Ultrasound-guided lymphangiography and interventional embolization of chylous leaks following esophagectomy

AbstractObjectivesPostoperative chylothorax is a serious complication after transthoracic esophagectomy, and is associated with major morbidity due to dehydration and malnutrition. For patients with high-output fistula, re-thoracotomy with ligation of the thoracic duct is the treatment of choice. Radiologic interventional management is an innovative procedure that has the potential to replace surgery in the treatment algorithm.MethodsFour patients with high-output chylous leaks following esophagectomy are presented. Ultrasound-guided lymphangiography with embolization of the thoracic duct and/or disruption of the cisterna chyli was performed to occlude the leakage site. Radiologic interventions and procedure-related outcomes are described in detail.ResultsIn all four patients, ultrasound-guided lymphangiography of the groin with injection of Lipiodol was able to detect and visualize the leakage site in the lower mediastinum. In three patients, the leak could be successfully occluded by Lipiodol embolization. In one patient, embolization failed and the disruption technique was successfully performed. No procedure-related complications were observed.ConclusionsIn case of a postoperative chylothorax, radiologic intervention is feasible and safe. The procedure is indicated for high-output chylous fistulas after esophagectomy, and should be applied early after the diagnosis of this postoperative complication.

Download Full-text

Chylothorax after esophagectomy treated with inguinal intranodal lymphangiography and transvenous retrograde thoracic duct embolization

Clinical Journal of Gastroenterology ◽

10.1007/s12328-021-01429-z ◽

2021 ◽

Author(s):

Yuta Sato ◽

Yoshihiro Tanaka ◽

Takeharu Imai ◽

Hiroshi Kawada ◽

Naoki Okumura ◽

...

Keyword(s):

Esophageal Cancer ◽

Thoracic Duct ◽

Gastric Tube ◽

Treatment Options ◽

Effective Treatment Option ◽

Major Morbidity ◽

Posterior Mediastinal ◽

Posterior Mediastinal Route ◽

Intranodal Lymphangiography ◽

High Output

AbstractChylothorax after esophagectomy is a serious complication that is associated with major morbidity due to dehydration and malnutrition. Reoperation with ligation of the thoracic duct is considered for patients with high-output chyle leaks that have failed conservative management. In this report, we present the treatment options for chylothorax after esophagectomy: inguinal intranodal lymphangiography and transvenous retrograde thoracic duct embolization. A 74-year-old man with esophageal cancer had been operated with thoracoscopic esophagectomy. Six days after surgery, he presented with high-output chyle leaks. Conservative treatment did not result in a significant improvement. Inguinal intranodal lymphangiography and transvenous retrograde thoracic duct embolization were performed 13 days after surgery and were technically and clinically successful. Inguinal intranodal lymphangiography and transvenous retrograde thoracic duct embolization are an effective treatment option, especially for patients after esophagectomy with reconstruction performed via the posterior mediastinal route, without the potential for damage the gastric tube and omentum.

Download Full-text

PS02.168: THORACIC DUCT EMBOLIZATION IN HIGH-OUTPUT CHYLOTHORAX AFTER ESOPHAGECTOMY FOR ESOPHAGEAL CANCER

Diseases of the Esophagus ◽

10.1093/dote/doy089.ps02.168 ◽

2018 ◽

Vol 31 (Supplement_1) ◽

pp. 169-170

Author(s):

Taku Michiura ◽

Shuji Kariya ◽

Hirokazu Miki ◽

Hiromi Mukaide ◽

Kentaro Inoue ◽

...

Keyword(s):

Esophageal Cancer ◽

Thoracic Duct ◽

Conflicts Of Interest ◽

Clinical Success ◽

Clinical Results ◽

Success Rates ◽

Iodinated Contrast ◽

Leakage Site ◽

Lymphatic Fluid ◽

High Output

Abstract Background Chylothorax after thoracic surgery is initially managed conservatively, but when persistent high-output chylothorax (> 1000 mL/day) is managed conservatively, the mortality rate exceeds 50%. The objective of this study was to examine the clinical results of thoracic duct embolization (TDE) in cases of chylothorax after esophagectomy for esophageal cancer. Methods The data of 9 patients (7 men, 2 women) whounderwent TDE for persistent high-output chylothorax after esophagectomy for esophageal cancer were gathered retrospectively. Lymphangiography was used to identify the supply route of lymphatic fluid from the lumbar lymphatics to the leakage site and lipiodol extravasation and its site. Transcatheter thoracic ductography was used to identify communication between the thoracic duct and the leakage site and extravasation of the iodinated contrast agent. TDE was performed by percutaneous transabdominal approach to cut off the supply route. The technical success and clinical success (drainage volume ≥ 10mL/kg/day within 7 days after TDE) of TDE were evaluated. Results The technical and clinical success rates of TDE were 89.9%, with no serious complications observed. In 44% of patients, the thoracic duct had ruptured. In the other 56%, the ruptured was in a collateral route bypassing the thoracic duct; the leaking lymphatic fluid was supplied without passing through the thoracic duct in 50% of these patients, but clinical success was achieved even in such patients. Conclusion TDE was found to be a safe method of treatment, with no serious complications. Disclosure All authors have declared no conflicts of interest.

