Computed tomography lymphangiography via intrametatarsal pad injection is feasible in cats with chylothorax

OBJECTIVE To evaluate the feasibility of CT lymphangiography via intrametatarsal pad injection in cats with chylothorax. ANIMALS 7 client-owned cats. PROCEDURES This was a multicenter, retrospective, descriptive study. Medical records and imaging data from 4 veterinary hospitals were reviewed to identify cats with chylothorax that had undergone intrametatarsal pad injection via CT lymphangiography. In total, 7 client-owned cats were included in the study. Signalment, history, image findings, and follow-up data were recorded. Descriptive statistics were used to analyze the success rate of thoracic duct (TD) enhancement and describe relevant clinical findings. RESULTS Enhancement of TDs was successful in 6 of the 7 cats within 5 to 15 minutes after initiating intrametatarsal pad injection under general anesthesia. Successful migration of contrast medium into the lymphatic vessels cranial to the popliteal lymph nodes was observed in all cats within 5 minutes after injection. The recommended dose of contrast medium to achieve TD enhancement was 1 mL/kg (0.5 mL/kg/pad; concentration, 350 mg of iodine/kg). Only 1 cat had mild swelling of the paws after the procedure, and it recovered quickly without pain medication; no cats experienced lameness. Similar to dogs and unlike in previously published reports, 72% of TD branches were located in the right hemithorax. CLINICAL RELEVANCE CT lymphangiography via intrametatarsal pad injection is a feasible and safe procedure for cats with chylothorax. This technique provides detailed information regarding the unique TD anatomy and cisterna chyli location. It also contributes to surgical planning.

P-OGC37 Lymphatic embolisation for chylous abdomen following oesophagectomy

Background A 78 year old man underwent an Ivor Lewis oesophagectomy (laparoscopic converted to open abdominal phase, right thoracotomy) for a T2 N2 (3/81) R0 Type II GOJ adenocarcinoma post FLOT neoadjuvant chemotherapy. He developed a chylous abdomen requiring drainage radiologically. A percutaneous lymphatic embolisation was performed which showed a leak in the region of the cisterna chyli which was successfully treated. Methods A lymph node in each groin was cannulated under US guidance using spinal needles and an infusion of Lipiodol was started at a rate of 6ml/hr each side. Lymphatic opacification was monitored under fluoroscopy with contrast having reached the cisterna chyli within 30 minutes. Contrast was seen extravasating near cisterna chyli, confirming an injury at this site. A lumbar trunk lymphatic was cannulated with a Chiba needle and wire enabling positioning of a microcatheter as close to the point of injury as possible. Onyx liquid embolic was used to embolise the feeding lymphatic trunk. Results Post-procedural drain outputs demonstrated an immediate significant drop, with losses of only 300ml/24hr within 48 hours. Drain outputs continued to taper and the drains removed shortly after. The cisterna chyli is typically thought of as a retroperitoneal/para-aortic structure not prone to instrumentation during an ILGO. Despite reviewing the intra-operative footage, a definitive moment/point of injury remains unclear. Conclusions Conservative management of abdominal chyle leak including use of TPN and octreotide is often effective but in sustained large volume ascites(>1000mls/24hr) this is unlikely to succeed. Percutaneous lymphatic embolization can be offered as a treatment option for these patients.

Reactivate Your Second Heart

Sitting or standing without moving the leg muscles puts additional stress on your heart, as blood and lymph pool in the legs. Tightening and relaxing the calf muscles can prevent the pooling of the blood. The inactivity of the calf muscles does not allow the blood to flow upward and may result in “sitting disease,” contributing to the development of diabetes and cardiovascular disease. Activating the calf muscles as well as other leg muscles are strategies to support cardiovascular health. Thus, the calf muscles are sometimes called “our second heart.” The important function of our “second heart” is to act as a pump to return venous blood and lymph fluids upward, which can occur only when we interrupt sitting with many brief exercises by frequently standing up during the day. Suggestions regarding how to implement short breaks are included. Note that, medically, the term second heart refers to the cisterna chyli, which brings the lymphatic fluids up from the abdomen; however, in this article, second heart is used in a common popular sense of the term as the description of the calf muscle to pump the venous blood toward the heart.

