The essential role of thoracic duct embolization in management of traumatic iatrogenic chylothorax / O papel fundamental da embolização do ducto torácico no manejo de quilotórax traumático iatrogênico

Abstract This study aims to describe a case series of patients who underwent thoracic duct embolization (TDE) to treat traumatic iatrogenic chylothorax (TIC). Three patients were included: Case #1, a 49-year-old woman with follicular lymphoma developed a TIC following video-assisted thoracoscopic surgery to resect a solid right paravertebral mass and was treated with TDE using microcoils and N-butyl cyanoacrylate (NBCA) glue. Case #2, a 68-year-old man with cardiac amyloidosis developed a TIC following heart transplantation and was treated with TDE using microcoils and ethylene vinyl alcohol copolymer. Case#3: A 6-year-old patient with congenital heart disease developed a TIC following a Fontan procedure and was treated with TDE using NBCA glue. All lesions were identified during lymphangiography and TDE was successfully performed in all cases. TDE is a safe and valuable technique that provides minimally invasive treatment for TCI.

Resumo Este estudo objetiva descrever uma série de casos de pacientes submetidos a embolização do ducto torácico (EDT) para tratamento de quilotórax iatrogênico (QI). Três pacientes foram incluídos. Caso 1: um homem de 49 anos com linfoma folicular apresentou QI após ressecção de uma massa paravertebral por toracoscopia vídeo-assistida e foi submetido a EDT com micromolas e n-butil-cianoacrilato (NBCA). Caso 2: um homem de 68 anos com amiloidose cardíaca apresentou QI após ser submetido a transplante cardíaco e foi submetido a EDT com micromolas e copolímero de etileno e álcool vinílico. Caso 3: um paciente de 6 anos com malformação cardíaca congênita apresentou QI após cirurgia de Fontan e foi submetido a EDT com NBCA. Todas as lesões foram identificadas durante a linfangiografia, e a EDT foi realizada com sucesso. A EDT é uma técnica segura e valiosa, que pode oferecer um tratamento minimamente invasivo em casos de QI.

Tratamiento supermicroquirúrgico del linfocele inguinal con linfedema intercurrente: restauración de la fisiología linfática / Supermicrosurgical approach to inguinal lymphocele with lymphedema: restoring the lymphatic physiology

Resumen Introducción: El linfocele es una patología que puede ocurrir por la disrupción linfática durante una cirugía, siendo frecuente luego de una linfadenectomía inguinal. Existen diversos enfrentamientos para prevenirlo o minimizarlo, sin embargo, los resultados son inconsistentes. Caso clínico: Reportamos el caso de una mujer, con linfocele recurrente en zona inguinal derecha y linfedema distal de la extremidad secundario a una biopsia ganglionar, tratado exitosamente mediante supermicrocirugía para restaurar el drenaje linfático. La extremidad inferior tenía un exceso de volumen de 7,03%. Se realizaron estudios preoperatorios con linfografía por resonancia magnética y linfografía con verde de indocianina para identificar los vasos linfáticos y realizar anastomosis linfático-venosas (ALV). Se identificaron tres vasos linfáticos aferentes y se realizó una capsulectomía total. Se realizaron tres ALV término-terminales supermicroquirúrgicas en zona inguinal y una ALV distal en pierna. Durante seguimiento no hubo recidiva del linfocele, evidenciándose una reducción del exceso de volumen de la extremidad afectada de un 105,26%. El linfocele inguinal y linfedema pueden ser tratados exitosamente mediante supermicrocirugía, restaurando el flujo linfático de manera fisiológica, evitando la recurrencia de linfocele y mejorando los síntomas del linfedema.

Introduction: Lymphocele may occur after the disruption of lymphatic channels during a surgical procedure. After inguinal lymphadenectomy are very common, and many different approaches have been tried to prevent or minimize the formation of lymphoceles with inconsistent results. Clinical Case: We report a case of a female patient who presented with right recurrent inguinal lymphocele and lower limb lymphedema after lymph-node biopsy that was successfully treated with lymphatic supermicrosurgery restoring the lymph flow. Lower extremity had an excess volume of 7,03% compared to the healthy contralateral limb. Preoperative study with magnetic resonance lymphangiography and indocyanine green lymphography were done to identify intraoperatively lymphocele afferent and distal lymphatic vessels to perform lymphovenous anastomosis (LVA). Three different afferent lymphatics were identified and total capsulectomy was performed. Three end-to- end supermicrosurgical LVA in the groin and one distal LVA on the leg were performed. The surgery was uneventful, and there were no postoperative complications. In the follow-up, no lymphocele was noticed and lymphedema had visibly reduced with a reduction of excess volume of 105.26%. Inguinal lymphocele and lymphedema can be successfully treated with supermicrosurgery since it is a physiological approach to restore the lymphatic flow, in order to avoid lymphocele recurrence and to improve lymphedema symptoms.

Linfedema: actualización en el diagnóstico y tratamiento quirúrgico / Lymphedema: update in diagnosis and surgical treatment

El linfedema es la acumulación de fluido rico en proteínas en el intersticio, secundario a anomalías en el sistema de transporte linfático. En países desarrollados se relaciona más frecuentemente al tratamiento quirúrgico del cáncer. El diagnóstico clínico y a través de técnicas de imágenes es fundamental para evaluar el estado funcional del sistema linfático. Los objetivos principales en el manejo del linfedema son limitar la morbilidad del paciente, mejorar la funcionalidad y la calidad de vida. El tratamiento quirúrgico es una alternativa cuando las medidas conservadoras ya no son suficientes. Existen procedimientos que buscan prevenir el desarrollo del linfedema y técnicas que incluye procedimientos fisiológicos (reconstructivos) y resectivos que se utilizan cuando el linfedema ya está establecido. El éxito depende de una buena elección de los pacientes y la realización de un tratamiento individualizado. A continuación se presenta una revisión en cuanto a las últimas estrategias diagnósticas y actualización en las técnicas quirúrgicas con énfasis en el tratamiento microquirúrgico.