Download Full-text

An overview of ultrasound-guided transnodal lymphangiography with percutaneous thoracic duct embolization

Journal of Vascular and Interventional Radiology ◽

10.1016/j.jvir.2013.12.553 ◽

2014 ◽

Vol 25 (3) ◽

pp. S205-S206

Author(s):

S.T. Kee Bansal ◽

J. McWilliams ◽

E.W. Lee

Keyword(s):

Thoracic Duct ◽

Ultrasound Guided

Download Full-text

High-output chyloperitoneum following laparoscopic Nissen fundoplication treated with retrograde transvenous thoracic duct embolization

CVIR Endovascular ◽

10.1186/s42155-020-00110-9 ◽

2020 ◽

Vol 3 (1) ◽

Cited By ~ 1

Author(s):

Gernot Rott ◽

Frieder Boecker

Keyword(s):

Thoracic Duct ◽

Nissen Fundoplication ◽

Laparoscopic Nissen Fundoplication ◽

Laparoscopic Nissen ◽

High Output

Download Full-text

Safety and Efficacy of a Potential Treatment Algorithm by Using Manual Compression Repair and Ultrasound-Guided Thrombin Injection for the Management of Iatrogenic Femoral Artery Pseudoaneurysm in a Large Patient Cohort

Journal of Vascular Surgery ◽

10.1016/j.jvs.2014.11.052 ◽

2015 ◽

Vol 61 (1) ◽

pp. 281

Author(s):

M. Dzijan-Horn ◽

N. Langwieser ◽

P. Groha

Keyword(s):

Femoral Artery ◽

Treatment Algorithm ◽

Potential Treatment ◽

Thrombin Injection ◽

Manual Compression ◽

Ultrasound Guided ◽

Artery Pseudoaneurysm ◽

Safety And Efficacy ◽

Patient Cohort ◽

Large Patient

Download Full-text

Thoracic duct identification with indocyanine green fluorescence during minimally invasive esophagectomy with patient in prone position

Diseases of the Esophagus ◽

10.1093/dote/doaa030 ◽

2020 ◽

Vol 33 (12) ◽

Cited By ~ 2

Author(s):

Massimo Vecchiato ◽

Antonio Martino ◽

Massimo Sponza ◽

Alessandro Uzzau ◽

Antonio Ziccarelli ◽

...

Keyword(s):

Minimally Invasive ◽

Indocyanine Green ◽

Prone Position ◽

Thoracic Duct ◽

Minimally Invasive Esophagectomy ◽

Standard Procedure ◽

Transthoracic Esophagectomy ◽

Green Fluorescence ◽

Indocyanine Green Fluorescence ◽

Invasive Esophagectomy

Abstract Chylothorax is a serious complication of transthoracic esophagectomy. Intraoperative thoracic duct (TD) identification represents a possible tool for preventing or repairing its lesions, and it is most of the time difficult, even during high-definition thoracoscopy. The aim of the study is to demonstrate the feasibility of using near-infrared fluorescence-guided thoracoscopy to identify TD anatomy and check its intraoperative lesions during minimally invasive esophagectomy. A 0.5 mg/kg solution of indocyanine green (ICG) was injected percutaneously in the inguinal nodes of 19 patients undergoing minimally invasive esophagectomy in a prone position, before thoracoscopy. TD anatomy and potential intraoperative lesions were checked with the KARL STORZ OPAL1® Technology. In all of the 19 patients where transthoracic esophagectomy was feasible, the TD was clearly identified after a mean of 52.7 minutes from injection time. The TD was cut for oncological radicality in two patients, and it was successfully ligated under the ICG guide. No postoperative chylothorax or adverse reactions from the ICG injection occurred. The TD identification with indocyanine green fluorescence during minimally invasive esophagectomy is a simple, effective, and non-time-demanding tool; it may become a standard procedure to prevent postoperative chylothorax.

Download Full-text