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Correspondence |

Thoracic Duct Embolization, Unexplained Thoracic Duct Occlusions, and Lymphatic AnomaliesThoracic Duct Embolization and Lymphatic Anomalies FREE TO VIEW

Juan Carlos López-Gutiérrez, MD, PhD
Author and Funding Information

From the Department of Surgery, Vascular Anomalies Center, La Paz Children’s Hospital.

Correspondence to: Juan Carlos López-Gutiérrez, MD, PhD, Department of Surgery, Vascular Anomalies Center, La Paz Children’s Hospital, Paseo de la Castellana 261, 28046 Madrid, Spain; e-mail: queminfantil.hulp@salud.madrid.org


Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;143(2):578-579. doi:10.1378/chest.12-2097
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Published online
To the Editor:

I read with interest the article by Nadolski and Itkin1 in CHEST (January 2013) on thoracic duct embolization (TDE) for nontraumatic chylous effusion. The authors are to be applauded for approaching a difficult topic with poorly established standards and a high mortality rate. This is an important condition for chest physicians to understand and manage. Unfortunately, and despite the authors’ vast experience in the management of >160 patients with this frequently devastating disorder, the etiology of spontaneous or idiopathic chylothorax remains unexplained. What are the mechanisms for the thoracic duct undergoing obstruction in patients with no previous disease and normal MRI thoracic examinations? Up to 20% of patients with nontraumatic chylous effusions present with lymphatic anomalies (lymphatic malformations, generalized lymphatic disease [lymphangiomatosis], or Gorham-Stout disease).2 Children with massive lymphatic malformations in the neck, axilla, or groin do not develop lymphatic duct obstruction with lymphedema. We do not have information regarding compared outcomes of TDE in patients with or without associated lymphatic malformations.

It is evident that TDE will soon definitively replace surgical thoracic duct ligation (TDL) because morbidity is significantly reduced by using this technique. To better understand the benefits of this procedure, we need information about the routes of chyle recanalization after thoracic duct occlusion. Apparently, postoperative recurrent chylothorax or proximal chylous effusions are significantly reduced in patients undergoing TDE compared with those treated with TDL. This complication is common in patients with generalized lymphatic anomalies undergoing TDL. Are lymphatic-venous communications more easily opened and better functioning after TDE?

Nontraumatic chylothorax in children aged <10 years remains an unsolved problem. Because successful TDE has been reported in the treatment of post-cardiac surgery chylothorax in small children,3 there are optimistic expectations of TDE improving the mortality rate in the pediatric population affected by pulmonary or disseminated lymphangiomatosis.4 We encourage pediatric interventional radiologists and thoracic surgeons involved in the management of children with chylothorax in the context of life-threatening lymphatic anomalies to develop and promote noninvasive techniques in the management of these patients.

References

Nadolski GJ, Itkin M Thoracic duct embolization for non-traumatic chylous effusion: experience in 34 patients. Chest. 2013;143(1):158-163.
 
Doerr CH, Allen MS, Nichols FC III, Ryu JH Etiology of chylothorax in 203 patients. Mayo Clin Proc. 2005;80(7):867-870. [CrossRef] [PubMed]
 
Itkin M, Krishnamurthy G, Naim MY, Bird GL, Keller MS Percutaneous thoracic duct embolization as a treatment for intrathoracic chyle leaks in infants. Pediatrics. 2011;128(1):e237-e241. [CrossRef] [PubMed]
 
Ayuso-Velasco R, López-Gutiérrez JC Mortality in patients with osteolysis of lymphatic origin: a review of the experience with 54 patients and the literature [in Spanish]. An Pediatr (Barc). 2012;77(2):83-87. [CrossRef] [PubMed]
 

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References

Nadolski GJ, Itkin M Thoracic duct embolization for non-traumatic chylous effusion: experience in 34 patients. Chest. 2013;143(1):158-163.
 
Doerr CH, Allen MS, Nichols FC III, Ryu JH Etiology of chylothorax in 203 patients. Mayo Clin Proc. 2005;80(7):867-870. [CrossRef] [PubMed]
 
Itkin M, Krishnamurthy G, Naim MY, Bird GL, Keller MS Percutaneous thoracic duct embolization as a treatment for intrathoracic chyle leaks in infants. Pediatrics. 2011;128(1):e237-e241. [CrossRef] [PubMed]
 
Ayuso-Velasco R, López-Gutiérrez JC Mortality in patients with osteolysis of lymphatic origin: a review of the experience with 54 patients and the literature [in Spanish]. An Pediatr (Barc). 2012;77(2):83-87. [CrossRef] [PubMed]
 
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