Tratamiento conservador del quilotórax posquirúrgico en paciente pediátrico / Conservative treatment of post-surgical chylothorax in pediatric patient

INTRODUCCIÓN. El quilotórax resulta de un daño al conducto torácico por ruptura, laceración, desgarro o compresión. Es una patología rara de derrame pleural en la edad pediátrica, pero frecuente como complicación posterior a cirugía cardiotorácica. La base del tratamiento conservador se ha fundamentado en: drenaje inicial, modificación de la dieta, uso de somatostatina o análogos sintéticos como octreotide, cirugía, prevención y manejo de complicaciones. Fue preciso describir la experiencia institucional clínica así como su abordaje. CASO CLÍNICO. Paciente masculino de 4 meses de edad, que ingresó a la Unidad Pediátrica Área de Emergencias del Hospital de Especialidades Carlos Andrade Marín, el 13 de septiembre de 2019 con antece-dente quirúrgico de atresia de esófago corregida en etapa neonatal. Acudió con dificultad respiratoria, radiografía de tórax que evidenció derrame pleural derecho, toracentesis diagnóstica con salida de líquido de aspecto turbio y lechoso; se colocó tubo de tórax derecho. Se prescribió ayuno inicial, nutrición parenteral durante 4 semanas hasta comprobar resolución del quilotórax. Fue dado de alta en condición estable tras 43 días de hospitalización. DISCUSIÓN. La evidencia científica registró que el tratamiento conservador del quilotórax se basó en: drenaje, reposo digestivo inicial, nutrición parenteral, modificación cualitativa de la dieta enteral y uso de octreotide; el mismo que fue aplicado al paciente de este caso clínico con evolución favorable. CONCLUSIÓN. El tratamiento conservador y multidisciplinario en el abordaje del qui-lotórax fue exitoso y no necesitó manejo quirúrgico.

INTRODUCTION. Chylothorax results from damage to the thoracic duct by rupture, la-ceration, tear or compression. It is a rare pathology of pleural effusion in pediatric age, but frequent as a complication after cardiothoracic surgery. The basis of conservative treatment has been based on: initial drainage, diet modification, use of somatostatin or synthetic analogues such as octreotide, surgery, prevention and management of complications. It was necessary to describe the clinical institutional experience as well as its approach. CLINICAL CASE. A 4-month-old male patient was admitted to the Emergency Area Pediatric Unit of the Carlos Andrade Marín Specialties Hospital on september 13, 2019 with a surgical history of esophageal atresia corrected in the neonatal stage. He went with respiratory distress, chest X-ray that showed right pleural effusion, diagnostic thoracentesis with outflow of cloudy and milky fluid; a right chest tube was placed. Initial fasting was prescribed, parenteral nutrition for 4 weeks until resolution of the chylothorax was verified. He was discharged in stable condition after 43 days of hospitalization. DISCUSSION. The scientific evidence recorded that the conservative treatment of chylothorax was based on: drainage, initial digestive rest, parenteral nutrition, qualitative modification of enteral diet and use of octreotide; the same that was applied to the patient of this clinical case with favorable evolu-tion. CONCLUSION. Conservative and multidisciplinary treatment in the approach to chylothorax was successful.

Thoracic duct lymphangioma and chylous ascites in a 24-year-old female

Lymphangiomas are rare and correspond to 0.7% to 4.0% of mediastinal tumors, and isolated mediastinal location occurs in 1% of cases. They are benign tumors that originate from a congenital malformation of the lymphatic vessels and are diagnosed more frequently in children less than 2 years of age. Chylous ascites is a clinical manifestation of thoracic duct lymphangioma and is composed of lymph accumulation caused by dilation of this lymphatic channel. It appears milky in the peritoneal cavity, containing triglyceride levels higher than 200 mg/dl. We report the case of a young patient with chylous ascites and lymphangioma of the thoracic duct, who was conservatively treated with octreotide and a low-fat diet with medium-chain triglycerides.

