Ligation of the thoracic duct without thoractomy as an effective treatment for postoperative chylothorax: A newly designed surgical procedure

We describe herein a newly designed surgical procedure for ligating the thoracic duct to treat postoperative chylothorax, without performing a thoractomy. This technique was successfully performed on a 50-year-old man who developed chylothorax following resection of carcinoma of the esophagus whose case is briefly presented. The advantages of this procedure include the following: the integrity of the thorax is maintained, there is less traumatization, the need for a drainage tube is eliminated, shorter hospitalization is required, and the thoracic duct is much more easily exposed than by conventional transthoracic approaches. No similar report was found in our research of the literature.     

Introduction of lymphangiography and percutaneous embolization of the thoracic duct in a stepwise approach to the management of chylous fistulas

BACKGROUND: Chylous fistula occurring after head and neck or thoracic surgery is an uncommon but well-described complication, with a reported incidence of 1% to 2.5%. Conservative management can be successful and consists of dietary measures combined with suction drainage. This article reports on percutaneous embolization of the thoracic duct through catheterization of the retroperitoneal lymph vessels. METHODS: Two patients, in whom conservative management for cervical chylous fistula failed, underwent lymphangiography with opacification of the thoracic duct, followed by radioguided catheterization and embolization. RESULTS: Embolization was successful in both patients. In 1 patient the procedure had to be repeated once to stop the chylous drainage. CONCLUSIONS: Radioguided percutaneous catheterization and embolization of the retroperitoneal lymph vessels offers an excellent treatment option for patients with persistent chylous fistulas after failure of conservative management. We revised our stepwise management protocol (de Gier, Head Neck 1996; 18:347-351) and now consider this procedure as the secondary intervention step.     

乳糜胸的治疗进展

乳糜胸的治疗取决于患者的潜在病因及个体临床状况,如何选择最佳的治疗方案较为困难.目前主要的治疗方法包括中链甘油三酯饮食、静脉营养、药物治疗、胸腔穿刺、胸膜固定术、胸腹膜分流术、胸导管结扎或栓塞术等.本文就乳糜胸的治疗进展做一综述.     

Advantage of earlier thoracoscopic clipping of thoracic duct for post-operation chylothorax following thoracic aneurysm surgery

We report that an earlier thoracoscopic clipping of the thoracic duct was advantageous in a case of post-operation chylothorax that occurred following thoracic aneurysm surgery. A 61-year-old man developed chylothrax on postoperative day 2 following graft replacement of the descending thoracic aorta using a left-sided thoracotomy. Since a replaced graft infection is lethal, earlier thoracoscopic clipping of the thoracic duct through the right side chest wall was indicated. The patient underwent thoracoscopic clipping on postoperative day 7 and was successfully treated. The duration of drainage was 2 days and oral intake was started on the seventh day. From our results, we recommend a thoracoscopic procedure through the opposite (right) side chest wall in the early stage of chylothorax development following thoracic aneurysm surgery.     

膈上胸导管结扎术在食管癌切除术中的应用

目的探讨胸导管结扎术对食管癌术后乳糜胸的预防和治疗作用。方法回顾性分析我院2003年1月至2009年6月的两组共836例食管癌切除术后的乳糜胸发生情况和治疗效果。其中结扎组431例,术中常规在膈上水平整块结扎胸导管,非结扎组405例,术中未常规结扎胸导管,术后并发乳糜胸者,再次采用手术治疗。结果结扎组无术后乳糜胸发生。非结扎组术后发生乳糜胸15例（3．7％）,治愈13例（86．7％）,死亡2例（13．3％）,1例死于呼吸功能衰竭,1例死于多器官功能衰竭。结论食管癌切除术中常规结扎胸导管可有效预防术后乳糜胸的发生。膈上胸导管结扎法稳妥有效。食管癌术后并发乳糜胸应积极手术治疗。     

