[Persistent chylothorax in patient with lymphangioleiomyomatosis].

PubMed

Palmeiro, R; Arosa, V; Cuerda, C; Bretón, I; Camblor, M; Rodríguez, Ma C; García Peris, P

2012-01-01

Lymphangioleiomyomatosis (LAM) is a rare disease that affects women in fertile age and presents a systemic progressive evolution, being the lung and the mediastinic lymph nodes the most affected organs. The pulmonary disease is characterized by dyspnea, pleural effusion, hemoptysis and spontaneous pneumothorax, being the chylothorax a frequent complication in the course of this disease, appearing in up to 30% of cases. The treatment of chylothorax is not standardized and it is necessary a multidisciplinary approach: nutritional, pharmacological, respiratory and even surgery. These patients present high risk of malnutrition due to the constant loss of chyle, therefore a suitable nutritional management is essential to avoid more complications.

Lymphatic endothelial cell line (CH3) from a recurrent retroperitoneal lymphangioma.

PubMed

Way, D; Hendrix, M; Witte, M; Witte, C; Nagle, R; Davis, J

1987-09-01

An endothelial cell line derived from a massive recurrent chyle-containing retroperitoneal lymphangioma was isolated in monolayer culture. Scanning and transmission electron microscopy and immunohistochemistry confirmed a close resemblance to blood vascular endothelium with typical cobblestone morphology, positive immunofluorescence staining for endothelial marker Factor VIII-associated antigen and fibronectin, and prominent Weibel-Palade bodies. The endothelial cells also exhibited other ultrastructural features characteristic of lymphatic endothelium, including sparse microvillous surface projections, overlapping intercellular junctions, and abundant intermediate filaments. This endothelial cell line represents a new source of proliferating lymphatic endothelium for future study, including structural and functional comparison to blood vascular endothelium.

Conservative treatment of postoperative chylothorax: a case report.

PubMed

Wagh, Sachinkumar; Deshmukh, Sanjay; Ankolikar, Shrikant

2018-02-06

Chylothorax is a well-documented complication of thoracic trauma and is associated with high rates of morbidity and mortality. Treatment for chylothorax includes conservative measures (total parenteral nutrition, pleural drainage, and pleurodesis) and surgery (thoracic duct ligation). We present the case of a 65-year-old man who developed chylothorax after an elective surgical procedure. In this report conservative treatment aims to reduce chyle flow, to drain the pleural cavity in an effective manner, and to prevent chronic sequelae. Optimal conservative treatment, started immediately upon diagnosis, effectively reduces the need for reoperation and long-term hospitalization, and it might prevent further sequelae of chylothorax. The chylothorax was successfully treated conservatively, which may reduce the need for reoperation.

Chest drainage systems in use

PubMed Central

Zisis, Charalambos; Tsirgogianni, Katerina; Lazaridis, George; Lampaki, Sofia; Baka, Sofia; Mpoukovinas, Ioannis; Karavasilis, Vasilis; Kioumis, Ioannis; Pitsiou, Georgia; Katsikogiannis, Nikolaos; Tsakiridis, Kosmas; Rapti, Aggeliki; Trakada, Georgia; Karapantzos, Ilias; Karapantzou, Chrysanthi; Zissimopoulos, Athanasios; Zarogoulidis, Konstantinos

2015-01-01

A chest tube is a flexible plastic tube that is inserted through the chest wall and into the pleural space or mediastinum. It is used to remove air in the case of pneumothorax or fluid such as in the case of pleural effusion, blood, chyle, or pus when empyema occurs from the intrathoracic space. It is also known as a Bülau drain or an intercostal catheter. Insertion of chest tubes is widely performed by radiologists, pulmonary physicians and thoracic surgeons. Large catheters or small catheters are used based on each situation that the medical doctor encounters. In the current review we will focus on the chest drain systems that are in use. PMID:25815304

[Postsurgical chylous ascites: case report and literature review].

PubMed

Olivar Roldán, J; Fernández Martínez, A; Martínez Sancho, E; Díaz Gómez, J; Martín Borge, V; Gómez Candela, C

2009-01-01

Chylous ascites derives from chyle leakage into the peritoneal cavity, either due to rupture or obstruction of abdominal lymphatic vessels. The main clinical sign is abdominal distention, while diagnosis requires the presence of triglycerides in ascitic fluid. Neoplasms are the most common cause of chylous ascites, although less common causes, such as abdominal surgery, should also be considered. The mainstay of therapy is hyperproteic diet with fat restriction and middle-chain triglycerides. Parenteral nutrition is reserved for cases in which dietary treatment fails to restore an optimal nutritional status or is contraindicated, whereas surgery is considered for patients that are deemed refractory to conservative therapy. We present a case of chylous ascites secondary to retroperitoneal lymphadenectomy.

THE MANAGEMENT OF CHYLOTHORAX

PubMed Central

Connolly, John E.; Smith, John W.

1959-01-01

Chylothorax is readily diagnosed from the characteristic qualities of the effusion. Treatment should initially be conservative, consisting of multiple aspirations followed, if necessary, by suction drainage. Approximately half of the patients will not respond to these measures, and direct ligation and division of the duct is necessary for cure. This operation is most readily carried out through the right chest, the thoracic duct being ligated just above the diaphragm. In cases in which the duct is surrounded by tumor, radiotherapy to the mediastinum is often successful in controlling the reaccumulation of chyle, but irradiation is generally not recommended until after a tissue diagnosis has been made by thoracotomy. Nutritional problems are often concomitants of chylothorax. ImagesFigure 1 (Case 1).Figure 2 (Case 1).Figure 3 (Case 2).Figure 4 (Case 2).Figure 5 (Case 3).Figure 6 (Case 3). PMID:13671361

Primary chylous vaginal discharge in a 9-year-old girl: CT-lymphangiogram and MR appearance.