Lymphedema is the accumulation of protein-rich fluid in the interstitium, secondary to abnormalities in the lymphatic transport system. In developed countries it is more often related to surgical treatment of cancer. The clinical diagnosis and through imaging techniques is fundamental to evaluate the functional status of the lymphatic system. The main objectives in managing lymphedema are to limit patient morbidity, improve functionality and quality of life. Surgical treatment is an option when conservative measures are no longer sufficient. There are procedures that seek to prevent the development of lymphedema, and techniques that include physiological (reconstructive) and resective procedures that are used when lymphedema is already established. Success depends on a good selection of patients and the completion of an individualized treatment. The following is a review article of the latest diagnostic strategies and update in surgical techniques with emphasis on microsurgical treatment.

Função linfática do membro superior no pré-operatório de câncer de mama / Preoperative upper limb lymphatic function in breast cancer surgery

OBJETIVO: Descrever o padrão linfocintilográfico do membro superior em mulheres no pré-operatório de câncer de mama. MÉTODOS: Foram estudadas 37 pacientes que realizaram a linfocintilografia até 30 dias antes da cirurgia, sendo 37 estudos linfocintilográficos de membros superiores ipsilaterais à cirurgia e 32 contralaterais. O protocolo de exame consistiu na realização de imagens estáticas do membro superior em semiflexão após 10 minutos, 1 e 2 horas da injeção subcutânea de 1 mCi (37 MBq) de dextran-99mTc no dorso da mão. Foram feitas análises da velocidade de aparecimento dos linfonodos axilares (I, visíveis aos 10 minutos; II, 1 hora; III, 2 horas e IV, não visíveis) e do grau (intensidade) de captação dos mesmos (a, acentuada; b, moderada; c , discreta e d, ausente). RESULTADOS: Quatro (11 por cento) pacientes apresentaram o padrão de estado da funcionalidade linfática considerado ideal (Ia) no membro superior ipsilateral, enquanto seis (19 por cento) apresentaram no contralateral. Três (8 por cento) apresentaram a pior classificação (IVd) no membro superior ipsilateral e duas (6 por cento) no contralateral. As demais pacientes apresentaram estados intermediários de velocidade e intensidade de captação. CONCLUSÃO: Este estudo encontrou relevantes alterações na linfocintilografia pré-operatória, demonstrando a preexistência de diferenças funcionais do sistema linfático.

OBJECTIVE: To describe the preoperative upper limb lymphoscintigraphic pattern in women with breast cancer. METHODS: Thirty-seven patients undergoing lymphoscintigraphy within 30 days of surgery were investigated. Lymphoscintigraphic studies of 37 upper limbs ipsilateral to surgery and 32 contralateral upper limbs were performed. The examination protocol consisted in obtaining static images of the upper limb in semi-flexion after 10 minutes, and 1 and 2 hours after subcutaneous injection of 1 mCi (37 MBq) of Tc-99m-dextran in the dorsum of the hand. The velocity of axillary lymph node visualization (I, visible at 10 minutes; II, 1 hour; III, 2 hours; and IV, invisible) and degree (intensity) of nodal uptake (a, marked; b, moderate; c,mild; and d, absent) were analyzed. RESULTS: Optimal lymphatic functional pattern (Ia) was observed in four (11 percent) patients, in the ipsilateral upper limb, and six (19 percent), in the contralateral upper limb. Worse condition was observed in three (8 percent) patients (IVd) in the ipsilateral upper limb and two (6 percent) patients in the contralateral upper limb. The remaining patients showed intermediate states of velocity and uptake intensity. CONCLUSION: This study found relevant changes in preoperative lymphoscintigraphy, demonstrating preexisting functional differences in the lymphatic system.

Evaluación de Dos Tipos de Medios de Contraste para Linfografía Directa en Perro / Evaluation of Two Contrast Media for Direct Lymphography in Dog

Se realizó una evaluación de dos medios de contraste para la linfografía directa en 24 caninos mestizos no acondroplásicos, clínicamente sanos. Se utilizó un medio de contraste hidrosoluble (diatrizoato de sodio y meglúmina) y un medio liposoluble (aceite de adormidera yodada), en dosis de 96 mg de yodo por kg de peso para el miembro torácico y de 192 mg de yodo por kg de peso para el miembro pélvico. Las imágenes se evaluaron de acuerdo al grado de contraste y definición de las estructuras evidenciables por esta técnica. En ambos medios de contraste el grado de definición obtenido en los miembros y en el sistema colector central fue bueno, sin embargo, se logró un grado de contraste superior con el medio liposoluble, principalmente a nivel de sistema linfático central. Algunos ejemplares evidenciaron la presencia de émbolos pulmonares al usar un medio liposoluble.

Two contrast media for direct lymphography in 24 healthy dogs not achondoplasic were evaluated. It used a hidrosoluble contrast media (sodium diatrizoato and meglumina) and another lyposoluble media (Ionided adormidera's oil) in dose of 96 mg/I/kg to the thoracic member and 192mg/I/kg for a rear member. The images were evaluated indeed of contrast level and definition of structures for each contrast media. The definition degree for each contrast media both the members and central collector system were good, however its was better for the lyposoluble contras media, especially in the central collector system. Some dogs show embolous in the lungs vessel when lyposoluble media was used.