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The Chyle Files: Chylothorax Abigail Mariano, VMD Small Animal Surgery Resident December 20, 2013.

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Presentation on theme: "The Chyle Files: Chylothorax Abigail Mariano, VMD Small Animal Surgery Resident December 20, 2013."— Presentation transcript:

1 The Chyle Files: Chylothorax Abigail Mariano, VMD Small Animal Surgery Resident December 20, 2013

2  Disruption or abnormality of the thoracic duct or tributaries of the lymphatics resulting in accumulation of chyle in pleural space What is it?

3  Dogs and cats  Breed predispositions: Afghan hounds, Shiba Inus, Oriental cat breeds  No sex predilection  No age predilection Population

4  Cough  Abnormal respiration  Shallow/restrictive  Tachypnea  Orthopnea  Acute respiratory distress  Cyanosis  Muffled heart/lung sounds  Increased bronchovesicular sounds dorsally  Weight loss Presenting clinical signs

5  Transudate  <1500 nucleated cells/uL  <2.5 g/dL total protein  Modified transudate  nucleated cells/uL  g/dL total protein  Exudate  >7000 nucleated cells/uL  >3 g/dL total protein Effusions

6 Chyle

7

8  Cytology, fluid analysis  Paired fluid and serum triglycerides  Cholesterol : Triglyceride ratio  Ether clearance test  Sudan stain for lipid droplets  +/- Culture and sensitivity Fluid diagnostics

9  Trauma to the thoracic duct (uncommon in animals)  Secondary to ANY condition that causes obstruction of the thoracic duct, prevents lymph flow to venous circulation, or increases in lymphatic flow Etiopathogenesis

10  Cardiac disease (congenital or acquired)  Pericardial disease  Dirofilariasis  Pulmonary hypertension  Lung lobe torsion  Diaphragmatic hernia  Trauma  Neoplasia  Infection (fungal granuloma)  Congenital or acquired abnormalities of the thoracic duct  Venous thrombi  Idiopathic*** Etiopathogenesis

11  Failure to identify an underlying cause  Diagnosis of exclusion Idiopathic chylothorax

12  CBC/Chem/UA  Chest radiographs  Heartworm antigen test  Echocardiography  Thoracic/abdominal CT  Lymphangiography Other diagnostics Brisson, AJVR, 2006

13  Medical Management  Surgery  Definitive  Salvage Procedures Treatment options

14  Low fat diet  TPN  Medium chain triglycerides?  Steroids?  Thoracocentesis as needed Medical management

15  Rutin (Benzopyrone) mg/kg TID, PO  Octreotide 10ug/kg TID, SQ days Medical management

16  Good for traumatic chylothorax  2 weeks  When to go to surgery…  Large persistent volume  >4 weeks  No studies comparing medical vs. surgical management Medical management

17  Cisterna chyli is abdominal lymph reservoir  Thoracic duct (TD) arises from cisterna chyli  TD is major lymphatic vessel for return of lymph to venous system  TD anatomy varies, especially in idiopathic chylothorax cases  Dogs: right->left  Cats: left Anatomy The path of the lymph fluid

18 Cisterna chyli Brisson, AJVR, 2006

19 Thoracic duct Brisson, AJVR, 2006

20

21 Pre-operative planning  Lymphangiography  Intestinal (mesenteric)  Open, laparoscopic or U/S guided  Popliteal  Rads vs. Fluoro vs. CT  CT shows more branches  Missed branches  Post-op confirmation Naganobu, Vet Surg 2006 Johnson, Vet Surg 2009 Esterline, Vet Rad/US 2005

22 Lymphangiogram Sicard et al. Vet Surg 2005

23  To identify the lymphatics during surgery  Feed high fat meal prior to surgery  Methylene blue  Heterocyclic aromatic compound  1% aqueous, 0.5mg/kg (up to 10mg) or 0.2mls diluted  Injected: lymph nodes (popliteal, inguinal, mesenteric), diaphragm, distal limb/paw pad, esophagus or via lymphatic catheterization  Complications: Heinz body anemia, increased ALP, renal failure Intraoperative identification

24 Methylene blue Enwiller, Vet Surg 2003

25 Methylene blue Sicard, Vet Surg, 2003

26 Methylene blue Enwiller, Vet Surg 2003

27  Thoracic duct ligation  Pericardiectomy  Cisterna chyli ablation  Omentalization  Embolization  Shunts  Pleural Port  Pleurodesis  Pleural stripping Surgical Options

28 Thoracic Duct Ligation Redirection of chyle away from the thoracic duct into new lymphaticovenous anastomoses [Image modified from JAAHA, 18:769-77, 1982]

29 Thoracic Duct Ligation: Open Goal: occlude duct at entry to thorax  Approach  9 th -10 th intercostal thoracotomy  Transdiaphragmatic  Dorsal to aorta, ventral to sympathetic trunk  Individual vs. en bloc  Ligation vs. ablation