PubMed

Shahlaee, A H; Burton, E M; Sabio, H; Plouffe, L; Teeslink, R

1997-09-01

Chylous reflux is a manifestation of primary or secondary lymphatic obstruction. Primary lymphatic obstruction is defined as lymphangiectasia and incompetency of lymphatic valves without an underlying cause. Lymphangiectasia resulting from trauma, neoplasm, irradiation, or inflammation characterizes secondary lymphatic obstruction. Leakage of chyle into the uterus, vagina, bladder, or rectum can occur with either primary or secondary lymphatic obstruction. We report a patient with chylous vaginal discharge, a rare presentation of primary chylous reflux syndrome. CT-lymphangiography and magnetic resonance imaging clearly depicted this disorder. To our knowledge, only 20 cases of chylous vaginal discharge have been reported previously; chylous vaginal drainage occurred in the absence of chylous uterine reflux in only three. Although this is a rare anomaly, chylous reflux should be considered in a child with chronic vaginal discharge and lower extremity swelling.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Lyon, Stuart, E-mail: lyonsey@optusnet.com.au; Mott, Nigel, E-mail: nigelmott76@hotmail.com; Koukounaras, Jim

Chylothorax is an uncommon type of pleural effusion whose etiology may be classified as traumatic or nontraumatic. Low-output chylothoraces usually respond well to conservative management, whereas high-output chylothoraces are more likely to require surgical or interventional treatment. Conservative management focuses on alleviation of symptoms, replacement of fluid and nutrient losses, and reduction of chyle output to facilitate spontaneous healing. Surgical management can be technically difficult due to the high incidence of variant anatomy and the high-risk patient population. Percutaneous treatments have rapidly developed and evolved during the past 14 years to represent a minimally invasive treatment compared with the moremore » invasive nature of surgery. Percutaneous therapies provide a range of treatment options despite difficult or variant anatomy, with a reported high success rate coupled with low morbidity and mortality. This article is a review of etiology, diagnosis, and treatment of chylothorax, with a focus on interventional management techniques.« less

The fluid mechanics of nutrition: Herman Boerhaave's synthesis of seventeenth-century circulation physiology.

PubMed

Orland, Barbara

2012-06-01

This paper investigates the theory of nutrition of Herman Boerhaave, the famous professor of medicine and chemistry at the university of Leyden. Boerhaave's work, which systematized and synthesized the knowledge of the time, represents a shift from a humoral to a hydraulic model of the body in medicine and culture around 1700. This epistemological reconfiguration of early modern physiological thinking is exemplified with respect to the changing meanings of milk. While over centuries the analogy between blood and milk played an essential role in understanding the hidden workings of the nutritional faculties, following the discovery of the blood circulation the blood-milk analogy was transformed into a chyle-milk analogy. Yet Boerhaave's interpretations show that the use of new knowledge tools did not simply displace the old ways of reasoning. Instead, analogies continued to serve as epistemic instruments. Old theories and new insights overlapped, and contemporary knowledge assimilated past ideas. Copyright © 2011. Published by Elsevier Ltd.

Postoperative Chylothorax of Unclear Etiology in a Patient with Right-sided Subclavian Central Venous Catheter Placement

PubMed Central

Asghar, Samie; Shamim, Faisal

2017-01-01

A young male underwent decompressive craniotomy for an intracerebral bleed. A right-sided subclavian central venous catheter was placed in the operating room after induction of anesthesia. Postoperatively, he was shifted to Intensive Care Unit (ICU) for mechanical ventilation due to low Glasgow coma scale. He had an episode of severe agitation and straining on the tracheal tube in the evening same day. On the 2nd postoperative day in ICU, his airway pressures were high, and chest X-ray revealed massive pleural effusion on right side. Under ultrasound guidance, 1400 milky white fluid was aspirated. It was sent for analysis (triglycerides) that confirmed chyle and hence, chylothorax was made as diagnosis. A duplex scan was done which ruled out thrombosis in subclavian vein. The catheter had normal pressure tracing with free aspiration of blood from all ports. Enteral feeding was continued as it is a controversial matter in the literature and he was monitored clinically and radiologically. PMID:29284881

Postoperative Chylothorax of Unclear Etiology in a Patient with Right-sided Subclavian Central Venous Catheter Placement.

PubMed

Asghar, Samie; Shamim, Faisal

2017-01-01

A young male underwent decompressive craniotomy for an intracerebral bleed. A right-sided subclavian central venous catheter was placed in the operating room after induction of anesthesia. Postoperatively, he was shifted to Intensive Care Unit (ICU) for mechanical ventilation due to low Glasgow coma scale. He had an episode of severe agitation and straining on the tracheal tube in the evening same day. On the 2 nd postoperative day in ICU, his airway pressures were high, and chest X-ray revealed massive pleural effusion on right side. Under ultrasound guidance, 1400 milky white fluid was aspirated. It was sent for analysis (triglycerides) that confirmed chyle and hence, chylothorax was made as diagnosis. A duplex scan was done which ruled out thrombosis in subclavian vein. The catheter had normal pressure tracing with free aspiration of blood from all ports. Enteral feeding was continued as it is a controversial matter in the literature and he was monitored clinically and radiologically.

Chylothorax in dermatomyositis complicated with interstitial pneumonia.

