Near infra-red fluorescence identification of the thoracic duct to prevent chyle leaks during oesophagectomy

Abstract Background Chyle leaks following oesophagectomy are a frustrating complication of surgery with considerable morbidity. The use of near infra-red (NIR) fluorescence in surgery is an emerging technology and the use of fluorescence to identify the thoracic duct has been demonstrated in animal work and early human case reports. This study evaluated the use mesenteric and enteral administration of indocyanine green (ICG) in humans to identify the thoracic duct during oesophagectomy. Methods Patients undergoing oesophagectomy were recruited to the study. Administration of ICG via an enteral route or mesenteric injection was evaluated. Fluorescence was assessed using a NIR fluorescence enabled laparoscope system with a visual scoring system and signal to background ratios. Visualisation of the thoracic duct under white light and NIR fluorescence was compared as well as any identification of active chyle leak. Patients were followed up post-operatively for adverse events and chyle leak. Results 20 patients received ICG and were included in the study. The enteral route failed to fluoresce the thoracic duct. Mesenteric injection (17 patients) identified the thoracic duct under fluorescence prior to white light in 70% of patients with a mean signal to background ratio of 5.35. In 6 participants, a possible active chyle leak was identified under fluorescence with 4 showing active chyle leak from what was identified as the thoracic duct. Conclusion This study demonstrates that ICG administration via mesenteric injection can highlight the thoracic duct during oesophagectomy and may be a potential technology to reduce chyle leak following surgery. Clinical trial registration Clinical trials.gov (NCT03292757).

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A systematic review of historical and current trends in Chagas disease

Therapeutic Advances in Infectious Disease ◽

10.1177/20499361211033715 ◽

2021 ◽

Vol 8 ◽

pp. 204993612110337

Author(s):

Diego-Abelardo Álvarez-Hernández ◽

Rodolfo García-Rodríguez-Arana ◽

Alejandro Ortiz-Hernández ◽

Mariana Álvarez-Sánchez ◽

Meng Wu ◽

...

Keyword(s):

Systematic Review ◽

Chagas Disease ◽

Case Reports ◽

Clinical Manifestations ◽

Human Case ◽

Acute Stage ◽

Diagnostic Tools ◽

Chronic Stage ◽

Pubmed Database ◽

Trypanocidal Drugs

Introduction: Chagas disease (CD) is caused by Trypanosoma cruzi. When acquired, the disease develops in stages. For diagnosis, laboratory confirmation is required, and an extensive assessment of the patient’s health should be performed. Treatment consists of the administration of trypanocidal drugs, which may cause severe adverse effects. The objective of our systematic review was to analyze data contained in the CD published case reports to understand the challenges that patients and clinicians face worldwide. Materials and methods: We performed a systematic review following the PRISMA guidance. PubMed database was explored using the terms ‘American trypanosomiasis’ or ‘Chagas disease’. Results were limited to human case reports written in English or Spanish. A total of 258 reports (322 patients) were included in the analysis. Metadata was obtained from each article. Following this, it was analyzed to obtain descriptive measures. Results: From the sample, 56.2% were males and 43.8% were females. Most cases were from endemic countries (85.4%). The most common clinical manifestations were fever during the acute stage (70.0%), dyspnea during the chronic stage in its cardiac form (53.7%), and constipation during the chronic stage in its digestive form (73.7%). Most patients were diagnosed in the chronic stage (72.0%). Treatment was administered in 56.2% of cases. The mortality rate for the acute stage cases was 24.4%, while for the chronic stage this was 28.4%. Discussion: CD is a parasitic disease endemic to Latin America, with increasing importance due to human and vector migration. In this review, we report reasons for delays in diagnosis and treatment, and trends in medical practices. Community awareness must be increased to improve CD’s diagnoses; health professionals should be appropriately trained to detect and treat infected individuals. Furthermore, public health policies are needed to increase the availability of screening and diagnostic tools, trypanocidal drugs, and, eventually, vaccines.

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Composite phaeochromocytomas—a systematic review of published literature

Langenbeck s Archives of Surgery ◽

10.1007/s00423-021-02129-5 ◽

2021 ◽

Author(s):

K. Dhanasekar ◽

V. Visakan ◽

F. Tahir ◽

S. P. Balasubramanian

Keyword(s):