Somatostatin analog treatment of a cervical thoracic duct fistula

BACKGROUND: Reoperation for recurrent thyroid cancer poses an increased risk of complications, including thoracic duct fistula. Treatment of this complication is controversial. A survey of thoracic literature reports the use of somatostatin analog, whereas no cases have reported the use of this therapy in cases arising from neck dissection. METHODS: We report a 16-year-old girl with recurrent papillary thyroid cancer who had a persistent lymphatic-cutaneous fistula develop after repeat modified left neck dissection. Despite conservative management, drainage persisted for 2 months. A regimen was begun that included TPN and injections of a somatostatin analog. RESULTS: Treatment with a somatostatin analog resulted in an immediate attenuation of drainage and subsequent closure of the fistula after 16 days of treatment. CONCLUSION: The use of somatostatin analog can increase the success of conservative management of thoracic duct fistulae.     

The practical value of applying chemical biliary duct embolization to chemical hepatectomy for treatment of hepatolithiasis

BACKGROUND: The high recurrence rate of hepatolithiasis, together with the high operative risk of hepatectomy for specifically located stones, has not been effectively settled until now. Thus, the aim of this study was to investigate the feasibility and effectiveness of using chemical biliary duct embolization (CBDE) to achieve chemical hepatectomy in a rabbit model of hepatolithiasis. MATERIALS AND METHODS: The animal model of hepatolithiasis was established using the methods of obstruction plus infection. Seven days later, the left hepatic ducts were embolized using phenol plus cyanoacrylate or absolute ethanol plus cyanoacrylate. Subsequently, the influence of CBDE on bile duct, liver, and stone formation was analyzed by histology, RT-PCR for procollagen, biochemistry, and enzymatic histochemistry for beta-glucuronidase (beta-G). RESULTS: CBDE resulted in the entire ablation of the diseased biliary duct mucosa and the complete occlusion of the diseased biliary duct lumen, thus effectively eradicating chronic proliferative cholangitis and preventing stone formation. More importantly, CBDE also resulted in the complete fibrosis and "self-cut" in the periphery of the embolized lobe, thus achieving chemical hepatectomy. Also of note, the embolized lobe exhibited a much lower level of endogenous beta-G than the nonembolized lobe, indicating an inhibitory effect of CBDE on beta-G. Besides, the mRNA level of procollagen I in the embolized bile duct wall of phenol embolization group was significantly higher than the ethanol embolization group. CONCLUSION: Chemical biliary duct embolization, especially using phenol plus cyanoacrylate, may prevent the recurrence of intrahepatic stone and concurrently achieve the effect of chemical hepatectomy.     

Influences of thoracic duct blockage on early enteral nutrition for patients who underwent esophageal cancer surgery

OBJECTIVES: We have previously reported the beneficial effects of immediate enteral nutrition (EN) after esophageal cancer surgery. This randomized control study was conducted to determine whether immediate EN is beneficial or not for patients whose thoracic ducts were ligated, as well as those whose thoracic ducts were preserved. PATENTS AND METHODS: Thirty-nine patients who underwent radical resection of the esophageal cancer entered this trial. After stratifying into two groups--patients whose thoracic ducts were preserved [D(+)] and those whose thoracic ducts were ligated [D(-)], they were randomly divided into two groups--the patients who received early EN and those who received parenteral nutrition (PN) followed by delayed enteral feeding. Thus, the number of patients in the D(+)-EN group, D(+)-PN group, D(-)-EN group and D(-)-PN group were 13, 12, 7 and 7, respectively. The mortality and morbidity rates, and several blood chemistries were compared between the EN groups and the PN groups. RESULTS: Total lymphocyte count showed a significant early increase and serum c-reactive protein (CRP) was significantly decreased in the D(+)-EN group compared to the D(+)-PN group. However those differences were not observed between the D(-) groups. Serum total bilirubin was significantly decreased in the both EN groups compared to the PN groups. The mortality and morbidity rates were not different between the EN group and the PN group in the D(+) patients and also in the D(-) patients. CONCLUSIONS: Patients whose thoracic ducts were ligated did not obtain any other benefit from early enteral feeding except for bilirubin metabolism. Early enteral feeding is not recommended for patients whose thoracic ducts are ligated during radical resection of a cancer in the thoracic esophagus.     