A Canine Model for Lymphangiography and Thoracic Duct Access

OBJECTIVE: To evaluate the technical feasibility of intranodal lymphangiography and thoracic duct (TD) access in a canine model.MATERIALS AND METHODS: Five male mongrel dogs were studied. The dog was placed in the supine position, and the most prominent lymph node in the groin was accessed using a 26-gauge spinal needle under ultrasonography (US) guidance. If the cisterna chyli (CC) was not opacified by bilateral lymphangiography, the medial iliac lymph nodes were directly punctured and Lipiodol was injected. After opacification, the CC was directly punctured with a 22-gauge needle. A 0.018-in microguidewire was advanced through the CC and TD. A 4-Fr introducer and dilator were then advanced over the wire. The microguidewire was changed to a 0.035-in guidewire, and this was advanced into the left subclavian vein through the terminal valve of the TD. Retrograde TD access was performed using a snare kit.RESULTS: US-guided lymphangiography (including intranodal injection of Lipiodol [Guerbet]) was successful in all five dogs. However, in three of the five dogs (60%), the medial iliac lymph nodes were not fully opacified due to overt Lipiodol extravasation at the initial injection site. In these dogs, contralateral superficial inguinal intranodal injection was performed. However, two of these three dogs subsequently underwent direct medial iliac lymph node puncture under fluoroscopy guidance to deliver additional Lipiodol into the lymphatic system. Transabdominal CC puncture and cannulation with a 4-Fr introducer was successful in all five dogs. Transvenous retrograde catheterization of the TD (performed using a snare kit) was also successful in all five dogs.CONCLUSION: A canine model may be appropriate for intranodal lymphangiography and TD access. Most lymphatic intervention techniques can be performed in a canine using the same instruments that are employed in a clinical setting.

Left-Sided Cisterna Chyli: a Case Report on a Rare Normal Anatomic Structure

The cisterna chyli, a dilated lymphatic sac in the retrocrural space, is usually located to the right of the aorta. We report a case of a left-sided cisterna chyli, which was incidentally detected on the radiologic examinations of a preoperative workup for cholangiocarcinoma. Computed tomography (CT) and magnetic resonance (MR) images revealed a cisterna chyli measuring 2.5 cm in length in the left retrocrural space. The dilated lumbar lymphatics joined with the cisterna chyli, which was continuous with the left-sided thoracic duct. To the best of our knowledge, this is the second antemortem case of a left-sided cisterna chyli in literature. The cisterna chyli can mimic retrocrural lymphadenopathy, solid tumor with cystic degeneration, abscess or hematoma. The left-sided cisterna chyli should be referred to as a structure so as to be cautious in surgical approach.

Resolution of Protein-Losing Enteropathy after Congenital Heart Disease Repair by Selective Lymphatic Embolization / 대한소아소화기영양학회지

With improving survival of children with complex congenital heart disease (CCHD), postoperative complications, like protein-losing enteropathy (PLE) are increasingly encountered. A 3-year-old girl with surgically corrected CCHD (ventricular inversion/L-transposition of the great arteries, ventricular septal defect, pulmonary atresia, post-double switch procedure [Rastelli and Glenn]) developed chylothoraces. She was treated with pleurodesis, thoracic duct ligation and subsequently developed chylous ascites and PLE (serum albumin ≤0.9 g/dL) and was malnourished, despite nutritional rehabilitation. Lymphangioscintigraphy/single-photon emission computed tomography showed lymphatic obstruction at the cisterna chyli level. A segmental chyle leak and chylous lymphangiectasia were confirmed by gastrointestinal endoscopy, magnetic resonance (MR) enterography, and MR lymphangiography. Selective glue embolization of leaking intestinal lymphatic trunks led to prompt reversal of PLE. Serum albumin level and weight gain markedly improved and have been maintained for over 3 years. Selective interventional embolization reversed this devastating lymphatic complication of surgically corrected CCHD.