30 Thoracic Duct Ligation Failure may occur due to incomplete ligation or formation of collateral lymphatics that bypass the ligature site instead of forming new lymphaticovenous drainage sites

31 Open ligation Tobias, 2010

32 TDL: Thoracoscopic  Goal: TDL without morbidity of thoracotomy, improved visualization  Approach  Sternal (or lateral)  2 instrument ports to allow dissection dorsal to aorta  Evaluate contralateral hemithorax for branches Mayhew JAVMA 2012; Allman, Radlinsky Vet Surg 2010; Sakals Vet Surg 2011; Radlinsky Vet Surg 2002; Leasure Vet Surg 2011

33 Singh, 2012

34 Pericardiectomy  Goal: decrease right sided venous pressure  Approach  Intercostal, median sternotomy, transdiaphragmatic, thoracoscopic (paraxyphoid or intercostal)  Pericardial window or subtotal pericardiectomy  Excise pericardium ventral to phrenic nerves Fossum, JVIM 2004, Carobbi Vet Rec 2008, McAnulty VS 2011

35 Open pericardiectomy

36 Cisterna chyli ablation  Goal: reroute lymphatic drainage  Major abdominal vessels, mesenteric root, azygous  Avoid lymphatic hypertension seen with TDL  Usually performed with TDL  Approach: ventral midline or paracostal incision  Mobilize kidney, excise tissue

37 Cisterna chyli ablation Combining cisterna chyli ablation with thoracic duct ligation [Image modified from JAAHA, 18:769-77, 1982]

38 Sicard et al. Vet Surg 2005

39

40 1 month post TDL with CCA Caudal vena cava Azygos vein Sicard et al. Vet Surg 2005

41 Omentalization  Goal: provides absorptive surface?  Drains back to TD  Angiogenesis  Source of immune cells  Diaphragmatic incision  Or- subcutaneous tunnel  Tack intrathoracically  Salvage vs Ancillary procedure

42 Omentalization

43 Embolization  Cyanoacrylate glue injected into cannulated mesenteric lymphatic vessel  Occluded 100% of TD in healthy dogs, but 33% clinical efficacy  Risk of emboli in circulation, lungs  Salvage procedure? Singh, Am J Vet Res 2011; Pardo ACVS 1995; Weisse JAVMA 2008 Photos courtesy of Weisse

44 Percutaneous catherization & embolization Singh et al. AJVR 2011

45 Shunts  Salvage procedure  Pleuroperitoneal- active  Pleuroperitoneal- passive  Pleurovenous shunt Smeak et al, JAVMA 2001 Willauer JAVMA 1987 Peterson Vet Surg 1996

46 Pleuroperitoneal active shunts Smeak et al. JAVMA 2001

47  Fenestrated silastic sheet placed in defect created in diaphragm or transdiaphragmatic tubes  Provides drainage into abdomen  Reabsorption via visceral and peritoneal lymphatics  Shunting drive by respiration  Longterm patency of drains discouraging  Fibrin clots, adhesions, omentum Pleuroperitoneal passive shunts

48 Pleurovenous shunts

49 PleuralPort  Percutaneous (or open)  Incision over 10 th rib  Tunnel 2-3 spaces cranially  Or-- place 1 st, then tunnel caudally  Port function days  Median 20 days  Complications  Kinking, migration, leakage, hemithorax access, obstruction, pocketing  Place as conjunctive therapy? Brooks, Vet Surg 2011

50

51 Out-dated modalities…  Pleurodesis  Talc, blood, antibiotics, mechanical abrasions  Do not form adhesions in dogs  Pain  Decortication (pleural stripping)  Hemorrhage  Intractable pneumothorax  Pain

52 Success: By the numbers ProcedureSuccess Rate Rutin67%* (cats) 1 Octreotide40% 2 TDL50-59% (dogs) % (cats) 3 TDL + SP60-100% (dogs) 80% (cats) 4 Thoracoscopic TDL + SP % (dogs) 5 TDL + CCA % (dogs) 6 TDL + SP + omentalization72.7% (dogs) 7 57% (d+c) 8 MST 209d (c) 211d (d) 9 Embolization33% 10 Adapted from Singh. Compendium 2012

53 Progression and sequelae  Fibrosing pleuritis  Inflammatory changes to mesothelial cells  Increase type III collagen  Decreased fibrinolysis  Restrictive pleuritis  Failure to expand lungs despite thoracocentesis  Pericarditis  Malnutrition, dehydration, loss of lipids, protein, fat-soluble vitamins, lymphocyte depletion