PubMed

Isoda, Kentaro; Kiboshi, Takao; Shoda, Takeshi

2017-04-01

Chylothorax is a disease in which chyle leaks and accumulates in the thoracic cavity. Interstitial pneumonia and pneumomediastinum are common thoracic manifestations of dermatomyositis, but chylothorax complicated with dermatomyositis is not reported. We report a case of dermatomyositis with interstitial pneumonia complicated by chylothorax. A 77-year-old woman was diagnosed as dermatomyositis with Gottron's papules, skin ulcers, anti-MDA5 antibody and rapid progressive interstitial pneumonia. Treatment with betamethasone, tacrolimus and intravenous high-dose cyclophosphamide was initiated, and her skin symptoms and interstitial pneumonia improved once. However, right-sided chylothorax began to accumulate and gradually increase, and at the same time, her interstitial pneumonia began to exacerbate, and skin ulcers began to reappear on her fingers and auricles. Although her chylothorax improved by fasting and parenteral nutrition, she died due to further exacerbations of dermatomyositis and interstitial pneumonia in spite of steroid pulse therapy, increase in the betamethasone dosage, additional intravenous high-dose cyclophosphamide and plasma pheresis. An autopsy showed no lesions such as malignant tumors in the thoracic cavity. This is the first report of chylothorax complicated by dermatomyositis with interstitial pneumonia.

Unconventional Management of Chyloascites After Laparoscopic Nissen Fundoplication

PubMed Central

Ospina, Karen A.; Lee, Earl H.; Rehring, Scott R.

2012-01-01

Background & Objectives: Chyloascites is a rare complication that can result from abdominal trauma, neoplasm, inflammatory conditions, or various abdominal surgeries. Few cases have been described secondary to iatrogenic injury from laparoscopic Nissen fundoplication. We describe a case in which this surgery resulted in chyloascites that was successfully treated by lymphatic glue embolization. Methods: A 37-year-old male presented with signs and symptoms consistent with chronic reflux disease. He underwent an uneventful laparoscopic Nissen fundoplication. Two weeks postoperatively, he was admitted for dehydration. During his admission, he began to develop a persistent cough, shortness of breath, and abdominal distention. Imaging and fluid analysis from thoracocentesis and paracentesis were consistent with chyle leakage. Despite nonoperative measures, the patient's presentation persisted. Results: Thoracic duct ligation was performed without success. Bipedal lymphangiography identified an extensive leak revealing a severely lacerated thoracic duct spilling contrast freely into the abdomen and no contrast entering the thoracic duct in the chest. The site of injury was successfully sealed off with percutaneous glue embolization through lymph channels. Conclusion: Chyloascites is a rare complication of laparoscopic Nissen fundoplication. When not successful with conservative measures, lymphatic glue embolization can provide effective treatment. PMID:23477184

Characteristics of Multi-Organ Lymphangiectasia Resulting from Temporal Deletion of Calcitonin Receptor-Like Receptor in Adult Mice

PubMed Central

Hoopes, Samantha L.; Willcockson, Helen H.; Caron, Kathleen M.

2012-01-01

Adrenomedullin (AM) and its receptor complexes, calcitonin receptor-like receptor (Calcrl) and receptor activity modifying protein 2/3, are highly expressed in lymphatic endothelial cells and are required for embryonic lymphatic development. To determine the role of Calcrl in adulthood, we used an inducible Cre-loxP system to temporally and ubiquitously delete Calcrl in adult mice. Following tamoxifen injection, Calcrlfl/fl/CAGGCre-ER™ mice rapidly developed corneal edema and inflammation that was preceded by and persistently associated with dilated corneoscleral lymphatics. Lacteals and submucosal lymphatic capillaries of the intestine were also dilated, while mesenteric collecting lymphatics failed to properly transport chyle after an acute Western Diet, culminating in chronic failure of Calcrlfl/fl/CAGGCre-ER™ mice to gain weight. Dermal lymphatic capillaries were also dilated and chronic edema challenge confirmed significant and prolonged dermal lymphatic insufficiency. In vivo and in vitro imaging of lymphatics with either genetic or pharmacologic inhibition of AM signaling revealed markedly disorganized lymphatic junctional proteins ZO-1 and VE-cadherin. The maintenance of AM signaling during adulthood is required for preserving normal lymphatic permeability and function. Collectively, these studies reveal a spectrum of lymphatic defects in adult Calcrlfl/fl/CAGGCre-ER™ mice that closely recapitulate the clinical symptoms of patients with corneal, intestinal and peripheral lymphangiectasia. PMID:23028890

Characteristics of multi-organ lymphangiectasia resulting from temporal deletion of calcitonin receptor-like receptor in adult mice.

PubMed

Hoopes, Samantha L; Willcockson, Helen H; Caron, Kathleen M

2012-01-01

Adrenomedullin (AM) and its receptor complexes, calcitonin receptor-like receptor (Calcrl) and receptor activity modifying protein 2/3, are highly expressed in lymphatic endothelial cells and are required for embryonic lymphatic development. To determine the role of Calcrl in adulthood, we used an inducible Cre-loxP system to temporally and ubiquitously delete Calcrl in adult mice. Following tamoxifen injection, Calcrl(fl/fl)/CAGGCre-ER™ mice rapidly developed corneal edema and inflammation that was preceded by and persistently associated with dilated corneoscleral lymphatics. Lacteals and submucosal lymphatic capillaries of the intestine were also dilated, while mesenteric collecting lymphatics failed to properly transport chyle after an acute Western Diet, culminating in chronic failure of Calcrl(fl/fl)/CAGGCre-ER™ mice to gain weight. Dermal lymphatic capillaries were also dilated and chronic edema challenge confirmed significant and prolonged dermal lymphatic insufficiency. In vivo and in vitro imaging of lymphatics with either genetic or pharmacologic inhibition of AM signaling revealed markedly disorganized lymphatic junctional proteins ZO-1 and VE-cadherin. The maintenance of AM signaling during adulthood is required for preserving normal lymphatic permeability and function. Collectively, these studies reveal a spectrum of lymphatic defects in adult Calcrl(fl/fl)/CAGGCre-ER™ mice that closely recapitulate the clinical symptoms of patients with corneal, intestinal and peripheral lymphangiectasia.

