|
 
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| REVIEW ARTICLE |
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| Year : 2021 | Volume
: 6
| Issue : 1 | Page : 15-21 |
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Thoracic duct injury: An up to date
José Luis Ruiz Pier1, Moheb A Rashid2
1 Cardiothoracic Surgeon at Hospital de Traumatología “Victorio de la Fuente Narváez” Instituto Mexicano del Seguro Social, Mexico City, Mexico
2 Scandinavian Cardiovascular Surgery Center, Gothenburg, Sweden
| Date of Web Publication | 22-Dec-2021 |
Correspondence Address:
José Luis Ruiz Pier
Cardiothoracic Surgeon at Hospital de Traumatología “Victorio de la Fuente Narváez” Instituto Mexicano del Seguro Social, Mexico City
Mexico
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jctt.jctt_19_21
Trauma represents a significant portion of the world's morbidity and mortality. Chest trauma accounts for approximately 25% of mortality in trauma patients, and this rate is much higher in patients with polytraumatic injuries. The thoracic cavity contains three major anatomical systems: the airway, lungs, and the cardiovascular system including the thoracic duct. Blunt or penetrating trauma can cause significant disruption to each of these systems that can quickly prove to be life threatening unless rapidly identified and treated. In the present article, the authors present a review of the thoracic duct injury evaluation and treatment.
Keywords: Chest trauma, chylothorax, thoracic duct
How to cite this article:
Ruiz Pier JL, Rashid MA. Thoracic duct injury: An up to date. J Cardiothorac Trauma 2021;6:15-21 |
| Introduction | |  |
Trauma represents a significant portion of the world's morbidity and mortality. According to the World Health Organization, over nine people die per minute due to some type of trauma, with a health expense equivalent to 12% to all diseases.[1] It has been estimated that of the 11 million deaths per year in the developed world, 0.8 million are the result of trauma. In recent research, the male sex predominated in chest trauma. Blunt trauma, as a result of road accidents, have affected more frequently the right side of the chest, while the left side was more commonly affected in penetrating injuries.[2]
The presence of severe lung contusion, a higher injury severity score, and abbreviated injury scale thoracic score, and advanced age are independent risk factors that are directly related to a higher mortality rate. The majority of the patients with a thoracic injury can be managed in emergency room with chest tube insertion, optimal pain control, and chest physiotherapy result in good outcomes in the majority of patients.[3],[4]
Chest tube is important for the drainage and evaluation of the amount and characteristics of the pleural collections from blunt or penetrating trauma, and it is considered the first-line approach.[5] Surgical exploration after thoracic trauma is rare, accounting for about 15% being penetrating trauma more likely to require surgical exploration than blunt trauma.[6]
Historically, lymphatic vessels have been considered on second place regards the rest of the circulatory system, because the size of the ducts and the colorless fluid content. The thoracic duct was first described in 1651 by Jean Pecquet, and this finding contradicted the Galen´s theory which stands that chyle was conducted by intestinal vessels directly to the liver, nevertheless the chylothorax was first described by Bartolet in 1633, and postulated that it was caused by rupture or obstruction of the thoracic duct or its branches, resulting in chyle leakage into the pleural space.[7]
| Anatomy and Embryology | | |
The formation of the thoracic duct begins between the 7th and 8th weeks of gestation, when the two vessels connect the lymphatic jugular sacs and the cisterna chyli. Initially, there were two thoracic ducts with multiple anastomoses between them, and the definitive duct is formed by the inferior portion of the right duct, transversal anastomoses, and the superior portion of the left duct.[8],[9]
The thoracic duct is classically divided into three portions: abdominal, thoracic, and cervical [Figure 1]. Anatomic variations have been described from necropsy studies, the most common in the terminal site, 46% ended in the internal jugular vein, 32% in the jugulosubclavian junction, and 18% in the left subclavian vein.[10]