Influences of thoracic duct blockage on early enteral nutrition for patients who underwent esophageal cancer surgery

Objectives: We have previously reported the beneficial effects of immediate enteral nutrition (EN) after esophageal cancer surgery. This randomized control study was conducted to determine whether immediate EN is beneficial or not for patients whose thoracic ducts were ligated, as well as those whose thoracic ducts were preserved.Patients and methods: Thirty-nine patients who underwent radical resection of the esophageal cancer entered this trial. After stratifying into two groups—patients whose thoracic ducts were preserved [D(+)] and those whose thoracic ducts were ligated [D(−)], they were randomly divided into two groups—the patients who received early EN and those who received parenteral nutrition (PN) followed by delayed enteral feeding. Thus, the number of patients in the D(+)-EN group, D(+)-PN group, D(−)-EN group and D(−)-PN group were 13, 12, 7 and 7, respectively. The mortality and morbidity rates, and several blood chemistries were compared between the EN groups and the PN groups.Results: Total lymphocyte count showed a significant early increase and serum c-reactive protein (CRP) was significantly decreased in the D(+)-EN group compared to the D(+)-PN group. However those differences were not observed between the D(−) groups. Serum total bilirubin was significantly decreased in the both EN groups compared to the PN groups. The mortality and morbidity rates were not different between the EN group and the PN group in the D(+) patients and also in the D(−) patients.Conclusions: Patients whose thoracic ducts were ligated did not obtain any other benefit from early enteral feeding except for bilirubin metabolism. Early enteral feeding is not recommended for patients whose thoracic ducts are ligated during radical resection of a cancer in the thoracic esophagus.     

Gastric cancer with carcinoma erysipeloides caused by spontaneous thoracic duct rupture: Report of a case

A case of extensive skin metastasis (carcinoma erysipeloides) resulting from spontaneous rupture of the metastasized Virchow lymph node in a 53-year-old woman is herein reported. Imaging evidence attributing this metastasis to spontaneous rupture of the fragile thoracic duct at the supraclavicular fossa is presented. The patient, who had already undergone gastric resection more than 6 years previously because of advanced gastric cancer, died approximately 4.5 months after the occurrence of lymphorrhea in her neck since the anticancer chemotherapy administered demonstrated little or no effect.     

Hemodynamic changes after resection of thoracic duct for en bloc resection of esophageal cancer

An en bloc resection of esophageal cancer is one of the most radical forms of esophagectomy, and includes the resection of the thoracic duct, but a relatively high hospital motality rate has been reported. There is very little knowledge on the pathophysiological changes after resection of the thoracic duct. We examined 24 patients who underwent en bloc resection. Some patients developed severe tachycardia or shock postoperatively which subsided after a massive infusion of plasma. Analysis of the fluid balance revealed that much more fluid was necessary during surgery and the postoperative 24 h than in patients treated by a standard esophagectomy. Postoperative lymphangiography or CT revealed abnormal collateral lymphatics around the kidneys or in the pelvic cavity. This suggests the development of the lymphaticovenous shunts, which differed depending on the anatomy of each patient. One patient with chronic hepatitis developed uncontrollable ascites. These are important findings which can hopefully reduce the high rate of hospital death after this operation.     

