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We have reported the first described case of idiopathic simultaneous chylopericardium and chylothorax and discussed its diagnostic and therapeutic considerations. Efficacy of thoracic duct ligation, pericardiectomy, and pleurodesis for this entity is established.
STUDY DESIGN: A description of the clinical picture of chylous leakage after spinal surgery. OBJECTIVES: To present the clinical course of three cases of chylous leakage after spinal surgery and to discuss the pathogenesis of the disease. SUMMARY OF BACKGROUND DATA: Chylous leakage is a rare complication after spinal surgery. It has been attributed to direct injury of a lymphatic trunk or one of its major tributaries by surgical maneuver. METHODS: Three cases of chylous leakage after circumferential thoracolumbar fusion for correction of kyphosis resulting from fracture were reported. RESULTS: All of the three cases were managed successfully; two cases of chyloretroperitoneum detected within 4 days after surgery were healed conservatively, but one case of chylothorax of which the onset was noticed 5 weeks after spinal surgery, required surgical ligation of the thoracic duct and pleurodesis. CONCLUSION: Early detection of this disease is important for a good prognosis. Retroperitoneal drainage is necessary for the detection and management of chyloretroperitoneum. The pathogenesis and management of the chylous leakage are discussed in this report.
STUDY DESIGN: A case report of lymphatic drainage after anterior retroperitoneal debridement and reconstruction for lumbar osteomyelitis. OBJECTIVES: To report a case of protracted lymphatic drainage after anterior lumbar surgery, a complication that has not been reported previously. SUMMARY OF BACKGROUND DATA: Lymphatic drainage after transthoracic surgery is a well-recognized complication. The possibility of lymphatic drainage after anterior lumbar surgery is less likely to be considered. METHODS: The cause, clinical symptoms and appearance, treatment, and differential diagnosis are reviewed. RESULTS: Lymphangiography is useful in diagnosis and should be performed early if the diagnosis is in doubt. Percutaneous drainage can facilitate early wound healing. CONCLUSION: Lymphatic drainage should be considered in the differential diagnosis of postoperative wound drainage, particularly after surgical debridement for osteomyelitis.
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STUDY DESIGN: Retrospective case report. PURPOSE: This case demonstrates that paraplegia can develop due to chylous leakage into the spinal canal without obvious retroperitoneal or intrathoracic involvement. BACKGROUND INFORMATION: This clinical presentation of chylous leakage has not been reported previously. RESULTS A 61-year-old female with osteoporosis suffered a pathologic fracture of the vertebral bodies T12 and L1 and developed partial paraplegia two weeks later. Imaging showed expansive pooling of intraspinal fluid without intrathoracic or retroperitoneal involvement. A blood-tinged fluid was aspirated from dorsal. Repeated surgery by a posterior approach with drainage of the fluid did not improve the patient's condition, so she was finally transferred to our hospital. Under the suspected diagnosis of lymphatic leakage a scintiscan with 123I-iodinephenylpentadekanacid-marked cream verified the presumption of a lymph fistula at the level of T12/L1, originating from the thoracic duct. By permanent draining of the posterior fistula without suction and strict intravenous alimentation the fluid production decreased continuously and finally ceased completely. Simultaneously, the neurologic state improved gradually without returning to normal completely. CONCLUSIONS: This case demonstrates that paraplegia can develop due to chylous leakage into the spinal canal without obvious retroperitoneal or intrathoracic involvement. This differential diagnosis should be kept in mind when treating patients with abundant fluid drainage into or from the spinal canal.