| Physiology | | |
The lymphatic system primary function is to transport chyle from the gastrointestinal tract into the systemic venous system, working as a diffuse network of vasculature that, transports, and reabsorbs a wide variety of molecules and cells. Contrary to the circulatory system that is propelled by the heart; the lymphatics use osmotic and oncotic forces, smooth muscle within vessel walls, and muscular contractions; and a combination of intrathoracic and intra-abdominal pressures and arterial pulsations helps in maintaining lymph flow in the thoracic duct. Morphological studies have confirmed that human lymphatic vessels are innervated, but recently, it has been demonstrated functionally that the thoracic duct innervation is predominantly adrenergic, and the functional contribution appears to be low. It carries almost 4 l of chyle daily, most of which originates in the digestive tract. The flow rate can be up to 100 ml per kilogram of body weight per day, depending on the diet consumed.[11],[12]
| Etiology of Thoracic Duct Injuries | | |
Thoracic duct leaks are most often due to traumatic injury,[13],[14],[15],[16] and iatrogenic injury.[17] The first documented case of traumatic thoracic duct injury was described by Quincke in 1875.[18] Traumatic transection of the thoracic duct due to chest trauma is unusual and rare.[19],[20] Approximately 3% of the patients with blunt thoracic trauma and 1.3% of penetrating thoracic trauma demonstrate thoracic duct leaks.[21] In addition, it is often identified late.[22],[23] The onset of symptoms depends on the etiology, and there are reported unusual causes, as simple or heavy exercise, blunt torso trauma, falling from heights, whiplash mechanism and other forms of neck hyperextension[24],[25],[26],[27],[28],[29] with traumatic or surgical causes presenting earlier compared to the other etiologies, at this point transections due to stab or gunshot injuries are included[30],[31],[32] [Figure 2]. | Figure 2: Surgical field of a 42-year-old female patient with a gunshot wound located in the left posterior axillary line of the 8th intercostal space
Click here to view |
| Clinical Presentation | | |
Typically, patients present with dyspnea due to pleural effusions.[33] Chronic leaking of chyle also results in malnourishment and susceptibility to infections, which is seen in nontraumatic causes as in malignancy or tuberculosis.[34],[35] However, in surgical and traumatic causes, the onset of symptoms may be immediate if the volume is more than 500 ml/day.[36],[37],[38]
Examination may reveal decreased breath sounds and dullness to percussion in areas of lymph collections. The symptoms are usually observed after 3 to 7 days following the injury, and then, the patient may go into collapse, characterized by dyspnea and hypotension, so that no radial pulse can be felt.[39],[40] Drainage of the fluid results in a most dramatic relief of all the symptoms, and within a few minutes, the patient is apparently well again. As the fluid reaccumulates, this chain of symptoms may be repeated again and again.[41] Depending on the level of injury, the chylothorax then may develop on one side, or bilaterally.[42],[43],[44],[45] Despite management with drainage and strict dietary changes, the need for surgical intervention may become necessary. A chylothorax should be considered in the differential diagnosis of trauma patients who sustain blunt chest trauma, particularly when these patients have thoracic injuries with pleural effusions. Patients who are symptomatic from chyle loss or have a high output of chyle will require surgical intervention.[46],[47],[48]
| Investigations | | |
After a complete history and clinical examination, the workup of the suspected thoracic duct leakage includes blood examination with complete blood cell count, serum glucose, total protein, triglycerides, albumin, and lactate dehydrogenase. Initially, a chest radiograph may show pleural effusion.[49]
Usually, it is unilateral in up to 78% of patients, and it involves the right side more commonly. As mentioned above, the varied course of the thoracic duct and its site of leak dictates the side of pleural effusion, injuries to the duct below the 5th thoracic vertebrae result in pleural effusion on the right side, and damage above this level occurs in a left-sided pleural effusion. Disruption of multiple tributaries to the thoracic duct can produce pleural effusion bilaterally. High suspicion should arise when a pleural effusion is recurrent or persistent, more so when it is milky, turbid, or serosanguinous.[50]