OK-432 sclerotherapy of cervical chylous lymphocele after neck dissection.

PubMed

Roh, Jong-Lyel; Park, Chan Il

2008-06-01

Postoperative cervical chylous lymphoceles are extremely rare circumscribed collections of lymph which are usually treated by drainage or surgical exploration, but rarely by sclerotherapy. We investigated the efficacy of OK-432 (Picibanil, Chungai Pharmaceutical Co., Tokyo, Japan) sclerotherapy in the treatment of cervical lymphocele after neck dissection. Four patients with postoperative lymphocele who could not be cured by repeated percutaneous needle aspiration and pressure dressing were treated with intralesional injection of 0.1-0.2 mg OK-432 after aspiration of fluid. The aspirated fluid was assessed biochemically and cytologically, and regular palpation and ultrasonography/computed tomography were used to evaluate outcomes and recurrences. Two patients with chyle leak during neck dissection had lymphoceles in the left supraclavicular region 3 weeks later. The other two patients had lymphoceles on the right neck 9 and 12 months, respectively, after neck dissection. All aspirated fluids were chylous in origin without tumor cells. OK-432 sclerotherapy scored all four lesions with no major complications except for fever and local pain for several days. No lymphocele recurrences or metastatic cancers were observed in any patient for >1 year after sclerotherapy. Intralesional injection of OK-432 may be a safe and effective alternative to surgical exploration in the treatment of cervical lymphocele after neck dissection.

Feasibility and Efficacy of Defatted Human Milk in the Treatment for Chylothorax After Cardiac Surgery in Infants.

PubMed

Fogg, Kristi L; DellaValle, Diane M; Buckley, Jason R; Graham, Eric M; Zyblewski, Sinai C

2016-08-01

Chylothorax is a well-described complication after cardiothoracic surgery in children. Medical nutritional therapy for chylothorax includes medium-chain triglyceride (MCT) formulas and reduction in enteral long-chain triglyceride intake to reduce chyle production. Human milk is usually eliminated from the diet of infants with chylothorax because of its high long-chain triglyceride content. However, given the immunologic properties of human milk, young infants with chylothorax may benefit from using human milk over human milk substitutes. We performed a retrospective cohort study to describe the feasibility and efficacy of defatted human milk (DHM) for the treatment for chylothorax in infants after cardiac surgery and to compare growth outcomes between infants treated with DHM (n = 14) versus MCT formula (n = 21). There were no differences in mortality or length of hospital stay between the DHM and MCT formula treatment groups. The DHM treatment group had a significantly higher weight-for-age z-score at hospital discharge compared to the MCT formula group with median z-scores of -1 (-2 to 0.5) and -1.5 (-2 to 0), respectively (p = 0.02). In infants with chylothorax after cardiac surgery, DHM is a safe and feasible medical nutritional treatment and may have potential benefits for improved nutrition and growth.

US-Guided, Direct Puncture Retrograde Thoracic Duct Access, Lymphangiography, and Embolization: Feasibility and Efficacy.

PubMed

Guevara, Carlos J; Rialon, Kristy L; Ramaswamy, Raja S; Kim, Seung K; Darcy, Michael D

2016-12-01

To describe technical details, success rate, and advantages of direct puncture of the thoracic duct (TD) under direct ultrasound (US) guidance at venous insertion in the left neck. All patients who underwent attempted thoracic duct embolization (TDE) via US-guided retrograde TD access in the left neck were retrospectively reviewed. Indications for lymphangiography were iatrogenic chyle leak, pulmonary lymphangiectasia, and plastic bronchitis. Ten patients with mean age 41.4 years (range, 21 d to 72 y) underwent US-guided TD access via the left neck. Technical details, procedural times, and clinical outcomes were evaluated. TD access time was defined as time from start of procedure to successful access of TD, and total procedural time was defined from start of procedure until TDE. All attempts at TD access via the neck were successful. Technical and clinical success of TDE was 60%. There were no complications. Mean TD access time was 17 minutes (range, 2-47 min), and mean total procedure time was 49 minutes (range, 25-69 min). Mean follow-up time was 5.4 months (range, 3-10 months). TDE via US-guided access in the left neck is technically feasible and safe with a potential decrease in procedure time and elimination of oil-based contrast material. Copyright © 2016 SIR. Published by Elsevier Inc. All rights reserved.

Absorption and metabolism of orally fed arachidonic and linoleic acid in the rat

DOE Office of Scientific and Technical Information (OSTI.GOV)

Nilsson, A.; Melin, T.

1988-11-01

({sup 3}H)arachidonic (({sup 3}H)20:4) and ({sup 14}C)linoleic acid ({sup 14}C)18:2 were fed to rats in Intralipid or cream. Later (30-240 min) the stomach, small intestine, plasma, and liver were analyzed for radioactivity in different lipid classes. ({sup 3}H)20:4 and ({sup 14}C)18:2 were emptied from the stomach and absorbed by the intestine at similar rates. The ({sup 3}H)20:4:({sup 14}C)18:2 ratio of the lipids in the small intestinal wall increased, however, with time. This was due to a higher retention of ({sup 3}H)20:4 than ({sup 14}C)18:2 in intestinal phospholipids. In contrast, more of the ({sup 14}C)18:2 was in triacylglycerol of the smallmore » intestine and plasma. The highest {sup 3}H:{sup 14}C ratios were found in phosphatidylethanolamine and phosphatidylinositol. The {sup 3}H:{sup 14}C ratio of intestinal phosphatidylcholine varied with the type of fat vehicle used, being highest in the Intralipid experiments. After feeding Intralipid (30-60 min), significantly more of the plasma ({sup 3}H)20:4 than plasma ({sup 14}C)18:2 was in diacylglycerol, the {sup 3}H:{sup 14}C ratio of which was much higher than that of plasma free fatty acids. ({sup 3}H)20:4 and ({sup 14}C)18:2 of chyle triacylglycerol are thus metabolized differently.« less

Development of a simple indocyanine green measurement method using an automated biochemical analyser.