Lymphangiographic Interventions to Manage Postoperative Chylothorax / 대한흉부외과학회지

BACKGROUND: Postoperative chylothorax may be caused by iatrogenic injury of the collateral lymphatic ducts after thoracic surgery. Although traditional treatment could be considered in most cases, resolution may be slow. Radiological interventions have recently been developed to manage postoperative chylothorax. This study aimed to compare radiological interventions and conservative management in patients with postoperative chylothorax.METHODS: We retrospectively reviewed periprocedural drainage time, length of hospital stay, and nil per os (NPO) duration in 7 patients who received radiological interventions (intervention group [IG]) and in 9 patients who received conservative management (non-intervention group [NG]).RESULTS: The baseline characteristics of the patients in the IG and NG were comparable; however, the median drainage time and median length of hospital stay after detection of chylothorax were significantly shorter in the IG than in the NG (6 vs. 10 days, p=0.036 and 10 vs. 20 days, p=0.025, respectively). NPO duration after chylothorax detection and total drainage duration were somewhat shorter in the IG than in the NG (5 vs. 7 days and 8 vs. 14 days, respectively).CONCLUSION: This study showed that radiological interventions reduced the duration of drainage and the length of hospital stay, allowing an earlier return to normal life. To overcome several limitations of this study, a prospective, randomized controlled trial with a larger number of patients is recommended.

Chylous Manifestations and Management of Gorham-Stout Syndrome / 대한흉부외과학회지

Gorham-Stout disease (GSD) was first described by Gorham and colleagues in 1954, but its precise mechanism and cause remain to be elucidated. In this condition, voluminous and potentially fatal chylous effusions into the thorax can occur. Herein, we describe a case of GSD in which the patient presented with massive pleural effusions and mottled osteolytic bone lesions. We performed multiple operations, including thoracic duct ligation using video-assisted thoracoscopic surgery and thoracotomic decortication, but these procedures did not succeed in preventing recurrent pleural effusion and chest wall lymphedema. After administering sirolimus (0.8 mg/m2, twice a day) and propranolol (40 mg, twice a day), the process of GSD in this patient has been controlled for more than 2 years.

Ascitis quilosa post cirugía abdominal: caso clínico y revisión de la literatura / Chylous ascites management: clinical case and literature review

Chylous ascites is a peritoneal collection with milky appearance, rich in triglycerides produced by the presence of thoracic or intestinal lymph in the abdominal cavity. The increasing number of surgical interventions has meant an increase of this disease in the last time. We present the case of a 39-yearsold woman with a history of a retroperitoneal cystic lesion in the abdominal ultrasound, which was a finding, and was followed up for 5 years. In the last control abdominal ultrasound showed an accelerated growth, the study was complemented with a Magnetic Resonance Imaging of the abdomen showed a retroperitoneal cystic lesion, 7 cm larger diameter in contact with aorta, left ureter and lower pole of the left kidney, suspecting malignancy, reason why its surgical resection was decided. It evolved after the surgical intervention with progressive increase of the abdominal perimeter, diffuse pain and early satiety, performing abdominal ultrasound showing a liver of normal structure with moderate ascites. The diagnostic paracentesis gave out 1,000 mL of milky-white liquid with triglycerides of 1,287 mg/dL. The diagnosis of chylous ascites was proposed, secondary to thoracic duct injury and it was managed with a diet with low intake of saturated, polyunsaturated and monounsaturated fats, with medium chain triglycerides with favorable results. The pathophysiology, etiology, nutritional and non-nutritional management of chylous ascites are discussed.

La ascitis quilosa es una colección peritoneal con apariencia lechosa, rica en triglicéridos producido por la presencia de linfa torácica o intestinal en la cavidad abdominal. El creciente número de intervenciones quirúrgicas ha significado un aumento de esta patología en el último tiempo. Se presenta el caso de una mujer de 39 años, con historia de una lesión retroperitoneal quística en la ecotomografía abdominal, que fue un hallazgo, realizándose seguimiento por 5 años. En la última ecotomografía de control presentó crecimiento acelerado por lo que se complementa estudio con una Resonancia Nuclear Magnética de abdomen que muestro lesión quística retroperitoneal de 7 cm de diámetro mayor en contacto con aorta, uréter izquierdo y polo inferior del riñón izquierdo, sospechándose malignidad, por lo que se decide su resección. Evolucionó posterior a la intervención quirúrgica con aumento progresivo del perímetro abdominal, dolor difuso y saciedad precoz, realizándose ecotomografía abdominal que muestra un hígado de estructura normal con ascitis moderada. La paracentesis diagnóstica dio salida a 1.000 mL de líquido blanquecino de aspecto lechoso con triglicéridos de 1.287 mg/dL. Se planteó el diagnóstico de ascitis quilosa, secundario a lesión del conducto torácico y se manejó con dieta con bajo aporte en grasas saturadas, poliinsaturadas y monoinsaturadas, con aporte de triglicéridos de cadena media con resultados favorables. Se discuten la fisiopatología, etiología, manejo nutricional y no nutricional de la ascitis quilosa.