The analysis of the pleural fluid will show white cell count with lymphocyte predominance and a nucleated cell count >70%. Triglyceride levels >110 mg/dL and cholesterol <200 mg/dL are typically found in patients suspected to have chylothorax. A triglyceride level >240 mg/dL has a sensitivity and specificity of >95%. The definitive diagnostic test is the detection of chylomicrons in the fluid by lipoprotein electrophoresis, though not performed routinely due to its high expense and availability.[51]
After confirming the presence of chylothorax, patients require additional evaluation to find out the etiology for the leak, and that includes computed tomography (CT) of the chest and abdomen. Although at times, CT may not provide the site of the leak and also in the presence of thoracic duct anomalies, CT may not yield much information.[52],[53]
Lymphangiography entails the injection of methylene blue in the subcutis of digits and is carried by the pedal lymphatics into the central system. Furthermore, Lipiodol contrast can be injected into the lymphatic vessel, and the probable site of the leak and anatomical variations can be visualized using fluoroscopy.[54],[55]
Lymphoscintigraphy is the injection of a technetium 99-labeled agent into the dorsum of the foot bilaterally. Later, imaging is done with single-photon emission computerized tomography which gives a good visualization of the thoracic duct.[56]
Recent studies suggest that near-infra-red fluorescence is nonionizing imaging and an easy-to-use method to detect thoracic duct leaks in open surgery or thoracoscopic interventions. Yet, no application to percutaneous sclerotherapy has been described, and hence it can also be a useful tool for percutaneous sclerotherapy.[57]
| Treatment | | |
The treatment of thoracic duct injuries and chylothorax is focused on decompression of the thorax, prevention of malnourishment, and close chyle leaks. This objective can be achieved by different means depending on the etiology, site of the transection, amount of chyle loss, and patient conditions. For the closure of the leakage, there are proposed nonsurgical procedures as well as thoracotomy with direct ligation of the thoracic duct or by thoracoscopy.
Nonsurgical treatment
There are no randomized, controlled studies to direct the management of chylothorax because of its infrequent occurrences and diverse presentations. The initial approach includes chest tube drainage that is considered to be effective and provides a mean of accurately monitoring the rate of chyle leakage.[58]
Severe nutritional depletion and immunodeficiency as a result of the loss of large amounts of chyle. The metabolic management includes monitoring the patient's weight, serum albumin, total protein, absolute lymphocyte count, and electrolytes. Along with replacing the daily losses, dietary modification can address nutritional needs. Administration of medium-chain triglycerides as a source of fat is an invaluable adjunct in the conservative management of chylous pleural effusions, with the objective of avoid malnutrition, minimize the thoracic duct flow to promote healing of the leak. If drainage remains unchanged, then oral intake should be discontinued, and total parenteral nutrition should begin. Some authors believe that the optimal approach includes a regimen of no oral intake, total parenteral nutrition, and chest tube drainage.[59]
Adjunct therapy with octreotide, a somatostatin analog that has an inhibitory effect on lymphatic fluid excretion, however, may be less effective in patients with a chest tube output of >1 L/d.[60]
Conservative treatment of lymph leakage in the absence of serious clinical symptoms, with patient monitoring and diet changes, has been shown more preferable than the invasive approach, although current data are insufficient to definitely confirm it. Failures occur in roughly 50% of patients and are more likely when chest tube output is >500 mL/d. In these patients, a more aggressive approach is necessary.[61]
The first report describing the percutaneous treatment of chyle leak with catheterization of the cisterna chyli in humans was published by Cope in 1998.[62] In the following years, his experience was replicated by other authors.[63]