PubMed

Sato, Yuka; Seimiya, Masanori; Yoshida, Toshihiko; Sawabe, Yuji; Hokazono, Eisaku; Osawa, Susumu; Matsushita, Kazuyuki

2017-01-01

Background The indocyanine green retention rate is important for assessing the severity of liver disorders. In the conventional method, blood needs to be collected twice. In the present study, we developed an automated indocyanine green method that does not require blood sampling before intravenous indocyanine green injections and is applicable to an automated biochemical analyser. Methods The serum samples of 471 patients collected before and after intravenous indocyanine green injections and submitted to the clinical laboratory of our hospital were used as samples. The standard procedure established by the Japan Society of Hepatology was used as the standard method. In the automated indocyanine green method, serum collected after an intravenous indocyanine green injection was mixed with the saline reagent containing a surfactant, and the indocyanine green concentration was measured at a dominant wavelength of 805 nm and a complementary wavelength of 884 nm. Results The coefficient of variations of the within- and between-run reproducibilities of this method were 2% or lower, and dilution linearity passing the origin was noted up to 10 mg/L indocyanine green. The reagent was stable for four weeks or longer. Haemoglobin, bilirubin and chyle had no impact on the results obtained. The correlation coefficient between the standard method (x) and this method (y) was r=0.995; however, slight divergence was noted in turbid samples. Conclusion Divergence in turbid samples may have corresponded to false negativity with the standard procedure. Our method may be highly practical because blood sampling before indocyanine green loading is unnecessary and measurements are simple.

Good response of low-fat/high-protein diet in a patient with chyluria.

PubMed

Triffoni-Melo, Andresa T; Diez-Garcia, Rosa Wanda; Barros Silva, Gyl Eanes; Garcia Caldas, Fernando de Freitas; Wichert-Ana, Lauro; Corte Denardi, Rafaela; Kato, Mery; Júnior Lucca, Leandro; Dantas, Márcio

2014-04-01

Chyluria is an inappropriate urinary excretion of chyle that turns the urine milky. A nutritional approach based on low-fat/high-protein content diet associated or not with medium-chain triglyceride (MCT) showed to be an efficient conservative treatment to improve the milky urine appearance in a patient with chyluria. A 30-year-old female patient was admitted with chyluria of unknown etiology. An ureteropyeloscopy revealed a single lesion in each kidney, both with linear aspect and measuring 5 mm in extension. These lesions were located close to the renal papillae and were leaking a cloudy and milky fluid. Both lesions were laser cauterized followed by improvement of the milky urine. However, the chyluria relapsed after few months and a low-fat/high-protein content diet with 10 g of soybean oil to meet the requirements essential fatty acids (EFA) and with MCT from coconut oil as alternative to prepare foods was started. Few weeks later the patient returned reporting consistent improvement of the milky urine appearance related with the use of the diet. However since the diet was tasteless and time consuming to prepare, she reported low compliance to diet with MCT and the milky urine relapsed. The MCT was discontinued and the diet with EFA source was maintained with better compliance. Since then the chyluria remains in remission. In conclusion, the dramatic improvement of the milky urine with low-fat/high-protein diet with EFA source observed in our patient demonstrates that this nutritional approach is efficient with fast results to treat chyluria during long term.

Phrenic nerve stimulation during neck dissection for advanced thyroid cancer involving level IV: is it worth doing it?

PubMed

Duque, Carlos S; Dueñas, Juan P; Marulanda, Marcela; Pérez, Diana; Londoňo, Andres; Roy, Soham; Khadem, Mai Al

2017-03-01

During thyroidectomy and neck dissection surgery for advanced or recurrent metastatic thyroid cancer under intraoperative monitoring, we used the available technology to assess the feasibility of such an intervention to monitor those patients with phrenic nerves at risk. A retrospective review of patients operated on from January 2009 to December 2015 by a single surgeon (CSD) was conducted. Patients who had neck and mediastinal dissection, with or without total thyroidectomy, due to advanced or recurrent metastatic disease to the neck were selected. The procedures were done under intraoperative nerve monitoring using nerve monitoring systems (NIM 2.0 or 3.0; Medtronic, Jacksonville, FL, USA). A total of 19 patients were included in the study, with a mean age of 57.6 years ± 16.3 and a male/female ratio of 10:9. Overall, all patients had an intact phrenic nerve at the conclusion of the surgery. One patient had an aggressive tumor that precluded sacrifice of the left recurrent laryngeal nerve and ipsilateral thoracic duct. The procedure was complicated by a temporary impairment of the diaphragm contraction with intraoperative nerve monitoring as well as a chyle fistula. This was due to the manipulation of the tissue surrounding the phrenic nerve. Intraoperative nerve monitoring of the phrenic nerve offers the surgeon a "potential" method of ensuring phrenic nerve integrity in cases of advanced thyroid cancers with gross level IV metastatic disease. Further prospective studies are needed to assess the risks of this intervention and evaluate the method of recording diaphragm contraction movement.

High serum lactate as an adjunct in the early prediction of anastomotic leak following oesophagectomy.