Postoperative Chylothorax: the Use of Dynamic Magnetic Resonance Lymphangiography and Thoracic Duct Embolization

Dynamic enhanced magnetic resonance lymphangiography can be used to provide anatomic and dynamic information for various lymphatic diseases, including thoracic duct injury, and can also help to guide the thoracic duct embolization procedure. We present a case of postoperative chylothorax demonstrated by dynamic enhanced MR lymphangiography. In this case, the chyle leakage site and location of cisterna chyli were clearly visualized by dynamic enhanced MR lymphangiography, thus allowing for management with thoracic duct embolization.

The key points of prevention for special surgical complications after radical operation of gastric cancer / 中华胃肠外科杂志

Incidence of gastric cancer is high in China and standard radical operation is currently the main treatment for gastric cancer. Postoperative complications, especially some special complications, can directly affect the prognosis of patients, even result in the increase of mortality. But the incidences of these special complications are low, so these complications are often misdiagnosed and delayed in treatment owing to insufficient recognition of medical staff. These special complications include (1) Peterson hernia: It is an abdominal hernia developed in the space between Roux loop and transverse colon mesentery after Roux-Y reconstruction of digestive tract. Peterson hernia is rare and can quickly result in gangrenous ileus. Because of low incidence and without specific clinical symptoms, this hernia does not attract enough attention in clinical practice, so the outcome will be very serious. Once the diagnosis is made, an emergent operation must be performed immediately. Peterson space should be closed routinely in order to avoid the development of hernia. (2) Lymphatic leakage: It is also called chyle leakage. Cisterna chylus is formed by gradual concentration of extensive lymphatic net to diaphragm angle within abdominal cavity. Lymphadenectomy during operation may easily damage lymphatic net and result in leakage. The use of ultrasonic scalpel can decrease the risk of lymphatic leakage in certain degree. If lymphatic leakage is found during operation, transfixion should be performed in time. Treatment includes total parenteral nutrition, maintenance of internal environment, supplement of protein, and observation by clamp as an attempt. (3)Duodenal stump leakage: It is one of serious complications affecting the recovery and leading to death after subtotal gastrectomy. Correct management of duodenal stump during operation is one of key points of the prevention of duodenal stump leakage. Routine purse embedding of duodenal stump is recommend during operation. The key treatment of this complication is to promt diagnosis and effective hemostasis.(4) Blood supply disorder of Roux-Y intestinal loop: Main preventive principle of this complication is to pay attention to the blood supply of vascular arch in intestinal edge. (5) Anastomotic obstruction by big purse of jejunal stump: When Roux-en-Y anastomosis is performed after distal radical operation for gastric cancer, anvil is placed in the remnant stomach and anastomat from distal jejunal stump is placed to make gastrojejunal anastomosis, and the stump is closed with big purse embedding. The embedding jejunal stump may enter gastric cavity leading to internal hernia and anastomotic obstruction. We suggest that application of interruptable and interlocking suture and fixation of stump on the gastric wall can avoid the development of this complication.