PURPOSE: We compared the clinical effectiveness of renal pedicle lymphatic disconnection for chyluria performed by retroperitoneoscopy and by open surgery. MATERIALS AND METHODS: Three male and 4 female patients 33 to 68 years old (mean age 49) with chyluria underwent retroperitoneoscopic renal pedicle lymphatic disconnection. Chyluria was on the left side in 5 cases and on the right side in 2. Open renal pedicle lymphatic disconnection was performed in 4 men and 2 women 33 to 61 years old (mean age 45.8). Chyluria was on the left and right sides in 3 cases each. Mean operative time, intraoperative blood loss, postoperative intestinal function recovery time, intraoperative and postoperative complications, postoperative hospital delay and operative outcome were compared in these 2 groups. RESULTS: Compared with the open surgery group results in the retroperitoneoscopic group were superior in terms of operative time (42 to 90 minutes, mean +/- SD 65.0 +/- 18.8 versus 120 to 220, mean 156.7 +/- 38.8), intraoperative blood loss (20 to 50 ml., mean 29.3 +/- 10.2 versus 60 to 250, mean 171.7 +/- 76.5), postoperative intestinal function recovery time (24 to 48 hours, mean 36.0 +/- 6.9 versus 24 to 72, mean 54.0 +/- 21.1), intraoperative and postoperative complications, and postoperative hospital stay (3 to 6 days, mean 4.7 +/- 0.7 versus 7 to 9 days, mean 7.8 +/- 1.0). In the open surgery group primary anastomosis was performed in 1 case due to injury to a renal artery branch during the operation. Chyluria resolved the day after surgery in the 2 groups. No obvious complications developed postoperatively. The followup of 2 to 12 months (mean 6.7 +/- 4.0) showed no recurrence of chyluria. CONCLUSIONS: Retroperitoneoscopic renal pedicle lymphatic disconnection completely ligates the lymphatic vessels with minimal invasion, less blood loss, rapid recovery and a good short-term outcome.
PURPOSE: We present our experience with retroperitoneoscopic renal pedicle lymphatic disconnection. We compared the clinical efficacy of this treatment for chyluria with that of open surgery. MATERIALS AND METHODS: From January 1998 to June 2004, 53 patients (55 renal units) with chyluria underwent renal pedicle lymphatic disconnection via the retroperitoneoscopic and conventional open approaches. The diagnosis of chyluria was confirmed by the ether test and the side of chylous reflux was determined by cystoscopy. Operative time, intraoperative blood loss, postoperative intestinal recovery and hospital stay were evaluated. Increases in hemoglobin and serum albumin were compared before and after surgery during followup. RESULTS: Retroperitoneoscopic renal pedicle lymphatic disconnection or open surgery was performed successfully in all patients. In terms of operative time, intraoperative blood loss, postoperative intestinal recovery and hospital stay retroperitoneoscopy was superior to conventional open surgery. During retroperitoneoscopy the inferior vena cava was injured in 1 case but repaired successfully by laparoscopy without conversion to open surgery. Postoperative gross hematuria in 1 case disappeared 4 days later. In the open surgery group the renal segmental artery was inadvertently injured in 1 case and anastomosis was performed successfully. Wound healing was delayed in 1 case due to hypoalbuminemia. Recurrence developed in 2 patients during the 6 to 84-month followup. CONCLUSIONS: Retroperitoneoscopic renal pedicle lymphatic disconnection for chyluria has the advantages of minimal invasion and rapid recovery compared with open surgery.
PURPOSE OF REVIEW: The purpose of this review is to present a novel radiologic percutaneous transabdominal technique for treating high-output chylothorax by thoracic duct embolization, and to demonstrate that it can be potentially safer than the traditional treatment by surgical open-chest thoracic duct ligation. RECENT FINDINGS: Pedal lymphography is initially performed to opacify large retroperitoneal lymph channels; a suitable duct more than 2 mm in diameter is then punctured transabdominally to allow catheterization and embolization of the thoracic duct under fluoroscopic guidance. If feeding lymphatic channels are too small for catheterization, they can often be occluded by needle disruption. This percutaneous interventional technique, which has been used in 60 patients with mostly high-output chylothorax caused by thoracic surgery, resulted in a 65% cure rate with no morbidity. Back-up surgical thoracic duct ligation was performed promptly on suitable lower risk patients when the percutaneous procedure failed. SUMMARY: We have found that two thirds of patients presenting with life-threatening chylothorax can be safely treated by percutaneous transabdominal thoracic duct blockage. When successful, this novel interventional procedure can obviate repeat major thoracic surgery and shorten hospital stays.