PubMed

Ip, B; Ng, K T; Packer, S; Paterson-Brown, S; Couper, G W

2017-10-01

Anastomotic leak (AL) following oesophagectomy carries a high mortality and morbidity. Early detection and intervention is required for a successful outcome. We have examined the role of a high postoperative serum lactate in predicting which patients are at risk of developing an anastomotic leak(AL). All patients who underwent transthoracic oesophagectomy over a 3-year period were identified from a prospectively collected database. Medical records were reviewed to identify the highest serum lactate recorded from blood gas analysis over each 24hr post-operative period. Patients who underwent transhiatal and left thoraco-abdominal oesophagectomies were excluded. Patients who developed a chyle leak were excluded. Of a total of 136 oesophagectomies included for analysis, 18 developed an AL (13.2%). Of these patients, 10 underwent thoracoscopic oesophageal mobilization with cervical anastomosis and the rest an Ivor Lewis procedure. Predictive factors for AL included neoadjuvant chemotherapy (15/18 83.3% vs 55/118 46.6% p = 0.0046) and number of positive lymph nodes (mean 4.2 vs control mean 2.3 p = 0.045). Overall net fluid balance was comparable between the 2 groups, although AL patients received slightly more fluid on Day 3. High lactate levels on days 1-3 were associated with an AL. Using a Day 2 lactate of 1.7 mmol/L, the sensitivity of predicting AL was 72% and specificity 88%. The mean lag time using existing diagnostic modalities was 7.9 days. A serum lactate of >1.7 mmol/l on day 2 should raise the possibility of a potential AL. Such patients should be selected for more intensive monitoring, optimization and selective gastroscopy. Crown Copyright © 2017. Published by Elsevier Ltd. All rights reserved.

Scholars and scientists in the history of the lymphatic system.

PubMed

Natale, Gianfranco; Bocci, Guido; Ribatti, Domenico

2017-09-01

The discovery of the lymphatic system has a long and fascinating history. The interest in anatomy and physiology of this system paralleled that of the blood cardiocirculatory system and has been maybe obscured by the latter. Paradoxically, if the closed blood system appeared open in Galen's anatomy and physiology, and took a very long time to be correctly described in terms of pulmonary and general circulation by ibn Al-Nafis/Michael Servetus/Realdo Colombo and William Harvey, respectively, the open lymphatic system was incorrectly described as a closed circuit connected with arteries and veins. In ancient times only macroscopic components of the lymphatic system have been described, although misinterpreted, including lymph nodes and lacteals, the latter being easily identified because of their milk-like content. For about 15 centuries the dogmatic acceptance of Galen's notions did not allow a significant progress in medicine. After Vesalius' revolution in anatomical studies, new knowledge was accumulated, and the 17th century was the golden age for the investigation of the lymphatic system with several discoveries: gut lacteals (Gaspare Aselli), cloacal bursa (Hieronimus Fabricius of Acquapendente), reservoir of the chyle (Jean Pecquet), extra-intestinal lymphatic vessels (Thomas Bartholin and Olaus Rudbeck dispute), hepatic lymph circulation (Francis Glisson). In the Enlightenment century Frederik Ruysch described the function of lymphatic valves, and Paolo Mascagni provided a magnificent iconography of the lymphatic network in humans. In recent times, Leonetto Comparini realized three-dimensional reconstructions of the liver lymphatic vessels, and Kari Alitalo discovered the lymphatic growth factor/receptor system. Far from a complete understanding of its anatomy and function, the lymphatic system still needs to be profoundly examined. © 2017 Anatomical Society.

Primary intestinal lymphangiectasia (Waldmann's disease).

PubMed

Vignes, Stéphane; Bellanger, Jérôme

2008-02-22

Primary intestinal lymphangiectasia (PIL) is a rare disorder characterized by dilated intestinal lacteals resulting in lymph leakage into the small bowel lumen and responsible for protein-losing enteropathy leading to lymphopenia, hypoalbuminemia and hypogammaglobulinemia. PIL is generally diagnosed before 3 years of age but may be diagnosed in older patients. Prevalence is unknown. The main symptom is predominantly bilateral lower limb edema. Edema may be moderate to severe with anasarca and includes pleural effusion, pericarditis or chylous ascites. Fatigue, abdominal pain, weight loss, inability to gain weight, moderate diarrhea or fat-soluble vitamin deficiencies due to malabsorption may also be present. In some patients, limb lymphedema is associated with PIL and is difficult to distinguish lymphedema from edema. Exsudative enteropathy is confirmed by the elevated 24-h stool alpha1-antitrypsin clearance. Etiology remains unknown. Very rare familial cases of PIL have been reported. Diagnosis is confirmed by endoscopic observation of intestinal lymphangiectasia with the corresponding histology of intestinal biopsy specimens. Videocapsule endoscopy may be useful when endoscopic findings are not contributive. Differential diagnosis includes constrictive pericarditis, intestinal lymphoma, Whipple's disease, Crohn's disease, intestinal tuberculosis, sarcoidosis or systemic sclerosis. Several B-cell lymphomas confined to the gastrointestinal tract (stomach, jejunum, midgut, ileum) or with extra-intestinal localizations were reported in PIL patients. A low-fat diet associated with medium-chain triglyceride supplementation is the cornerstone of PIL medical management. The absence of fat in the diet prevents chyle engorgement of the intestinal lymphatic vessels thereby preventing their rupture with its ensuing lymph loss. Medium-chain triglycerides are absorbed directly into the portal venous circulation and avoid lacteal overloading. Other inconsistently effective treatments have been proposed for PIL patients, such as antiplasmin, octreotide or corticosteroids. Surgical small-bowel resection is useful in the rare cases with segmental and localized intestinal lymphangiectasia. The need for dietary control appears to be permanent, because clinical and biochemical findings reappear after low-fat diet withdrawal. PIL outcome may be severe even life-threatening when malignant complications or serous effusion(s) occur.