Case Reports ◽

Descriptive Analysis ◽

Management Strategies ◽

Gastrointestinal Symptoms ◽

Rare Condition ◽

Epidemiological Data ◽

Human Case ◽

Rare Tumour ◽

Palpable Mass

Abstract Introduction Composite phaeochromocytoma is a tumour containing a separate tumour of neuronal origin in addition to a chromaffin cell tumour. This study reports on two cases from a single centre’s records and presents a systematic literature review of composite phaeochromocytomas. Methods In addition to describing 2 case reports, a systematic search of the Medline database from inception up to April 2020 was done for human case reports on composite phaeochromocytomas. Relevant titles and/or abstracts were screened, and full texts were reviewed to identify appropriate studies. Data was extracted and a descriptive analysis of presentation, clinical features, management strategies and outcomes was performed. The quality of included studies was assessed using a critical appraisal checklist. Results There were 62 studies included, with a total of 94 patients. Of 91 patients where data was available, the median (range) age of patients was 48 (4–86) years. Of 90 patients where information was provided, 57% were female. In at least 28% of patients, a genetic cause was identified. Common presenting features include abdominal pain, palpable mass, cardiovascular and gastrointestinal symptoms. The most common tumour component with phaeochromocytoma is ganglioneuroma; other components include ganglioneuroblastoma, neuroblastoma and malignant peripheral nerve sheath tumours. In patients with follow-up data (n=48), 85% of patients were alive and well at a median (range) follow-up time of 18 (0.5–168) months. Conclusion Composite phaeochromocytoma is a rare tumour, with a significant genetic predisposition. This review summarises available epidemiological data, which will be useful for clinicians managing this rare condition.

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Guidance Level for Brevetoxins in French Shellfish

Marine Drugs ◽

10.3390/md19090520 ◽

2021 ◽

Vol 19 (9) ◽

pp. 520

Author(s):

Nathalie Arnich ◽

Eric Abadie ◽

Zouher Amzil ◽

Marie-Yasmine Dechraoui Bottein ◽

Katia Comte ◽

...

Keyword(s):

Working Group ◽

Case Reports ◽

Human Case ◽

Portion Size ◽

Shellfish Poisoning ◽

Marine Biotoxins ◽

Toxicological Data ◽

Set Up ◽

First Time ◽

Environmental And Occupational Health

Brevetoxins (BTXs) are marine biotoxins responsible for neurotoxic shellfish poisoning (NSP) after ingestion of contaminated shellfish. NSP is characterized by neurological, gastrointestinal and/or cardiovascular symptoms. The main known producer of BTXs is the dinoflagellate Karenia brevis, but other microalgae are also suspected to synthesize BTX-like compounds. BTXs are currently not regulated in France and in Europe. In November 2018, they have been detected for the first time in France in mussels from a lagoon in the Corsica Island (Mediterranean Sea), as part of the network for monitoring the emergence of marine biotoxins in shellfish. To prevent health risks associated with the consumption of shellfish contaminated with BTXs in France, a working group was set up by the French Agency for Food, Environmental and Occupational Health & Safety (Anses). One of the aims of this working group was to propose a guidance level for the presence of BTXs in shellfish. Toxicological data were too limited to derive an acute oral reference dose (ARfD). Based on human case reports, we identified two lowest-observed-adverse-effect levels (LOAELs). A guidance level of 180 µg BTX-3 eq./kg shellfish meat is proposed, considering a protective default portion size of 400 g shellfish meat.

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Post-thyroidectomy hypocalcemia exacerbated by chyle leak

Endocrinology Diabetes and Metabolism Case Reports ◽

10.1530/edm-14-0110 ◽

2015 ◽

Vol 2015 ◽

Author(s):

Naweed Alzaman ◽

Anastassios G Pittas ◽

Miriam O'Leary ◽

Lisa Ceglia

Keyword(s):

Total Thyroidectomy ◽

Thoracic Duct ◽

Treatment Options ◽

Oral Intake ◽

Neck Surgery ◽

List Type ◽

Chyle Leak ◽

Thoracic Duct Injury ◽

Extensive Lymph Node ◽

Learning Points

Summary Transient hypocalcemia after thyroidectomy is not uncommon and the risk increases with the extent of neck surgery. We report a case of severe and prolonged hypocalcemia after total thyroidectomy complicated by thoracic duct injury. Hypoparathyroidism and thoracic duct injury are potential complications following total thyroidectomy with extensive lymph node dissection. This case suggested that having both conditions may complicate treatment of hypoparathyroid-induced hypocalcemia by way of losses of calcium and vitamin D in the chyle leak. Learning points This report highlights chyle leak as an uncommon cause of prolonged hypocalcemia in patients who have undergone extensive neck surgery. Chyle has an electrolyte concentration similar to that of plasma. Medical treatment options for a chyle leak include fat-free oral diet or parenteral nutrition without oral intake, pharmacological treatment (primarily octreotide).

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PS02.056: TIMELY LIGATION OF THORACIC DUCT IN POST ESOPHAGECTOMY CHYLE LEAK: KEY TO SUCCESSFUL MANAGEMENT

Diseases of the Esophagus ◽

10.1093/dote/doy089.ps02.056 ◽

2018 ◽

Vol 31 (Supplement_1) ◽

pp. 136-136

Author(s):

Sanjeev Parshad ◽

Parvinder Sandu ◽

Shekar Gogna ◽

Abhijeet Beniwal ◽

Rajendra Karwasra

Keyword(s):

