Figures
- Figure 1
a) Chest radiograph and b) CT scan of the thorax in November 2018, showing a remaining mild right pleural effusion with an 800 mL daily output, despite 2 months of adequate chest tube drainage and a high-protein and low-fat diet.
- Figure 2
Intranodal lymphangiography. a, b) Cisterna chyli are not seen. Tiny lymphatic vessels are going up (dashed arrows), most visible around the right kidney (full arrow). c, d) no lymphatic vessels are seen at the thoracic level.
- Figure 3
CT scan of the thorax 24 h after intranodal lymphangiography. Lymphatic vessels a) around the right infero-posterior parietal pleura (black arrows) and b) around the inferior vena cava (white arrows).
- Figure 4
Percutaneous embolisation of lymphatic vessels. a) The 22G needle (Chiba, Cook Company, USA) is inserted percutaneously under CT guidance (arrows) into the lymphatic vessel, which was already opacified by lymphangiography. b) Aspiration of lymph in the syringe (arrow) confirms that the tip of needle is within the lymphatic vessel. c) Absolute ethanol is injected slowly through the needle into the lymphatic vessel until the patient feels pain, indicating that the ethanol has reached the pleural space. For this procedure, a total of 8 mL absolute ethanol was injected.
- Figure 5
CT scan of the thorax without contrast. a) CT scan of the thorax in November 2018, before sclerotherapy showing mild right pleural effusion. b) CT scan of the thorax in January 2019, 2 months after sclerotherapy showing no recurrence of right pleural effusion.
- Figure 6
Thoracic duct anatomy and different routes of access for sclerotherapy. a) Simplified thoracic duct anatomy. b) Different routes of access to perform sclerotherapy for chylothorax: 1) transabdominal thoracic duct embolisation by catheterisation of the thoracic duct via the cisterna chyli; 2) retrograde transvenous embolisation of the thoracic duct through the lymphovenous junction; and 3) direct embolisation of the abnormal lymphatic vessel.
Tables
- Table 1
Blood tests
Test Result in patient Normal values White blood cells x109 L−1 5.47 4–10 Haemoglobin g·dL−1 13.3 12.5–17.5 Platelets x109 L−1 233 150–450 Prothrombin % 82 70–140 Proteins g·L−1 63.4 66–87 Albumin g·L−1 27 35–52 Sodium mmol·L−1 131 136–145 Potassium mmol·L−1 4.1 3.5–4.5 Chlorine mmol·L−1 95 98–107 Creatinine μmol·L−1 81 62–106 ASAT U·L−1 27 <40 ALAT U·L−1 36 <41 HIV (Elisa test) Negative HCV antibodies Negative HBV antigen HbS Positive (378 COI) <0.9 Filariasis antibodies Negative ASAT: aspartate amino transferase; ALAT: alanine amino transferase; HCV: hepatitis C; HBV: hepatitis B; COI: cut off index.
- Table 2
Main causes of chylothorax
Traumatic Iatrogenic
Thoracic and cervical surgery
Oesophagus surgery
Retroperitoneal surgery
Cervical vascular catherisation
Thoracic irradiation
Non-iatrogenic
Penetrant and non-penetrant trauma
Increased thoracic pressure (peripartum, heavy cough or vomiting)
Nontraumatic
Malignant Lymphoma, chronic lymphocytic leukaemia, multiple myeloma
Lung cancer, oesophagus cancer, mediastinal metastasis of other cancers
Kaposi sarcoma
Non-malignant obstruction of the thoracic duct or aberrant lymphatic flow Sarcoidosis
Amyloidosis
Superior vena cava thrombosis
Lymphangioleiomyomatosis
Castleman disease
Goiter
Constrictive pericarditis
Yellow-nail syndrome
Chylous ascites
Congenital Turner syndrome
Noonan syndrome
Infectious diseases Tuberculosis
Histoplasmosis
Mediastinitis
Filariasis
Idiopathic
Idiopathic