Primary intestinal lymphangiectasia (Waldmann's disease)

PubMed Central

Vignes, Stéphane; Bellanger, Jérôme

2008-01-01

Primary intestinal lymphangiectasia (PIL) is a rare disorder characterized by dilated intestinal lacteals resulting in lymph leakage into the small bowel lumen and responsible for protein-losing enteropathy leading to lymphopenia, hypoalbuminemia and hypogammaglobulinemia. PIL is generally diagnosed before 3 years of age but may be diagnosed in older patients. Prevalence is unknown. The main symptom is predominantly bilateral lower limb edema. Edema may be moderate to severe with anasarca and includes pleural effusion, pericarditis or chylous ascites. Fatigue, abdominal pain, weight loss, inability to gain weight, moderate diarrhea or fat-soluble vitamin deficiencies due to malabsorption may also be present. In some patients, limb lymphedema is associated with PIL and is difficult to distinguish lymphedema from edema. Exsudative enteropathy is confirmed by the elevated 24-h stool α1-antitrypsin clearance. Etiology remains unknown. Very rare familial cases of PIL have been reported. Diagnosis is confirmed by endoscopic observation of intestinal lymphangiectasia with the corresponding histology of intestinal biopsy specimens. Videocapsule endoscopy may be useful when endoscopic findings are not contributive. Differential diagnosis includes constrictive pericarditis, intestinal lymphoma, Whipple's disease, Crohn's disease, intestinal tuberculosis, sarcoidosis or systemic sclerosis. Several B-cell lymphomas confined to the gastrointestinal tract (stomach, jejunum, midgut, ileum) or with extra-intestinal localizations were reported in PIL patients. A low-fat diet associated with medium-chain triglyceride supplementation is the cornerstone of PIL medical management. The absence of fat in the diet prevents chyle engorgement of the intestinal lymphatic vessels thereby preventing their rupture with its ensuing lymph loss. Medium-chain triglycerides are absorbed directly into the portal venous circulation and avoid lacteal overloading. Other inconsistently effective treatments have been proposed for PIL patients, such as antiplasmin, octreotide or corticosteroids. Surgical small-bowel resection is useful in the rare cases with segmental and localized intestinal lymphangiectasia. The need for dietary control appears to be permanent, because clinical and biochemical findings reappear after low-fat diet withdrawal. PIL outcome may be severe even life-threatening when malignant complications or serous effusion(s) occur. PMID:18294365

[Chylopericardium as a complication of cardiac surgery: report of two cases and review of the literature].

PubMed

Velinović, Milos; Vranes, Mile; Kocica, Mladen; Djukić, Petar; Mikić, Aleksandar; Vukomanović, Vladislav; Kacar, Sasa; Putnik, Svetozar; Marković, Dejan; Seferović, Petar M

2007-01-01

Chylopericardium refers to existing communication between the pericardial sac and the thoracic duct carrying the chyle. The objective of our report was to highlight the specificity of diagnosis and treatment of this rare but tedious condition through the analysis of two case reports. Male patient, aged 63 years, with chylopericardium was diagnosed perioperatively (implantation of artificial aortic--St. Jude No 21 and mitral valve--St. Jude No 29). Etiology of pericardial effusion was established by Sudan III staining of punctate specimen obtained by subxiphoid pericardial puncture. Probable cause of chylopericardium was the lesion of ductus thoracicus during cross-clamping of the superior caval vein with a Cooley clamp. Initial treatment included diet rich in medium-chain triglycerides which resulted in resolution of the effusion. During five-year follow-up, there were no recurrences of pericardial effusion. The second patient was female, 21 years old, with chylopericardium after partial pericardiectomy performed because of the chronic severely symptomatic pericardial effusion, resistant to other forms of treatment. Pericardiocentesis provided 650 ml of yellowish fluid with a high concentration of cholesterol (3.2 mmol/l), triglycerides (16.6 mmol/l), and proteins (64.7 g/l), which verified chylopericardium, most probably as a consequence of the lesion of ductus thoracicus during partial pericardiectomy. Diet rich in medium-chain triglycerides failed to decrease the effusion, after two weeks of treatment (daily secretion 250-350 ml). Lymphography revealed lesion of ductus thoracicus, most probably at Th9/Th10 level, with no direct visualization of extravasal accumulation of contrast media. Surgical ligation of ductus thoracicus was performed through the right thoracotomy. However, postoperative secretion increased to 1000 ml/day. Patient underwent redo surgery comprising the ligation of lymphatic vessels, guided by extravasation of intraoperatively iwected methylene-blue indicator. During one-year follow-up, there were no recurrences of pericardial effusion. In conclusion, intraoperative lymphography significantly contributed to successful surgical treatment of patients with chylopericardium.

A novel robotic surgical technique for thyroid surgery: bilateral axillary approach (BAA).