Mortality Rate ◽

Thoracic Duct ◽

Conflicts Of Interest ◽

Surrounding Tissue ◽

Chyle Leak ◽

Threatening Condition ◽

Life Threatening ◽

Carcinoma Esophagus ◽

Esophagectomy For Cancer

Abstract Background Chyle leak after esophagectomy for carcinoma esophagus is a rare but life threatening condition with reported an incidence of 1–6%. Mortality rate of up to 50% have been reported. Management of chyle leak is controversial. We reviewed our experience with iatrogenic chylothorax after esophagectomy for carcinoma esophagus. Methods From 2003 to 2017, 560 patients underwent esophagectomy for cancer at our department of oncosurgery. Eight patients developed post operative chyle leak. Transthoracic or transabdominal ligation of duct was done in six patients with in first week. 100 ml of cream was given 30 min before induction to visualize the leak intraoperatively. We used 4–0 prolene pledgeted suture to ligate the duct. Results Six patients who underwent early ligation could be salvaged and the two who were managed conservatively succumbed. Oringer et al. pointed towards conservative treatment having little place in the management of chylothorax in nutritionally depleted patients. Hence, prompt ligation of thoracic duct decreases morbidity and mortality of chylothorax. Thus the role of early surgery needs to stressed. There is a wide difference of mortality rate of conservative management of 82% with respect to the mortality rate of surgery of 10–16%. Though no conclusion data are available regarding the indication and time point of surgical ligation of the thoracic duct, it is important not to procrastinate while the condition deteriorates to a level at which surgery would be detrimental.Administration of cream to the patient (through feeding jejunostomy) around half an hour before surgery makes identification of site of leak simpler.The importance of pledgeted sutures cannot be denied as the thoracic duct is paper thin and chyle contains no fibrin. Thus non pledgeted sutures will tear it further. Infact, stitching should not be done through the duct but into the surrounding tissue around the duct and should allow the pledgets to close the duct. Conclusion Disclosure All authors have declared no conflicts of interest.

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Oesophagectomy with en bloc resection of the thoracic duct: risk factors for post-operative chyle leak and current management

Annals of Esophagus ◽

10.21037/aoe.2019.08.04 ◽

2019 ◽

Vol 2 ◽

pp. 13-13

Author(s):

Brian Ip ◽

Ka Ting Ng ◽

Simon Packer ◽

Simon Paterson-Brown ◽

Graeme Couper

Keyword(s):

Risk Factors ◽

Thoracic Duct ◽

En Bloc Resection ◽

Bloc Resection ◽

Current Management ◽

En Bloc ◽

Chyle Leak

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Near infra-red fluorescence-guidance for percutaneous sclerotherapy of thoracic duct leak

American Journal of Otolaryngology ◽

10.1016/j.amjoto.2020.102463 ◽

2020 ◽

Vol 41 (4) ◽

pp. 102463

Author(s):

Catarina Brito ◽

Pedro Vilela

Keyword(s):

Thoracic Duct ◽

Red Fluorescence ◽

Percutaneous Sclerotherapy ◽

Infra Red

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Brain Dysfunction in LAMA2-Related Congenital Muscular Dystrophy: Lessons From Human Case Reports and Mouse Models

Frontiers in Molecular Neuroscience ◽

10.3389/fnmol.2020.00118 ◽

2020 ◽

Vol 13 ◽

Author(s):

Andrea J. Arreguin ◽

Holly Colognato

Keyword(s):

Muscular Dystrophy ◽

Mouse Models ◽

Case Reports ◽

Congenital Muscular Dystrophy ◽

Brain Dysfunction ◽

Human Case

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Emission and absorption in the infra-red spectra of mercury, zinc, and cadmium

Proceedings of the Royal Society of London. Series A, Containing Papers of a Mathematical and Physical Character ◽

10.1098/rspa.1919.0009 ◽

1919 ◽

Vol 95 (669) ◽

pp. 280-299 ◽

Cited By ~ 1

Keyword(s):

White Light ◽

Vapour Pressure ◽

Wave Length ◽

Mercury Vapour ◽

Stimulate Emission ◽

First Line ◽

Absorption Bands ◽

Infra Red ◽

Partial Parallelism ◽

Lower Voltage

In a previous paper the writer pointed out that well-marked absorption bands exist in the infra-red region of the spectrum caused by passing white light through non-luminous mercury vapour. These bands occur at λ 1·014, λ 1·129. and λ 1·205, the first and third of these being especially strong. This investigation has since been extended further into the infra-red with mercury vapour, and it has also been repeated with the vapours of zinc and cadmium in place of that of mercury. The results serve to establish at least a partial parallelism in the behaviour of the three metals, the resemblance being most marked in the region of the first line of the series represented by v = (2·5, S)—( m , P), at which wave-length absorption takes place in the case of all three metals with extremely small vapour-pressure. On account of the ease with which the wave-length corresponding to v = (2·5, S)—( m , P) was absorbed, it was suspected that it should be emitted under electronic bombardment. At the suggestion of Prof. McLennan an investigation was undertaken with mercury vapour, in order to determine the speed which electrons must be given in order to stimulate emission of the wave-length λ 1·014. If we apply the quantum relation ve = hv to the frequency of this wave-length, we get V = 1·26 volts. In the experiments which will be described herein, the wave-length λ 1·014 was actually emitted with a voltage as low as 5 volts. There were strong indications that even a lower voltage would suffice to stimulate emission of the wave-length, but under the conditions of the experiment the radiations of this wave-length when emitted were reabsorbed by the intervening layers of mercury vapour.

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