The percutaneous embolization of chylothorax is a minimally invasive procedure that can be performed using local anesthesia with the patient under conscious sedation associated with no mortality and minimal morbidity. The technique starts with a radiologic demonstration of the cisterna chyli via pedal lymphography, followed by percutaneous, transperitoneal access to the cisterna chyli using a modified Seldinger technique. Once a catheter has been correctly inserted, the thoracic duct is opacified with nonionic contrast medium. After identification of the leak, embolization of the duct is performed with microcoils, glues,[64] or both.[65]
The whole procedure is usually accomplished in about 3 h, but challenging cases can require twice this time. An advantage over surgery of the percutaneous technique is that it can identify all branches of the thoracic duct and the specific site of leakage while allowing embolization of one or more leak sites.[66],[67] It has been used to resolve chyle leakages after surgical procedures,[68] and even an unsuccessful thoracic duct ligature surgery avoiding reinterventions with success.[69]
There has been reported an approach using endoscopic ultrasound and fine-needle injection directly into the thoracic duct 1.5 ml of sodium morrhuate, using color flow Doppler to identify surrounding structures and delineate its relation to the azygous vein.[70] The use of intrapleural streptokinase, 250,000 units twice daily for 3 days, in one patient result in a decrease in the amount of leakage, but no other reports in this regard have been found.[71]
Surgical treatment
Approximately 50% of patients with traumatic chylothorax fail to respond to nonsurgical management and usually necessitate surgical intervention. This is achieved by thoracic duct ligation using right thoracotomy. This operation entails single-lung ventilation with access to the thoracic duct by a seventh interspace right lateral thoracotomy. The thoracic duct is isolated low in the chest within soft tissue between the esophagus, aorta, and azygous vein overlying the vertebrae [Figure 3]. Exposure can be aided by placing a temporary nasogastric tube in the esophagus, and downward retraction of the diaphragm. This soft tissue is mass ligated at three adjacent positions with nonabsorbable suture [Figure 4]. Patients are kept nothing per mouth on total parenteral nutrition for 5 days postoperatively before advancing the diet to confirm resolution of the chyle leak.[72] It has been reported during tumor resection; parts of the thoracic duct were removed which resulted in a large lymph leak. This was addressed by creating a lymphovenous anastomosis to a branch of the subclavian vein, with no longer follow-up to recommend it as a regular practice.[73],[74],[75] | Figure 4: Surgical view showing the ligated thoracic duct as pointed out by the forceps
Click here to view |
Thoracotomy has long been the conventional surgical approach in dealing with chylothorax due to thoracic duct injury which has been refractory to conservative treatment.[22] The development of video-assisted thoracoscopic surgery (VATS) provides an alternative means of dealing with thoracic duct injuries, thereby reducing the morbidity from thoracotomy and prolonged chylous leak.[76] Inderbitzi first reported the successful thoracoscopic management of a postoperative chylothorax by fibrin glue application.[77] The literature supports the use of VATS for specific indications including thoracic duct injury. Patients with traumatic chylothorax should be given the opportunity of conservative management given the rate of response to this approach. If treatment fails, VATS can provide superior visualization of the duct over the traditional open surgical approach due to the magnification of 10-folds, thus the thoracic duct can be clearly seen, and the angled camera provides a view under the vertebral body.[78],[79]
Conservative treatment is expensive and fails in the majority of the high-output chylous fistulae. On the other hand, VATS is uniformly effective and is less expensive with low morbidity. Surprisingly, however, conservative treatment continues to be recommended by most authors.[80]
Acknowledgment
We acknowledge the assistance of Hania Ruiz Bugarin for her help with drawing the diagram of [Figure 1].