PubMed

Woo, Jung-Woo; Kim, Seo Ki; Park, Inhye; Choe, Jun Ho; Kim, Jung-Han; Kim, Jee Soo

2017-02-01

Bilateral axillo-breast approach (BABA) robotic thyroidectomy (RT) is proven to be a feasible method for the treatment of well-differentiated thyroid cancers in terms of oncology as well as cosmesis. However, BABA RT causes postoperative sternal discomfort and needs an incision over the nipple areolar area. Here, we suggest a novel robotic surgical technique for thyroid surgery that does not need a breast incision-bilateral axillary approach (BAA). We recruited 51 patients who were willing to undergo the novel BAA robotic thyroid surgery. We performed a propensity score-matched analysis to compare the BAA robotic thyroid surgery group (BAA group) with the conventional open thyroid surgery group (open group). Mean operation time in the BAA group (129.7 min) was significantly longer than that in the open group (103.1 min) (p < 0.001). However, no significant differences in the mean number of metastatic lymph nodes (LNs), mean number of retrieved LNs, vocal cord palsy, hypoparathyroidism, and mean stimulated thyroglobulin level were observed between the two groups. There was no case of postoperative bleeding or chyle leak. Of the 51 patients who had undergone the BAA procedure, 27 patients answered the questionnaire. The mean scale, ranging from 0 to 10, at postoperative 1 day/2 weeks was as follows: voice change score, 3.0/1.6; swallowing difficulty score, 4.0/2.0; anterior neck pain score, 4.6/3.6; anterior neck numbness score, 5.4/4.3; right chest pain score, 3.8/2.1; left chest pain score, 3.6/2.3; right chest numbness score, 3.2/2.8; left chest numbness score, 2.4/2.7; right breast pain score, 0.9/0; left breast pain score, 1.2/0; right breast numbness score, 1.7/0; and left breast numbness score, 2.6/0, respectively. BAA robotic thyroid surgery is a novel, safe, and feasible oncoplastic method, especially for patients who have fear of procedures around the nipple areolar complex.

Complications of Bilateral Neck Dissection in Thyroid Cancer From a Single High-Volume Center.

PubMed

McMullen, Caitlin; Rocke, Daniel; Freeman, Jeremy

2017-04-01

The morbidity of bilateral lateral neck dissection (BLND) for thyroid cancers has not been described in detail. This study delineates the specific complications arising from BLND for thyroid cancers at a single high-volume center. To determine the morbidity associated with BLNDs for differentiated thyroid cancers at our institution. This was a retrospective review of medical records performed to identify patients having undergone BLNDs for thyroid cancers by a single surgeon at an academic, tertiary medical center in Toronto, Ontario, Canada, from 1988 to 2015. Patients who underwent BLND for papillary, follicular, or medullary thyroid cancers were identified through operative procedure codes and review of operative and pathology reports. The indication for this procedure was suspicious bilateral lateral compartment on imaging and clinical examination. Sixty-two patients who underwent BLND for thyroid cancers, with or without total thyroidectomy and central compartment dissection, were identified. The main outcome measures for this study were unanticipated medical or surgical complications during the operation or in the postoperative period. Secondary measures were oncologic outcomes, including regional structural or biochemical recurrence. Of the 62 patients, 24 were male (39%), and 38 (61%) were female. Their mean age was 46 years (range, 17-80 years). The overall risk of permanent hypoparathyroidism was 37%. There was 1 case of unanticipated permanent recurrent nerve paralysis and 1 case of temporary nerve paresis. Postoperative chyle fistula occurred in 6 cases (10%). There were 3 readmissions within 30 days of surgery, 1 pulmonary embolism, and 1 perioperative mortality. Fifty percent of patients had pN0 contralateral necks despite preoperative clinical suspicion. Four patients were found to have anaplastic thyroid cancers intraoperatively. Five patients (8%) developed nodal recurrence in the neck. Four patients died of their disease within available follow-up (mean, 3.2 years). Bilateral lateral neck dissection for thyroid cancers confers a significant amount of morbidity, including a significant rate of hypoparathyroidism. Knowledge of the complications of this procedure, especially in the setting of questionable survival benefit, may assist in preoperative decision-making and patient counseling.

Hounsfield units are a useful predictor of pleural effusion cytological type in dogs but not in cats.

PubMed

Woods, Sarah J; Spriet, Mathieu; Safra, Noa; Cissell, Derek D; Borjesson, Dori L

2018-04-23

All categories of pleural effusion subjectively display as soft tissue opacity on computed tomography (CT). Quantitative measurement using Hounsfield units (HU) has the potential to bring additional information regarding the nature of the fluid in a noninvasive way. The purposes of this retrospective cross-sectional analytical study were to compare Hounsfield units of different pleural effusion categories in dogs and cats, assess association between specific cytologic parameters and Hounsfield units, and evaluate the effect of dependent vs. nondependent aspect of the effusion pool on Hounsfield unit. A total of 111 patients (74 dogs and 37 cats) with pleural effusion, that underwent thoracic CT and diagnostic thoracocentesis, were included in the study. Effusions were cytologically categorized as exudate, transudate, modified transudate, hemorrhage, or chyle. Significant differences existed in Hounsfield units between categories in dogs (P < 0.0001) but not in cats (P = 0.334). Canine chylous effusion (6.1 ± 4.7 HU (mean ± standard deviation)) and transudate (5.6 ± 2.0) were significantly lower than exudate (20.3 ± 9.5) and hemorrhage (21.4 ± 9.2). No significant differences were found between modified transudate (13.6 ± 10.3) and other categories. Significant, weak linear correlation was identified in dogs between Hounsfield units and total protein (P = 0.018, R   = 0.089), red blood cells (P = 0.021, R   = 0.077), and total nucleated cells (P = 0.013, R   = 0.089). The Hounsfield units of dependent effusion was not significantly higher than the nondependent effusion, except for canine chylous effusion (P = 0.008). Fourteen Hounsfield units was identified as the most clinically useful threshold: <14 HU identified transudate or chylous effusion with a sensitivity of 100% and a specificity of 69%. A threshold >14 HU had a specificity of 100% and a sensitivity of 69% for identifying exudate, modified transudate, or hemorrhage. © 2018 American College of Veterinary Radiology.

[The key points of prevention for special surgical complications after radical operation of gastric cancer].

PubMed

Xu, Hao; Wang, Weizhi; Li, Panyuan; Zhang, Diancai; Yang, Li; Xu, Zekuan

2017-02-25

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.