胆道镜治疗肝切除术后肝内胆管结石合并胆管狭窄的疗效分析

目的 探讨胆道镜治疗肝切除术后肝内胆管结石合并胆管狭窄的疗效.方法 回顾性分析2000年1月至2011年12月暨南大学第二临床医学院深圳市人民医院收治的1241例肝内胆管结石合并胆管狭窄患者的临床资料.根据患者肝切除术后治疗方案分为术后胆道镜组(652例患者,应用胆道镜经T管窦道取石)和保守治疗组(589例患者,门诊随访有症状时给予利胆和抗生素类药物治疗).分析两组患者的结石治疗效果、狭窄解除效果和并发症治疗效果,两组间计数资料比较采用,检验.结果 术后胆道镜组患者结石清除率为96.63％(630/652),高于保守治疗组患者的76.23％(449/589),两组比较,差异有统计学意义(x2=113.407,P＜0.05).术后胆道镜组患者共发现胆管狭窄1237支,其中膜状狭窄(狭窄段＜2 mm)698支、短管状狭窄(2 mm≤狭窄段≤5 mm)529支、长管状狭窄(狭窄段＞5 mm)8支、“门缝样”狭窄(其内大量结石)2支;狭窄解除率为99.35％(1229/1237),6支长管状狭窄和2支“门缝样”狭窄未能解除.保守治疗组患者共发现胆管狭窄986支,狭窄解除率为80.43％(793/986),两组比较,差异有统计学意义(x2=238.994,P＜0.05).术后胆道镜组中9例患者发生严重并发症.5例胆道大出血患者(碎石电极击穿胆管壁3例、球囊扩张2例)出血量均＞ 1500 ml,通过球囊压迫止血,其中1例反复出血3次,在第3次出血停止后行出血胆管所在肝叶切除术而治愈.肝内重症胆管炎2例,经过急诊胆道镜治疗,解除胆管梗阻而治愈.窦道形成不全2例,均为80岁以上患者,经十二指肠镜放置胆管塑料支架管后治愈,但肝内胆管结石未能取出.结论 肝切除术后规范的胆道镜治疗能有效解除肝内胆管狭窄,取尽结石.     

A 2-wk conservative treatment regimen preceding thoracic duct ligation is effective and safe for treating post-esophagectomy chylothorax

Background

Chylothorax is a pathologic condition defined by an accumulation of lymphatic fluid, the chyle, in the thorax. Postoperative chylothorax is a potentially lethal complication, with a reported mortality rate of 15.4%–25%.

Patients and methods

Esophageal cancer patients hospitalized for elective radical esophagectomy by thoracotomy (n = 10,574) were consecutively enrolled between January 1996 and December 2011. Patients (n = 306) who experienced post-esophagectomy chylothorax were assigned to a 48-h (group A, n = 186) or to a 2-wk (group B, n = 120) conservative treatment regimen. For patients with a daily chylothorax output >1000 mL, thoracic duct ligation (TDL) was performed by thoracotomy. Measured outcomes included frequency of TDL, overall and treatment-specific morbidity and mortality rates, and the rate of chylothorax recurrence.

Results

A total of 171 patients (171 of 306 [55.9%]) underwent TDL. A larger proportion of patients in group A required TDL compared with group B (72.6% versus 30.0%, P < 0.001). Group A had a significantly higher rate of overall morbidity compared with group B (31.7% versus 19.2%, P = 0.02). Moreover, the overall mortality rate was significantly higher in group A (14.0% versus 4.2%, P = 0.006). Chylothorax recurred in nine patients (9 of 306 [2.9%]), and there was no difference between the two groups (3.2% versus 2.5%, P = 1.000).

Conclusions

The 2-wk regimen reduced the requirement for TDL and the overall morbidity and mortality rates compared with the 48-h regimen. Importantly, this regimen does not increase the risk of chylothorax recurrence.     

胆胰镜下钬激光碎石术治疗术后难取性胆管结石

目的探讨胆胰镜下钬激光碎石治疗术后难取性胆管结石的价值。方法选取39例胆道镜难以取出的肝内胆管结石和3例胆道镜处理失败的肝外胆管结石患者,在胆胰镜下行钬激光碎石术,钬激光输出功率1.5~3.0 J,脉冲频率5~10 Hz。结果 39例行胆胰镜下钬激光碎石术2~6次,平均2.3次;36例取净结石,结石取净率92.3%(36/39);4例胆道镜处理失败的胆道结石行胆胰镜下钬激光碎石术1次予以取净。结论对于术后难取性胆管结石,胆胰镜下钬激光碎石术是安全、有效的新方法。     

Long‐term follow‐up of the treatment of renal angiomyolipomas after selective arterial embolization with alcohol

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

To present our institution’s experience of selective embolization of renal angiomyolipomas with alcohol and the long‐term follow up data.