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Roberto GA, Britto CM, Gabriel SA, Sardenberg RA. Epidemiological profile of thoracic trauma in Brazil: A systematic review. Panam J Trauma Crit Care Emerg Surg 2021;10:31-8.  |
| 2. | Garg GK, Mutreja JK, Dalal S, Singla SL. Clinical and management profile of thoracic trauma patients. Int J Health Clin Res 2021;4:51-5. |
| 3. | Eray C, Kubilay I, Ozgur OY. Clinical analysis with trauma scoring in blunt thoracic trauma. Kafkas J Med Sci 2021;11:208-13. |
| 4. | Beshay M, Mertzlufft F, Kottkamp HW, Reymond M, Schmid RA, Branscheid D, et al. Analysis of risk factors in thoracic trauma patients with a comparison of a modern trauma centre: A mono-centre study. World J Emerg Surg 2020;15:45. |
| 5. | Kostov K. Diagnosis and treatment of thoracic injuries and traumatic hemopneumothorax. J IMAB 2021;27:3611-4. |
| 6. | Bertoglio P, Guerrera F, Viti A, Terzi AC, Ruffini E, Lyberis P, et al. Chest drain and thoracotomy for chest trauma. J Thorac Dis 2019;11:S186-91. |
| 7. | Ratnayake CB, Escott AB, Phillips AR, Windsor JA. The anatomy and physiology of the terminal thoracic duct and ostial valve in health and disease: Potential implications for intervention. J Anat 2018;233:1-14. |
| 8. | Tijerina GO, Elizondo ORE, Ruiz FR, Ortegón GE, Guzmán LS. Morphology of the thoracic duct and its clinical importance. Med Univer 2007;9:73-6. |
| 9. | Riquet M, Le Pimpec Barthes F, Souilamas R, Hidden G. Thoracic duct tributaries from intrathoracic organs. Ann Thorac Surg 2002;73:892-8. |
| 10. | Phang K, Bowman M, Phillips A, Windsor J. Review of thoracic duct anatomical variations and clinical implications. Clin Anat 2014;27:637-44. |
| 11. | Goswami AK, Khaja MS, Downing T, Kokabi N, Saad WE, Majdalany BS. Lymphatic anatomy and physiology. Semin Intervent Radiol 2020;37:227-36. |
| 12. | Telinius N, Baandrup U, Rumessen J, Pilegaard H, Hjortdal V, Aalkjaer C, et al. The human thoracic duct is functionally innervated by adrenergic nerves. Am J Physiol Heart Circ Physiol 2014;306:H206-13. |
| 13. | Plaza de los Reyes M, Evans P, Roizblatt D, Geni R, Behar M, Fuentes N. Full tracheal rupture associated with posterior thoracic duct injury to blunt chest trauma: A case report. Rev Chil Cirugía 2017;69:157-61.. |
| 14. | Babu A, Rattan A, Ranjan P, et al. Chylothorax due to blunt torso trauma: A rare etiology. J Trauma Treat 2015;4:243-8. |
| 15. | Smith D, Woliver E. Traumatic chylothorax. Arch Surg 1941;43:627-32. |
| 16. | Kakamad FH, Salih RQ, Mohammed SH, HamaSaeed AG, Mohammed DA, Jwamer VI, et al. Chylothorax caused by blunt chest trauma: A review of literature. Indian J Thorac Cardiovasc Surg 2020;36:619-24. |
| 17. | Kapadia N, Jenasamant SS, Rawat GS, Kamkhedkar S, Shah P, Kapadia P. Thoracic duct injury after decortication of lung, new technique to repair thoracic duct in this challenging situation: A case report. Asian Cardiovasc Thorac Ann 2021;29:558-61. |
| 18. | Dorsey JF, Morris GE. Traumatic rupture of the thoracic duct with chylothorax: A brief review of the literature. JAMA 1942;119:337-8. |
| 19. | Litzau M, Welch J. Chylothorax after blunt trauma. Vis J Emerg Med 2018;10:58-9. |
| 20. | Seitelman E, Arellano JJ, Takabe K, Barrett L, Faust G, Angus LD. Chylothorax after blunt trauma. J Thorac Dis 2012;4:327-30. |
