Surgical Management of Lymphatic Leakage

Lymphatics are found in almost every organ in the body, and they produce a variety of waste products that must be eliminated. lymphatic leakage is a typical occurrence. It can cause immunodeficiency as well as nutritional issues. Furthermore, it has a significant morbidity and death rate, depending on the existence of an underlying illness. Lymphatic leakage can be congenital, traumatic, or cancerous, and occurs when the lymphatic system is disrupted. It might take the following forms: Chylothorax, Lymphatic Fistula, Chylous Ascites. treatment of lymph leaks includes: reduction of lymphatic flow through physiological or pharmacological manipulation; replacement of fluid and electrolytes, as well as interventional procedure and/or direct surgical closure. In this review we’ll be discussing lymphatic system anatomy, its leakage and its management.

Unusual Left Periclavicular Cutaneous Lymphatic Fistula After Port Explantation Without Lymph Vessel Injury: Imaging and Interventional Treatment

Complex oncological treatment can be associated with lymphatic vascular injury that is burdened by considerable morbidity. Lymphatic imaging and interventional techniques offer new minimally invasive treatment options. We report the case of a 59-year-old woman with an unusual lympho-veno-cutaneous fistula, diagnosed by magnetic resonance lymphangiography and treated by minimally invasive embolization therapy and venous recanalization.

Percutaneous afferent lymphatic vessel sclerotherapy for postoperative lymphatic leakage after previous ineffective therapeutic transpedal lymphangiography

Background To demonstrate the efficacy of percutaneous computed tomography (CT)-guided afferent lymphatic vessel sclerotherapy (ALVS) in the treatment of postoperative lymphatic leakage (LL) after ineffective therapeutic transpedal lymphangiography (TL). Methods A retrospective review in this institute involving 201 patients was conducted from May 2011 to September 2018. Patients diagnosed with postoperative LL undergoing ineffective therapeutical TL before the performance of percutaneous CT-guided ALVS were involved. Technical success and clinical success of TL and ALVS were established. The technical success and efficacy of ALVS in the treatment of postoperative LL after ineffective therapeutic TL were assessed. The clinical success rate of ALVS is also assessed, and the complications are reviewed. Results In total, nine patients were involved including three patients (33.3%) presented with chylothorax, three patients (33.3%) presented with inguinal lymphatic fistula/lymphocele, and three patients (33.3%) presented with lymphatic fistula in the thigh; 27 ± 18 days (mean ± standard deviation) after surgery, therapeutic TL was successfully performed and showed definite afferent lymphatic vessel and leakage site in all the patients. Due to clinical failure after TLs, the following ALVS was performed with a mean interval of 12 ± 8 days after TL. The technical success rate was 9/9 (100.0%, 95% confidence interval [CI] 63.1–100.0%). An average of 2.7 ± 1.3 mL 95% ethanol as sclerosant agent was injected during the procedure. The clinical success was observed in 8 of the 9 patients (88.9%, 95% CI 51.8–99.7%) with a time between ALVS and the LL cure of 8 ± 6 days. No complications were reported. Conclusions Our results showed the role of percutaneous CT-guided ALVS as a safe, feasible, and effective salvage treatment for postoperative LL after ineffective TL.

A medical epopee: recurrent fungal endocarditis, heart transplantation and chylopericardium

Background Candida prosthetic endocarditis is associated with high mortality rates and valve replacement surgery, together with antifungal treatment, play a major role in eradicating the fungal infection. Valve reoperations in these scenarios may be relatively common due to the high infection relapse rates and, in some cases, heart transplantation may be an imposing therapy for infection resolution and for the heart failure related to the myocardial reoperation injury. Among the many postoperative complications related to heart transplantation, chylopericardium is a rare but challenging example. Case presentation We report the case of a 55-year-old man who was admitted to our hospital with a 1-month history of progressive dyspnea and fatigue. His past medical history included four open-heart surgeries for aortic and mitral valve replacement due to recurrent Candida parapsilosis infective endocarditis. Transthoracic echocardiogram showed a markedly reduced left ventricular systolic function and normofunctioning bioprosthetic valves. An inotropic dependency condition led to heart transplantation surgery. In the early postoperative period, a persistent chylous fluid started to drain from the pericardial tube, compatible with the diagnosis of chylopericardium. The lack of clinical response to total parenteral nutrition and intravenous infusion of octreotide imposed the need of interventional radiology with diagnostic lymphography through cisterna chyli puncture and thoracic duct catheterization, confirming the presence of a lymphatic fistula. A successful treatment outcome was achieved with percutaneous thoracic duct embolization using coils and n-butyl-cyanoacrilate glue, possibiliting hospital discharge. Conclusions Fungal endocarditis requires combined treatment (surgical and antimicrobial) for eradication. Valve replacement, while necessary, may lead to severe ventricular deterioration and heart transplantation may be the only viable therapeutic solution. Among the several postoperative complications of heart transplantation, chylopericardium is an uncommon and defiant example. Advances in interventional radiology like the percutaneous embolization allow a less invasive and highly efficient approach for this complication.