EP.WE.484Conservative management of post-operative chyle leak after surgery for a large adrenal cavernous haemangioma

Post-operative chyle leak is a rare but recognised complication after abdominal surgeries particularly those involving dissection adjacent to the retroperitoneal lymph nodes and/or lymphatic systems. There are limited cases of post-operative chyle leak associated with adrenal surgery reported in the literature with no consensus on its management. Lymphatics of the adrenal gland drain into the thoracic duct via regional lymph nodes or directly into the cisterna chyli, posterior to the aorta. If not adequately managed, chyle leak can be associated with hypovolemia, electrolyte imbalances, malnutrition and immunosuppression. These consequences can be attributed to the loss of fluid, electrolytes, lipids, proteins, and immunoglobulins. We hereby report a case of post-operative chyle leak in a 79-year-old male who underwent an open left adrenalectomy, left nephrectomy, splenectomy and distal pancreatectomy for a large, 20.8cm left adrenal cavernous haemangioma. Chyle leak was confirmed on post-operative day 7 based on high levels of triglycerides in the abdominal drain output. Intra-operatively there was no evidence of lymphatic damage. However, the major abdominal surgery involving retroperitoneal viscera close to the lymphatic trunk predisposed the patient to this complication. The patient was managed conservatively with the aim of decreasing chyle production by dietary manipulation and use of somatostatin. Enteral nutrition was continued with a strict low-fat diet and regular dietician input. These strategies contributed to the gradual resolution of chyle leak and the patient’s recovery.

A rare case of recurrent cystic dilatation of the cisterna chyli treated via an interventional approach

A 27-year-old man with a long history of intermittent, severe abdominal pain for approximately 10 years was evaluated by interventional radiology for a retrocrural cystic lesion found on magnetic resonance imaging (MRI). Prior to evaluation, he was extensively worked up by several gastrointestinal specialties and multiple surgeons without clear etiology of his abdominal pain. This retrocrural cystic lesion found on MRI was thought to be the source of his cyclic abdominal pain occurring every few months. Since the pain was aggravated by the consumption of fatty foods, the patient was advised to intake a large quantity of fatty foods and return for repeat serial computed tomography (CT) scans until this cystic lesion could be identified. Once identified, he was taken back to the procedural CT scanner for drainage and embolization with a mixture of N-butyl cyanoacrylate glue and lipiodol (1:3 ratio). 3 years post-intervention, this patient is now asymptomatic with complete resolution of his pain.

Canine Intestinal Lymphangiectasia Concomitant with Renal Cell Carcinoma

The etiology of dilation of lymphatic vessels, termed as intestinal lymphangiectasia, remains unknown. In most cases, it occurs secondary to other pathologic conditions such as gastrointestinal neoplasms. However, only a few cases of canine intestinal lymphangiectasia concurrent with non-gastrointestinal neoplasms have been reported so far. Moreover, the correlation between intestinal lymphangiectasia and non-gastrointestinal neoplasms has not been discussed in any other literature. In this study, we report a rare case of intestinal lymphangiectasia concomitant with renal cell carcinoma in an 11 year old female mixed Maltese, suggesting that non-gastrointestinal neoplasms could be associated with the development of intestinal lymphangiectasia. On gross observation, the small intestine was irregularly swollen presenting an accordion like shape. Microscopic examination revealed prominent dilatation of the lymphatic vessels, especially, within the submucosa and muscularis layer. The lacteals within the villi were dilated and presented “club-shaped” tips. The carcinoma might trigger intestinal lymphangiectasia by compressing the main lymphatic vessels or the cisterna chyli, subsequently increasing the pressure of the lymphatic vessels in the gastrointestinal tract. Moreover, metastasis of the carcinoma to the gastrointestinal tract could induce intestinal lymphangiectasia. Thus, the occurrence of intestinal lymphangiectasia must be considered when an abdominal neoplasm is located around major lymphatic vessels.