| 21. | Pillay TG, Singh B. A review of traumatic chylothorax. Injury 2016;47:545-50. |
| 22. | Brown SR, Fernandez C, Bertellotti R, Asensio JA. Blunt rupture of the thoracic duct after severe thoracic trauma. Trauma Surg Acute Care Open 2018;3:e000183. |
| 23. | Siasios I, Gatos C, Tasiou A. Late occurrence of traumatic chylothorax in a multi-trauma patient with a thoracic spine fracture-dislocation. J Med Cases 2015;6:586-71. |
| 24. | Benato C, Magnanelli G, Terzi A, Scanagatta P, Bonadiman C, Calabrò F. Very unusual case of post-traumatic chylothorax. Ann Thorac Surg 2006;81:1488-91. |
| 25. | Guleserian KJ, Gilchrist BF, Luks FI, Wesselhoeft CW, DeLuca FG. Child abuse as a cause of traumatic chylothorax. J Pediatr Surg 1996;31:1696-7. |
| 26. | Kolbasş I, Tezel Y, Cosşgun T, Kumar S, Gupta A. Chylothorax due to weight lifting: A rare etiology, south. Clin. I st. Euras 2020;31:75-7. |
| 27. | Torrejais JC, Rau CB, de Barros JA, Torrejais MM. Spontaneous chylothorax associated with light physical activity. J Bras Pneumol 2006;32:599-602. |
| 28. | Ma DS, Chang SW, Kim DH. Unusual airway obstruction due to thoracic duct injury after whiplash injury. Ulus Travma Acil Cerrahi Derg 2021;27:478-82. |
| 29. | Lee H, Han SH, Lee MK, Kwon OS, Kim JS, Chon SH, et al. Bilateral chylothorax due to blunt spine hyperextension injury: A case report. Trauma Inj 2019;32:107-10. |
| 30. | Oyebanji T, Ahmad J, Inuwa I. Traumatic chylothorax from a suprascapular stab wound. Ann Afr Surg 2020;17:39-41. |
| 31. | Carrillo R, Ojino J, Carrillo C. Chylothorax secondary to gunshot lesion. Cir Ciruj 2009;77:479-82. |
| 32. | Ruiz-Pier JL, Jesús SJ, Salvador MG. Thoracic duct injury after gunshot wound of the chest. J Cardiothorac Trauma 2020;5:39. |
| 33. | Lofrese G, Cultrera F, Visani J, Scerrati A, Mongardi L, Donati R, et al. Chylothorax in spine fractures: A rarely reported complication? Literature review with an example case. J Trauma Acute Care Surg 2020;89:e140-6. |
| 34. | Rodríguez-Hidalgo LA, Concepción-Urteaga LA, Cornejo-Portella JL, Alquizar-Horna ON, Aguilar-Villanueva DA, Concepción-Zavaleta MJ, et al. A case report of tuberculous chylothorax. Medwave 2019;19:e7655. |
| 35. | Vadala R, Talwar D, Talwar D. Recurrent non-traumatic idiopathic chylothorax: A diagnostic dilemma with therapeutic challenge. Respirol Case Rep 2020;8:e00637. |
| 36. | Barkat B, Karboubi G, Kabiri M. A patient with traumatic chylothorax. Int J Gen Med 2012;5:759-62. |
| 37. | Jenkins JL, Dillard F, Shesser R. Tension chylothorax caused by occult trauma. Am J Emerg Med 2004;22:321-3. |
| 38. | Glyn-Jones S, Flynn J. Traumatic tension chylothorax. Injury 2000;31:549-50. |
| 39. | Matson RC, Stacy JW. Traumatic chylothorax. Dis Chest 1940;6:332-6. |
| 40. | Kozul C, Jassal K, Judson R. Massive bilateral chylothorax post blunt trauma. Trauma Case Rep 2017;12:63-5. |
| 41. | Idris K, Sebastian M, Hefny AF, Khan NH, Abu-Zidan FM. Blunt traumatic tension chylothorax: Case report and mini-review of the literature. World J Clin Cases 2016;4:380-4. |
| 42. | Bohrer T, Paul KJ, Neukam O, Hernandez O, Ritter CO, Hagen R. Rupture of the thoracic duct as a result of injury with subsequent development of bilateral chylothorax. Open J Thorac Surg 2012;2:118-20. |