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Two cases of cutaneous chylous reflux are described. Both patients had many translucent white vesicles from which milk-like fluid wept intermittently. Lymphangiogram revealed dilated, tortuous lymphatic vessels and dermal backflow. Electron microscopic studies showed an abnormal ultrastructure of the dilated lymphatics.
Lymphatic filariasis, a mosquito-transmitted disease commonly known as Bancroftian filariasis, is characterized by debilitating pathology linked to the progression of lymphoedema to a chronic state of elephantiasis. We performed longitudinal measurements of endothelial adhesion and angiogenic molecules in 63 Polynesian patients living in an hyperendemic focus of Wuchereria bancrofti. Decreased serum concentrations of soluble (s-) L selectin (CD62L) were noticed in sera of of patients with chronic conditions (hydrocele and elephantiasis). Chyluria was associated with increased vascular endothelial growth factor (VEGF) levels, whereas elephantiasis presented a high endothelin-1 (ET-1) profile. By contrast, increased serum concentrations of soluble intercellular (sICAM-1, CD54), but not of vascular cell (sVCAM-1, CD106), adhesion molecules were observed in sera of patients with bacterial lymphangitis used as controls. These trends are consistent with the increased permeability of vascular structures, a major clinical feature observed in acute lymphatic pathology (of bacterial or filarial origin), and of fundamental differences in the pathogenesis of hydrocele and elephantiasis. Using markers correlated with the clinical status (high ET-1 and VEGF levels for elephantiasis and chyluria, respectively; low CD62L levels for hydrocoele and elephantiasis) it should be possible to monitor disease progression in lymphatic filariasis.
Chyluria is a urological manifestation of lymphatic system disease. Sclerotherapy of the renal pelvis (RPIS) using 1% silver nitrate, along with diethyl carbamazine, is the treatment most frequently used. Massive haematuria due to intrarenal aneurysm following RPIS has not been reported. A case is described here of arterial haemorrhage following instillation of silver nitrate which was treated by coil embolization. The haematuria was immediately stopped and the renal function returned to normal gradually.
BACKGROUND: Filariasis is an endemic problem in various Indian states. We evaluated the results of long-term follow up (10-20 years) of patients with filarial chyluria. METHODS: We conducted a retrospective analysis of 160 patients treated for filarial chyluria who presented to the Banaras Hindu University Hospital from 1982 to 1992. Eighty-four patients (52.5%) were treated using diethylcarbamazine (DEC) and a fat restricted diet and 76 patients (47.5%) underwent surgery. To examine the long-term effects of filarial chyluria we analysed data on post-treatment recurrence, weight gain, dietary freedom, chyluria free period and a number of other associated factors. RESULTS: Previous history of filariasis or its complication was documented in 19% of patients. In 71% of cases, cystoscopy showed that chylous efflux was predominant in the left ureteric orifice. The long-term remission rate was 62% in the conservatively managed group (DEC + fat restricted diet), whereas 90% of patients in the operated group were cured. Postoperative recurrence rate was 10%. There was more weight gain and dietary freedom along with a longer chyluria free period in the operated group relative to the conservatively managed group. CONCLUSIONS: Definitive surgical ablation of lymphatic urinary fistula is better than conservative medical management because it has a higher success rate, more dietary freedom and, therefore, better patient acceptability.
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Two hundred neck dissections performed at Toronto General Hospital over a 3 year period are reviewed. There were six intra-operative lymph leaks and five postoperative chylous fistulae. The postoperative chylous fistulae are analysed in detail and the approach to conservative management of lymph leaks is discussed. Two cases required re-exploration of the neck; difficulty in identifying the site of leakage and of sealing lymph channels is discussed. Also reported is the successful use of topical tetracycline powder in two cases and a review of the various treatment modalities advocated in the literature.
Two patients with chyluria who were successfully treated by surgical disconnection of the lymphatics from the renal pelvis are reported. One patient also had an associated glomerulonephritis, possibly secondary to filariasis. Although glomerulonephritis associated with filariasis has been reported previously the details of renal biopsies in man have included only light microscopic findings. In this patient immunofluorescent and electron microscopic studies showed mesangial deposits of immunoglobulins and complement which suggests that glomerulonephritis in patients with filariasis may be an immune complex type.
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