Simultaneous chylothorax and chylous ascites / 영남의대학술지

Chylothorax or chylous ascites are rare manifestations of liver cirrhosis. We report a rare case of simultaneous chylothorax and chylous ascites in a patient with hepatitis B virus-related liver cirrhosis. A 76-year-old woman was referred to our hospital with a pleural effusion on her right side. She had no history of recent medical procedures, trauma or tumor. There was no evidence of mass or thoracic duct obstruction in a computed tomography scan. Pleural fluid and ascites were confirmed as chylothorax and chylous ascites by chemistry analysis. Despite thorough conservative care, there was no improvement. Pleurodesis was planned, but hepatic encephalopathy developed suddenly and she did not recover.

Simultaneous chylothorax and chylous ascites / 영남의대학술지

Chylothorax or chylous ascites are rare manifestations of liver cirrhosis. We report a rare case of simultaneous chylothorax and chylous ascites in a patient with hepatitis B virus-related liver cirrhosis. A 76-year-old woman was referred to our hospital with a pleural effusion on her right side. She had no history of recent medical procedures, trauma or tumor. There was no evidence of mass or thoracic duct obstruction in a computed tomography scan. Pleural fluid and ascites were confirmed as chylothorax and chylous ascites by chemistry analysis. Despite thorough conservative care, there was no improvement. Pleurodesis was planned, but hepatic encephalopathy developed suddenly and she did not recover.

Optimal lymphadenectomy for thoracic esophageal cancer: three-field or modified two-field lymphadenectomy / 中华胃肠外科杂志

Differences in operative procedure and knowledge of esophageal cancer exist among surgeons from different countries and regions. There is controversy in the surgical treatment of esophageal cancer, especially in the extent of lymphadenectomy. Until now, results of the three-field lymphadenectomy and two-field lymphadenectomy are mostly reported by retrospective studies from Japan and China. Three-field lymphadenectomy has been initiated in Fujian Provincial Cancer Hospital since 1990s. After evaluating our database, we found that three-field was superior to two-field lymphadenectomy in terms of long-term survival for patients with upper thoracic esophageal cancer, whereas for those with middle or lower thoracic esophageal cancer, the survival benefit of three-field lymphadenectomy was reduced. Therefore, we propose to perform three-field lymphadenectomy for upper thoracic esophageal cancer. In middle or lower thoracic esophageal cancer, we suggest to perform modified two-field lymphadenectomy in most cases, and three-field lymphadenectomy in selective cases. Video-assisted two-field lymphadenectomy is feasible. Based on the national condition of China, we advise to perform thoracic duct removal only in patients with posterior mediastinal or peri-ductus node metastasis to achieve curative effect.

Effect of Octreotide Injection on Postoperative Drainage After Neck Dissection: A Preliminary Report of a Prospective, Matched Case-Control Study

OBJECTIVES: Somatostatin inhibits lymph production and reduces lymph flow into the lymphatic duct. We hypothesized that octreotide, a long-acting somatostatin analog, would reduce drainage after neck dissection (ND) by reducing the overall lymphatic flow in the neck as well as thoracic duct flow. METHODS: From 2012 to 2014, total 123 patients who had undergone left-sided comprehensive ND, were divided into an octreotide group (49 patients) and a control group (74 patients). Seventeen patients from the octreotide group and 17 from the control group were individually matched by age (±10 years), sex, body mass index (±1 kg/m2), type of cancer, surgeon, and the extent of surgery. These 34 patients were finally included in the study. RESULTS: The total fluid drainage volume (540.9 mL vs. 707.9 mL) and drainage volume during the period of octreotide use (the first 5 postoperative days) (461.1 mL vs. 676.4 mL) were significantly lower in the octreotide group. The duration of drain placement (6.3 days vs. 9.4 days) was also shorter in the octreotide group. In the octreotide group, the mean triglyceride concentration in the drainage fluid was significantly lower than that in the control group (43.1 mg/dL vs. 88.8 mg/dL). There was no complication associated with the use of octreotide. CONCLUSION: Our study has shown that postoperative octreotide injections reduce postoperative drainage and the duration of drain placement. Further studies with larger patient populations are warranted to confirm these results and to evaluate the clinical benefits for patients.