| 43. | Mohamed M, Alshenawy W, Kegarise C, Betten D. Bilateral chylothorax due to blunt trauma without radiographic evidence of traumatic injury. Clin Pract Cases Emerg Med 2017;1:111-4. |
| 44. | Akpinar V, Duran FY, Duman E, Ozkalkanli MY, Duran O, Horsanali B. Bilateral chylhotorax after falling from height. Case Rep Surg 2014;2014:618708. |
| 45. | Olotu O, Uchendu N, Holtrop J, Graham I, Buck J. Traumatic contralateral chylothorax in a patient with penetrating neck injury: A case report. J Surg Case Rep 2021;2021:rjab031. |
| 46. | Honari S. Traumatic transection of the thoracic duct. Chest 2014;146:355. |
| 47. | Mitchell KG, Feldman H, Meyers BF, Antonoff MB. Chyloptysis as a delayed sequela of penetrating thoracic trauma. JTCVS Tech 2021;9:180-2. |
| 48. | Cerezo A, Martín J, Frías I, de Miguel-Díez J. Recurrent Chylothorax Due To Secondary Superior Vena Cava Obstruction. Arch Bronconeumol 2018;54:434-5. |
| 49. | Bender B, Murthy V, Chamberlain RS. The changing management of chylothorax in the modern era. Eur J Cardiothorac Surg 2016;49:18-24. |
| 50. | McGrath EE, Blades Z, Anderson PB. Chylothorax: Aetiology, diagnosis and therapeutic options. Respir Med 2010;104:1-8. |
| 51. | Riley LE, Ataya A. Clinical approach and review of causes of a chylothorax. Respir Med 2019;157:7-13. |
| 52. | Expert Panel on Vascular Imaging and Interventional Radiology; Majdalany BS, Murrey DA Jr., Kapoor BS, Cain TR, Ganguli S, et al. ACR appropriateness criteria ® chylothorax treatment planning. J Am Coll Radiol 2017;14:S118-26. |
| 53. | Gilyard SN, Khaja MS, Goswami AK, Kokabi N, Saad WE, Majdalany BS. Traumatic chylothorax: Approach and outcomes. Semin Intervent Radiol 2020;37:263-8. |
| 54. | Cholet C, Delalandre C, Monnier-Cholley L, Le Pimpec-Barthes F, El Mouhadi S, Arrivé L. Nontraumatic chylothorax: Nonenhanced MR lymphography. Radiographics 2020;40:1554-73. |
| 55. | Heilman RD, Collins VP. Identification of laceration of the thoracic duct by lymphangiography. Preoperative radiography of the traumatized thoracic duct. Radiology 1963;81:470-2. |
| 56. | Das J, Thambudorai R, Ray S. Lymphoscintigraphy combined with Single-Photon Emission Computed Tomography-Computed Tomography (SPECT-CT): A very effective imaging approach for identification of the site of leak in postoperative chylothorax. Indian J Nucl Med 2015;30:177-9. [ PUBMED] [Full text] |
| 57. | Brito C, Vilela P. Near infra-red fluorescence-guidance for percutaneous sclerotherapy of thoracic duct leak. Am J Otolaryngol 2020;41:102463. |
| 58. | Valentine VG, Raffin TA. The management of chylothorax. Chest 1992;102:586-91. |
| 59. | Pakula AM, Phillips W, Skinner RA. A case of a traumatic chyle leak following an acute thoracic spine injury: Successful resolution with strict dietary manipulation. World J Emerg Surg 2011;6:10. |
| 60. | Novelli PM, Chan EG, Frazier AA, Villa Sanchez M. Interventional therapies for thoracic duct injury and intractable chylothorax. J Thorac Imaging 2019;34:258-65. |
| 61. | Premuzic V, Smiljanic R, Perkov D. A conservative approach to a thoracic duct injury caused by left subclavian vein catheterization. Egypt J Anaesth 2018;34:41-2. |
| 62. | Cope C, Kaiser LR. Management of unremitting chylothorax by percutaneous embolization and blockage of retroperitoneal lymphatic vessels in 42 patients. J Vasc Interv Radiol 2002;13:1139-48. |