1438 The Past, Present and Future Management of Complex Chyle Fistulae

Background Chyle leak/fistula is a rare complication of oesophageal surgery, usually consequent on an unintended breach of the thoracic duct, its tributaries, or the cisterna chyli. For high volume persistent leaks further surgery has been the traditional approach, however two cases have resulted in a new management approach at this Centre. Case Series The first patient, a 49-year-old, developed high volume drain output post three stage oesophagectomy. His jejunostomy feeding was discontinued, total parenteral nutrition and a somatostatin analogue, were commenced. Despite these measures, the drain output remained >1.5litres per day and an exploratory thoracotomy was performed. The second patient, an 81-year-old underwent a transhiatal-oesophagectomy. On postoperative day 10 he developed acute onset shortness of breath, CXR demonstrated a large left sided pleural effusion. CT thorax demonstrated multiloculated complex pleural effusions. US guided pig tail drain was placed in the largest targetable effusion. The fluid was chylous in appearance. In both cases, an interventional radiological approach, not previously performed at this centre, provided definitive management. Lymphangiography was performed via injection of 1mL of Lipoidol® every 5 minutes into the inguinal lymph nodes to identify the cisterna chyli. A guidewire was advanced via the cisterna chyli with coils and glue used to embolize the leaking tracts. Discussion The lessons from this experience provide an algorithm for the management of chyle leaks, that will change practice at this centre. Embolization or disruption of thoracic duct and cisterna chyli leaks will be first line therapy for complex chyle leaks, with surgery reserved for where this fails.

Using aneurysm clips for repair of cisterna chyli injury during posterior spinal fusion

Background: Injury to the cisterna chyli (CC) is a rare surgical complication with a lack of literature describing its repair. Aneurysm clips have been successfully used to repair durotomies. Its usage in lymphatic injury has never been described. We sought to demonstrate the use of aneurysm clips for the repair of lymphatic vessels. Case Description: A 60-year-old male retired physician with Parkinson’s disease underwent a lumbosacral instrumented fusion with pelvic fixation (L1-pelvis) in 2011. He returned 5 months postoperatively after a fall and was ambulatory with a cane upon admission. CT demonstrated worsening kyphosis with pedicular and superior endplate fracture at the fusion apex. MRI revealed spinal cord compression at the failed level. Extension thoracolumbar fusion was performed (T3-L1) with intraoperative violation of the anterior longitudinal ligament (ALL) during T12/L1 discectomy. CC laceration was suspected. The ALL was dissected from the CC and aorta, allowing visualization of the injury. Three curved aneurysm clips were applied to the lacerated CC, which was visually inspected to ensure a patent lumen. The disk space was filled with poly-methyl-methacrylate cement in place of an interbody cage, preventing migration of the clips. The patient underwent rehabilitation in an inpatient facility with improved ambulation. He has had regular clinic follow-up and was last seen in 2020 with no evidence of lymphedema noted. Conclusion: CC injury is rare, and usage of aneurysm clips in its repair has never been described. We demonstrate the safe use of aneurysm clips to repair CC injury with long-term favorable clinical outcomes.

Spontaneous bilateral chylothorax in both vena cava thrombosis; cisterna chyli ligation

Chilothorax, a rare clinical condition characterized by high triglyceride white fluid in the thoracic cavity; when the literature is examined, it is seen because of trauma, malignancy, complication of surgery, and rarely central catheter-related thromboplasty. In the treatment, diet change, nutrition, drainage with tube thoracostomy, conservative method, surgical procedure with thoracotomy are applied.In our case there was no response to nutritional changes, drainage, thoracotomy and somatostatin treatments. Cisterna chyli ligation was performed with laparotomy. We present a case of spontaneous bilateral chylothorax associated with superior and inferior vena cava thrombosis (without central catheter relationship).