Clinical Features of Herniated Disc at Cervicothoracic Junction Level Treated by Anterior Approach

OBJECTIVE: The anterior approach for C7-T1 disc herniation may be challenging because of obstruction by the manubrium and the narrow operative field. This study aimed to investigate the clinical and neurological outcomes of anterior approach for C7-T1 disc herniation. METHODS: We retrospectively evaluated 13 patients who underwent the anterior approach for C7-T1 disc herniation by a single surgeon within a period of 11 years (2003-2014). The minimum follow-up duration was 6 months. We describe the clinical presentation, radiographic findings, neurological outcome, and related complications. RESULTS: Of 372 patients with single-level anterior discectomy and fusion or artificial disc replacement for cervical disc herniation, 13 (3.5%) had C7-T1 disc herniation. The main clinical presentation was unilateral motor weakness in intrinsic hand muscles (11 patients), along with numbness, pain, and tingling sensation that radiate down the arm to the little finger. Most of the patients improved after surgery via the anterior approach. Ten patients underwent successful anterior discectomy and fusion by the standard supramanubrial Smith-Robinson approach, but 2 needed additional manubriotomy and sternotomy. In 1 patient, we performed surgery at a wrong level because the correct level was difficult to identify intraoperatively. Two patients had transient vocal dysfunction, but none had major complications related to injuries of the great vessels such as the thoracic duct or esophagus. CONCLUSION: For patients who require direct anterior decompression for C7-T1 disc herniation, the anterior approach is relatively feasible. However, care should be taken to overcome physical constraints by the manubrium and slope.

Manejo conservador de una fistula de quilo por disección radical de cuello: reporte de un caso y revisión de la literatura / Conservative management of chyle fistula diseción by radical neck: a case report and literature review

Se expone el caso de un paciente masculino de 59 años con diagnóstico de carcinoma medular de tiroides con metástasis ganglionares, al cual se le realiza una tiroidectomía total bilateral con disección radical de cuello modificada tipo III. En el postoperatorio se documenta fístula del conducto torácico. Se dio un manejo conservador con dieta hiperprotéica sin carbohidratos y rica en triglicéridos de cadena media el cual fue satisfactorio.

We describe the case of a 59-year-old male patient with a diagnosis of medullar thyroid carcinoma with affection of a cervical lymph node surgically managed with total thyroidectomy and bilateral radical neck dissection. It was diagnosed with a thoracic duct fistula. A conservative management with a strict diet of proteins enriched with medium chain triglycerides was performed in a successful way. Because of the case a review of the literature was performed.

A Case of Cervical Thoracic Duct Cyst / 대한이비인후과학회지

Thoracic duct cysts are very rare. They are usually asymptomatic but sometimes cause compressive effects on structures near them due to enlarged supraclavicular mass. The etiology of thoracic duct cysts is not fully understood, but the possibility of congenital weakness or atherosclerotic changes of ductal wall, trauma, and inflammatory reactions have been suggested. Although image studies are helpful, the excision of mass and the histological studies are needed for definite diagnosis. We now report this extremely rare case of cervical thoracic duct cyst in the left supraclavicular fossa, including its diagnostic methods and pathogenesis.

Thoracic Duct Embolization with Lipiodol for Chylothorax due to Thoracic Endovascular Aortic Repair with Debranching Procedure

Chylothorax is a rare postoperative complication of a thoracic surgical procedure. Here, we report a case of chylothorax after thoracic endovascular aortic repair with debranching for the distal arch aneurysm of the aorta. First, the patient was treated by a medical method (nil per os, fat-free diet, and octreotide), but this method failed. The patient strongly refused surgical treatment. Therefore, we tried to occlude the thoracic duct by lymphangiography Lipiodol, and this line of treatment was successful.

Aberrent Thoracic Duct Cyst in Postrior Mediastinum

Thoracic duct cysts in the upper portion of the diaphragm are mostly found in the neck and are rarely found in the mediastinum. Thoracic duct cysts should be differentiated from other mediastinal tumors or cysts, and surgical treatment is required to avoid the development of chylothorax if the cyst ruptures. Herein, we report the case of a patient with a thoracic cyst located just above the diaphragm that was treated with surgical resection.