of chylous fluid established the diagnosis. Patient had no history of trauma, cardiac surgery, central insertion of subclavian catheters or blunt injury. Computed tomography ruled out malignancies in the abdomen and chest. Clinical, laboratory and radiological investigations for the possible underlying cause of the condition were not determined. Management with a dietary regimen consisting of a medium-chain triglyceride-rich diet, octreotide pharmacological treatment and initial subxiphoid resection with pericardial tube drainage was unsuccessful. Surgical approach was required consisting of pericardio-peritoneal window with trans-abdominal ligation (clipping) of the thoracic duct above the diaphragm. Postoperative outcome was uneventful and there was a rapid recovery after surgical management.

Abdominal compression: a new intraoperative maneuver to detect chyle fistulas during left neck dissections that include level IV.

BACKGROUND: Chyle fistulas may occur after left neck dissections that include level IV, due to injury of the thoracic duct or of 1 of its major branches. Despite being unusual, this complication carries substantial postoperative morbidity and even mortality. So far, no effective intraoperative maneuver has been reported to detect this fistula at the end of a neck dissection. In this cohort study, we sought to describe a simple new maneuver, intraoperative abdominal compression, which can effectively help to identify an open major lymphatic duct on level IV at the end of a neck dissection. PATIENTS AND METHODS: From March 1989 to September 2010, 206 patients underwent neck dissections involving left level IV, and underwent intraoperative abdominal compression. There were 119 men and 87 women, with ages ranging from 18 to 81 years (median, 52 years). One hundred forty-four patients had squamous cell carcinomas, 54 had thyroid carcinomas, 5 had malignant melanomas, and 3 had salivary cancers. Distribution by type of left neck dissection was: selective including levels II, III, and IV (73 cases; 35.4%), selective including levels II, III, IV, and V (55 cases; 26.6%), selective including levels I, II, III, and IV (12 cases; 5.8%), modified radical (47 cases; 22.8%), and radical (19 cases; 9.2%). In all cases, at the end of the procedure, the endotracheal tube was temporarily disconnected from the ventilator. Keeping the dissected level IV area under clear visualization, an abdominal compression was performed. At this moment, any detected lymphatic leak was carefully clamped and tied with nonabsorbable sutures. After ventilating the patient, the intraoperative abdominal compression was repeated to reassure complete occlusion of the lymphatic vessel. RESULTS: In 13 cases (6.3%), a chyle leak was detected after performing the intraoperative abdominal compression. All leaks except for 2 were successfully controlled after 1 attempt. In these 2 patients, a patch of muscle and fat tissue was applied with fibrin glue on the top. In 1 of these patients, another chyle leak in a different location was detected only at the second intraoperative abdominal compression, and was also effectively closed. Postoperatively, there were 2 (1%) chyle fistulas, both among these 13 cases, and all were successfully managed with clinical measures only. No fistulas occurred among the remaining 193 patients in whom intraoperative abdominal compression did not demonstrate lymphatic leak. CONCLUSION: To our knowledge, this is the first description of a specific maneuver to actively detect a lymphatic fistula at the end of a left neck dissection involving level IV. In this study, intraoperative abdominal compression was able to detect an open lymphatic vessel in 6.3% of the cases, as well as to assure its effective sealing in the remaining 93.7% of the patients. Moreover, no life-threatening high-volume fistula was noted in this study.

Chyle fistula in right cervical area after thyroid surgery.

Thoracic duct injury is an infrequent (1-2.5%) but severe complication after neck surgery, leading to nutritional, metabolic and immunologic deficiencies. We report a case of a 34-year-old woman with a right thoracic duct injury after surgery of a thyroid medullar cancer effectively treated with conservative management (parenteral nutrition and intravenous somatostatin). Optimal treatment of these patients is unclear, without a clear limit between conservative and surgical treatment.

Visualização linfocintigráfica da desembocadura do ducto torácico / Lymphoscintigraphic visualization of the thoracic duct confluence

OBJETIVO: Avaliar a sensibilidade da linfocintigrafia intersticial na visualização da desembocadura do ducto torácico. MÉTODO: Foram analisados 535 exames linfocintigráficos realizados no Serviço de Medicina Nuclear do Hospital das Clínicas, Universidade Federal de Pernambuco (UFPE), no período de 1993 a 1999. Todas as linfocintigrafias foram realizadas através da injeção subcutânea, no primeiro espaço interdigital de cada pé, de 1 ml da solução de Dextran 500 marcado com Tecnécio-99 metaestável. RESULTADOS: A desembocadura do ducto torácico foi visualizada em 424 pacientes, que representam 79,3 por cento das linfocintigrafias realizadas. Na avaliação por sexo, a desembocadura do ducto torácico foi visualizada em 191 pacientes do sexo feminino, representando 77 por cento dos casos. Nos pacientes do sexo masculino, a desembocadura foi visualizada em 233 casos (80,9 por cento). CONCLUSÃO: O presente estudo confirma a importância da linfocintigrafia como método de escolha na avaliação da circulação linfática e demonstra que esse exame apresenta uma alta sensibilidade para a visualização da desembocadura do ducto torácico.

Ligation of the thoracic duct for the treatment of chylothorax in heart diseases.

In children, chylothorax occurs mainly after cardiac and thoracic surgeries. One of the recommended postsurgery treatments is ligation of the thoracic tract, when all other conservative treatments have failed. We report 4 cases of chylothorax in patients who were successfully treated with this approach, which resulted in a decrease in pleural drainage without recurrent chylothorax.

Treatment of postoperative chylothorax through laparoscopic thoracic duct ligation.

We report the laparoscopic transhiatal thoracic duct ligation to solve postoperative chylothorax after right total pleurectomy for malignant diffuse mesothelioma.

Estudo linfocintográfico da morfologia da desembocadura do ducto torácico / Morphological lymphoscintigraphic study of the thoracic duct

Foram analisadas 535 linfocintigrafias realizadas no Serviço de Medicina Nuclear do Hospital das Clínicas-UFPE, no período de 1993 a 1999, com o objetivo de estudar os diversos tipos de variações anatômicas encontradas a nível da desembocadura do ducto torácico. Em 424 pacientes (79,3 por cento) foi possível visualizar a desembocadura do ducto torácico, respectivamente: junção entre as veias jugular interna e subclávia a esquerda(87,3 por cento), junção entre as veias jugular interna e subclávia bilateral (11,1 por cento) e junção entre as veias jugular interna e subclávia a direita (1,6 por cento). Os resultados são similares aos da literatura, em relação à presença de variações anatômicas na desembocadura do ducto torácico, entretanto evideciam a importância da linfocintigrafia neste estudo. Permitem, ainda, estabelecer, de forma não invasiva, classificação morfolinfocintigráfica para a desembocadura do ducto torácico