54 Fibrosing pleuritis

55 Take-home points  Idiopathic is most common  Diagnosis based on appearance, cytology, triglycerides  Medical management frequently fails  No ONE surgical technique to recommend  TDL, CCA, pericardectomy and pleuralport?  More minimally invasive techniques emerging  Post-operative lymphagiograms may or may not be helpful  High morbidity with long term effusion

56 References  Allman DA, Radlinsky MG, Ralph AG, et al: Thoracoscopic thoracic duct ligation and thoracoscopic pericardiectomy for treatment of chylothorax in dogs. Vet Surg 39:21,  Brooks A. et. al. Vet Surg Use of the PleuralPort device for management of pleural effusion in six dogs and four cats.  Bussadori et al. Pleural omentalisation with en bloc ligation of the TD and PC for IC in 9 dogs and 4 cats. Vet J 188: , 2011  Carobbi B, White RAS, Romanelli G: Treatment of idiopathic chylothorax in 14 dogs by ligation of the thoracic duct and partial pericardectomy. Vet Rec 163:743, 2008  Chun H, Cho H, Cheon H, et al: Determination of optimal dosage and delay time for computed tomographic lymphangiography after percutaneous injection of iohexol into popliteal lymph nodes in dogs. J Vet Med Sci 71:873,  DaSilva CA, Monnet E. Long term outcome of dogs treated surgically for idiopathic chylothorax:11 cases ( ). JAVMA 239: ,2011  Enwiller TM, Radlinsky MG, Mason DE, et al: Popliteal and mesenteric lymph node injection with methylene blue for coloration of the thoracic duct in dogs. Vet Surg 32:359,  Esterline ML et al: Comparison of radiographic and CT lymphangiography for identification of the canine thoracic duct. Vet Radiol Ultrasound 2005;46:  Fossum TW. Chylothorax in cats: is there a role for surgery? J Fel Med Surg 3:73-79, 2001  Fossum TW, Mertens MM, Miller MW, et al: Thoracic duct ligation and pericardectomy for treatment of idiopathic chylothorax. J Vet Intern Med 18:307,  Hayashi K, Sicard G, Gellasch K, et al: Cisterna chyli ablation with thoracic duct ligation for chylothorax: results in eight dogs. Vet Surg 34:519,  Hinrichs et al. Lymphangiosarcomas in cats: a retrospective study of 12 cases. Vet Path 36: , 1999  Johnson EG et al. Computed tomographic lymphography of the thoracic duct by mesenteric lymph node injection. Vet Surg 38: ,2009.  Itkin M et al. Percutaneous thoracic duct embolization as a treatment for intrathoracic chyle leaks in infants. Pediatrics 2011 Jul;128(1):e  Kerpsack et al. Evaluation of mesenteric lymphangiography and TDL in cats with chylothorax: 19 cases ( ). JAVMA 205(5):711-5, 1994  Kovak JR, Ludwig LL, Bergman PJ, et al: Use of thoracoscopy to determine the etiology of pleural effusion in dogs and cats: 18 cases (1998–2001). J Am Vet Med Assoc 221:990, 2002  LaFond E, Weirich WE, Salisbury SK: Omentalization of the thorax for treatment of idiopathic chylothorax with constrictive pleuritis in a cat. J Am Anim Hosp Assoc 38:74,  McAnulty JF. Prospective comparison of cisterna chyli ablation to pericardectomy for treatment of spontaneously occurring idiopathic chylothorax in the dog. Vet Surg 40: ,  Naganobu et al: Lymphgraphy of the thoracic duct by the percutaneous injection of iohexol into the popliteal lyph node of dogs: experimental study and clinical application. Veterinary Surgery 35: ,  Pardo AD, et al. Transcatheter thoracicduct embolization in the dog. An experimental study. Vet Surg1989;18:279–285.  Peterson SL. Postcaval thrombosis and delayed shun migration after pleuroperitoneal venous shunting. Vet Surg 25: ,  Radlinsky MG, Mason DE, Biller DS, et al: Thoracoscopic visualization and ligation of the thoracic duct in dogs. Vet Surg 31:138,  Sicard GK et al: The use of a somatostatin analogue for the treatment of idiopathic chylothorax in dogs and cats. Proceedings ACVS  Sikkema DA, McLoughlin MA, Birhcard SJ. Effect of dietary fat on triglyceride and fatty acid composition of thoracic duct lymph in dogs. Vet Surg 1993;22:  Smeak DD, Birchard SJ, McLoughlin MA, et al: Treatment of chronic pleural effusion with pleuroperitoneal shunts in dogs: 14 cases (1985–1999). J Am Vet Med Assoc 219:1590,  Staiger et al: single paracostal approach to thoracic duct and cisterna chyli: experimental study and case series. Vet Surg 40: , 2011  Weisse et al: Potential applications of interventional radiology in veterinary medicine. JAVMA 233:1564, 2008


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