The roles of iodized oil-based lymphangiography and post-lymphangiographic computed tomography for specific lymphatic intervention planning in patients with postoperative lymphatic fistula: a literature review and case series

In the management of patients with postoperative lymphatic fistula (LF) in different locations, iodized oil-based lymphangiography (LAG) from trans-pedal or intranodal route is an established diagnostic approach with the potential to plan further interventional treatments. However, specific lymphatic interventions are indicated depending on different locations and morphologies of the LF. After a systematic literature review, four types of interventions can be considered, including direct leakage embolization/sclerotherapy (DLE/DLS), percutaneous afferent lymphatic vessel embolization (ALVE), percutaneous afferent lymphatic vessels disruption/sclerotherapy (ALVD/ALVS), and trans-afferent nodal embolization (TNE). In the iodized oil-based LAG, three potential lymphatic targets including confined leakage, definite afferent LVs, and definite closest afferent LNs should be comprehensively assessed. For optimal prospective treatment planning for LF, iodized oil-based post-lymphangiographic computed tomography (post-LAG CT) is a useful complement to the conventional iodized oil-based LAG, which can be performed easily after LAG. This review article summarized the current evidence of the specific lymphatic interventions in patients with postoperative LF and explored the potential benefits of post-LAG CT in the intervention planning from a case series.

Injury in axillary thoracic duct

Introduction: In adults, the lymph flow through the thoracic duct presents about 4 liters a day; therefore, its injury may lead to accumulation in the pleural cavity, causing acute and chronic changes in pulmonary function. However, if less frequent, such an accumulation can still be observed in surgery, as was the case of the patient reported in this study. The injuries are not so frequent and may be caused by neoplasms or during surgical procedures in in the thoracic region and trauma, such as esophagectomy, mediastinal and pleuropulmonary surgeries. The early recognition and adequate therapy for the fistula in the thoracic duct prevent secondary nutrient and lymphocyte depletion. Clinical diagnosis is mostly based on high chest drain output, accompanied by the milky aspect. Besides, computed tomography, lymphoscintigraphy and lymphoangiography are possible methods for diagnosis. The clinical series about injuries in the duct after thoracic surgeries report that 25% to 50% of the cases present the spontaneous closure of the fistula only with conservative measures, such as the introduction of parenteral nutrition or enteral diet with medium-chain triglycerides. The persistence of the fistula leads to the need for clinical-surgical treatment. Objective: To report the case of rare post-surgery complication in a patient submitted to modified radical mastectomy (left) with immediate breast reconstruction. Results: Forty-eight year old woman born in Santana do Parnaíba – SP, diagnosed with left-breast cancer, invasive breast carcinoma histological type, Luminal B, submitted to modified radical mastectomy (left) (Madden technique), with immediate breast reconstruction. The intraoperative period showed major impairment in left axillary lymph nodes involving lymph vessels and nodes. In the postoperative period, she presented high drainage in the suction drain, with milky aspect, in the left axillary region. Then came the hypotheses of surgical complications, such as secondary infection, seroma, and thoracic duct injury, or in some branch. The biochemical analysis of the milky fluid showed high concentration of triglycerides, and cytology described the presence of proteinaceous material and macrophages. A conservative conduct was chosen, with adjustment of hyperproteic, hypoglycific diet, rich in medium-chain triglycerides. Twenty days after tha diagnostic hypothesis, the patient underwent lymphoscintigraphy, which did not show the fistula. She evolved with gradual output reduction until the removal of the drain, and was discharged from the hospital in good conditions. At the time, the patient continues with the adjuvant treatment for breast neoplasm. Conclusion: Post-surgical lymphatic fistula in the axillary region is a rare complication; however, its early diagnosis and treatment is essential in order to prevent complications, such as malnutrition and worsened immunological status.