Embolization of the thoracic duct in patients with iatrogenic chylothorax

Abstract

Summary Chylothorax is leakage of lymphatic fluid accumulating in the pleural cavity due to the thoracic duct’s (TD) trauma or obstructions. It generally occurs as a traumatic complication after general thoracic surgery procedures (0.4%), especially after esophagectomy (4.7–8.6%). Traditionally, surgical intervention is performed if conservative management fails, but reports of high mortality (2.1%) and morbidity (38%) have led to the development of a minimally invasive percutaneous treatment method; TD embolization (TDE). The records of all patients treated for chylothorax with TDE from April 2015 to June 2019 were reviewed. Only patients with iatrogenic chylothorax were included. The outcomes measures are defined as a technical and a clinical success. A technical success, is defined as the ability to perform the embolization procedure, thereby injecting embolizing material Histoacryl with or without coils. A clinical success is defined as a complete cessation of lymphatic leakage into the pleural cavity without surgical intervention and, therefore, a cured patient. Lymphography was performed in all patients, and visualization of cisterna chyli was achieved in 14/17 patients (82.4%). Of the 17 patients included, 15 patients were successfully embolized and cured of chylothorax (88.2%). Successfully embolized patients had a median discharge time of 7 days. Most patients reported postprocedural pain, which was dealt with using conventional pain medication. TDE seems like a safe percutaneous treatment technique with a high clinical success rate in iatrogenic chylothorax patients which can be readily implemented if the clinical experience is available..

Treatment and outcomes of chylothorax in children: 20-year experience of a single institute

“…It is quite a liberal manner to step “back and forth” on the intensity of fat restriction without using a standard fixed protocol. Strategies that have been successful in shortening time to resolution of chylothorax and chest tube utilization in the pediatric population are specific steroids (hydrocortisone, dexamethasone, and methylprednisolone) and furosemide ( 14 ), thoracic duct embolization ( 9 , 15 , 16 ) and protocolized management ( 9 , 17 ). Most protocols categorized the severity of chylothorax by the volume of chyle output, using a cut-off of 20 mL/kg/day.…”

Non-conservative Management of Chylothorax

“…These anatomic variations are the underlying cause of the diversity of intervention success rates [ 2 , 9 , 11 ]. Moreover, there is a high risk of tearing along the course of the lymphatic pathway during esophagectomy and lymph node dissection due to the proximity of the course of the thoracic duct to other structures [ 1 , 12 , 13 ]. Any tear in the thoracic duct can quickly lead to the accumulation of large volumes of lymphatic fluid, since it usually transports around 2–4 L of chyle per day [ 11 ].…”

“…A 0.018-inch (0.46 mm) guidewire and microcatheter are used to cannulate the thoracic duct, which is then embolized using Concerto 3EA microcoils and an NBCA/lipiodol mixture (weight ratio 1:1). This procedure has a success rate of over 90% in chylothorax cases [ 1 , 2 , 4 , 14 , 19 , 20 ].…”

“…during esophagectomy and lymph node dissection due to the proximity of the course of the thoracic duct to other structures [1,12,13]. Any tear in the thoracic duct can quickly lead to the accumulation of large volumes of lymphatic fluid, since it usually transports around 2-4 L of chyle per day [11].…”

“…The classification of chylothorax depends on its etiology (traumatic, non-traumatic, or idiopathic). Regardless of the cause, the medical and surgical options to reduce lymph leakage for patients with chylothorax are similar to those for patients with high flow chylothorax (>25 mL/kg/day for child, 1,000 mL/day for adult) [ 1 - 8 ]. If even repeated interventions are not effective, surgical treatment might be the last option [ 7 , 9 , 10 ].…”