| 63. | Itkin M, Kucharczuk JC, Kwak A, Trerotola SO, Kaiser LR. Nonoperative thoracic duct embolization for traumatic thoracic duct leak: Experience in 109 patients. J Thorac Cardiovasc Surg 2010;139:584-89. |
| 64. | Anestis N, Christos FC, Ioannis P, Christos I, Lampros P, Stephanos P. Thoracic duct injury due to left subclavicular vein catheterization: A new conservative approach to a chyle fistula using biological glue. Int J Surg Case Rep 2012;3:330-2. |
| 65. | Marcon F, Irani K, Aquino T, Saunders JK, Gouge TH, Melis M. Percutaneous treatment of thoracic duct injuries. Surg Endosc 2011;25:2844-8. |
| 66. | Hoffer EK, Bloch RD, Mulligan MS, Borsa JJ, Fontaine AB. Treatment of chylothorax: Percutaneous catheterization and embolization of the thoracic duct. AJR Am J Roentgenol 2001;176:1040-2. |
| 67. | Hara H, Mihara M, Yamamoto M. Therapeutic lymphangiography for traumatic chylothorax. J Vasc Surg Venous Lymphat Disord 2018;6:237-40. |
| 68. | Marthaller KJ, Johnson SP, Pride RM, Ratzer ER, Hollis HW Jr. Percutaneous embolization of thoracic duct injury post-esophagectomy should be considered initial treatment for chylothorax before proceeding with open re-exploration. Am J Surg 2015;209:235-9. |
| 69. | Nadolski GJ, Itkin M. Lymphangiography and thoracic duct embolization following unsuccessful thoracic duct ligation: Imaging findings and outcomes. J Thorac Cardiovasc Surg 2018;156:838-43. |
| 70. | Robbins DH, Block M, Lewin D, Wallace M, Hoffman B. Control of traumatic chylothorax with EUS-guided thoracic duct injection sclerotherapy. Gastrointest Endosc 2004;59:212. |
| 71. | Kuan YC, How SH, Ng TH, Abdul Rani MF. Intrapleural streptokinase for the treatment of chylothorax. Respir Care 2011;56:1953-5. |
| 72. | Meguid RA. Chylothorax: Surgical ligation of the thoracic duct through thoracotomy. Oper Tech Thorac Cardiovasc Surg 2016;21:139-51. |
| 73. | Rodi T, Tung Nguyen B, Fritsche E, Rajan G, Scaglioni MF. Direct repair of iatrogenic thoracic duct injury through Lymphovenous Anastomosis (LVA): A case report. J Surg Oncol 2019;121:224-7. |
| 74. | Tracy B, Petruzzelli GJ. Management of intra-operative chyle leak during neck dissection: Recognition and control. Arch Otolaryngol Rhinol 2017;3:83-6. |
| 75. | Melduni RM, Oh JK, Bunch TJ, Sinak LJ, Gloviczki P. Reconstruction of occluded thoracic duct for treatment of chylopericardium: A novel surgical therapy. J Vasc Surg 2008;48:1600-2. |
| 76. | Aerts NR, Erling N Jr., Fontes PR. Thoracoscopic thoracic duct ligation for chylothorax after traumatic subclavian artery injury. J Thorac Cardiovasc Surg 2006;131:752-3. |
| 77. | Inderbitzi RG, Krebs T, Stirneman T, Ulrich A. Treatment of postoperative chylothorax by fibrin glue application under thoracoscopic view with use of local anesthesia. J Thorac Cardiovasc Surg 1992;104:209-10. |
| 78. | Lodhia JV, Konstantinidis K, Papagiannopoulos K. Video-assisted thoracoscopic surgery in trauma: Pros and cons. J Thorac Dis 2019;11:1662-7. |
| 79. | Ahmed N, Jones D. Video-assisted thoracic surgery: State of the art in trauma care. Injury 2004;35:479-89. |
| 80. | Kumar S, Kumar A, Pawar DK. Thoracoscopic management of thoracic duct injury: Is there a place for conservatism? J Postgrad Med 2004;50:57-9. [ PUBMED] [Full text] |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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