PATIENTS AND METHODS

This retrospective study included 34 patients treated between October 1997 and October 2007 (29 women and five men, mean age 44 years). Of these patients, nine had tuberous sclerosis, 14 were bilateral and 16 were multifocal. Indications for treatment were previous haemorrhage (14), size >4 cm (19) and increasing size over a short period (one). The largest treated lesion was 24.4 cm, and the mean (range) size was 11.9 (2.9–24.4) cm. All patients were treated by selective embolization using a mixture of alcohol and lipiodol. Three patients also had coiling of aneurysms and two patients had additional embolization with polyvinyl alcohol particles. The follow‐up was both radiological and clinical, with recurrence defined as growth by >2 cm or symptoms requiring further treatment.

RESULTS

The technical success rate was 100%, with only one significant complication of non‐target renal embolization, with self‐limiting effects. Minor complications included 11 patients with post‐embolization syndrome, all of which settled with conservative measures. The mean (range) combined radiological and clinical follow‐up was 44.2 (12–116) months, with all patients having a follow‐up of >1 year. Radiological success was achieved in 97%, with only one lesion growing by >2 cm. The combined clinical and radiological success rate was 85%, with two patients undergoing surgery, two having repeat embolization and one currently offered surgery due to a recent increase in size.

CONCLUSION

Our study provides long‐term evidence that selective arterial embolization with alcohol is a safe and effective method for improving clinical symptoms (85%) and preventing tumour progression (97%) in patients with renal angiomyolipoma.     

Lymphaticovenous bypass of the thoracic duct for the treatment of chylous leak in central conducting lymphatic anomalies

Background

Central conducting lymphatic anomalies (CCLA) may cause chylous leaks and protein-losing enteropathy (PLE) owing to dysfunction of the central lymphatic channels. Most of the treatment strategies for these conditions are palliative and provide transient improvement.

Review of endovascular stent‐assisted embolization for management of intracranial aneurysms

Objective: This was a retrospective review of the results using stent‐assisted coil embolization for management of intracranial aneurysms. Methods: The records of seven patients treated with stent‐assisted Gugliemi detachable coil (GDC) embolization were retrieved from the authors’ prospectively maintained database. The clinical presentation, site and type of aneurysms, treatment procedure and complications, and outcome of these identified cases were reviewed. Results: Between January 2002 and May 2004, seven patients with intracranial aneurysms, four of which were ruptured, were treated by stent‐assisted GDC embolization. Four aneurysms were located at the anterior circulation and three were at the posterior circulation. The indications for stent use were: giant aneurysm (>2.5 cm), dissecting pseudo‐aneurysm, broad‐necked aneurysm and the need for preservation of important parent arteries or branches. Concerning the technical aspect, all except one had successful stent deployment. One stent dislodged after apparent successful deployment. GDC embolization was continued and the aneurysm was partially occluded. More than 90% occlusion of aneurysm sac was achieved in six aneurysms. Intraoperative complications included over‐coagulation, failure in stent deployment, displacement of stent, coil entrapment and thromboembolism. One patient had added focal neurological deficit after the procedure, and one became vegetative due to an unrelated cause. The patient in whom the stent was dislodged suffered another subarachnoid haemorrhage 4 months later and died. Conclusion: Percutaneous intracranial stent is a new and useful device to assist embolization of cerebral aneurysms that were previously not amenable to endovascular therapy. These preliminary results suggest that this procedure could achieve satisfactory outcomes without significant complications.     

Ultrasound‐guided wire localization of focal ductal dilatation in the evaluation and treatment of pathologic nipple discharge

Patients presenting with pathologic nipple discharge (PND) often pose a diagnostic and therapeutic challenge. We used ultrasound to identify focal ductal dilatation—hypothesized to be a radiographic manifestation of the causative lesion—in patients with PND and no relevant clinical or radiographic findings. Twenty‐two excisions guided by ultrasound wire localization of focal duct dilation were performed. Surgical pathology revealed papilloma in 20 cases (91%); atypia or carcinoma was detected in 7 cases (32%). The ultrasound finding of focal duct dilatation enables excision of otherwise occult though clinically significant lesions and is worthy of further study.