Objectives: To investigate the diagnostic value of various lymphatic imaging techniques for thoracic duct (TD) outlet obstruction in patients with chylous leakage. Methods: A retrospective analysis was conducted on 23 patients with chylous leakage who were radiologically diagnosed with a TD outlet obstruction and underwent a TD exploration and reconstruction between January 2022 and February 2025. Non-enhanced magnetic resonance lymphangiography (MRL), 99Tcm-DX lymphoscintigraphy, and intranodal lymphangiography were employed to detect abnormalities in the central lymphatic vessels. The Receiver Operating Characteristic (ROC) curve was utilized to analyze the diagnostic performance of these imaging methods for TD outlet obstruction in lymphatic disorders. Results: Twenty-three patients (fifteen males and eight females) with chylous leakage were included in this study, with an average age of 59.78 ± 13.08 years. Non-enhanced MRL, 99Tcm-DX lymphoscintigraphy, and intranodal lymphangiography revealed TD outlet obstructions in 13, 17, and 18 patients, respectively. Twenty patients exhibited findings consistent with preoperative imaging during TD explorations; the intraoperative microscopic visualization demonstrated the difficulty of white chyle entering the bloodstream for these patients. The ROC curve analysis indicated that "at least two imaging modalities were positive" and had the highest Area Under the Curve (AUC) value (0.90); "intranodal lymphangiography" and "non-enhanced magnetic resonance lymphangiography" followed closely with respective AUC values of 0.76 and 0.73, and 99Tcm-DX lymphoscintigraphy exhibited a lower AUC value 0.63. Conclusions: The combined utilization of multimodal lymphatic imaging techniques demonstrated a high diagnostic accuracy in identifying TD outlet obstruction in patients with chylous leakage.

A postoperative chyle leakage (CL) is caused by intraoperative damage to the main lymphatic vessels or their tributaries. It is characterized by the secretion of a triglyceride-rich fluid, which classically has a characteristic milky appearance in a percutaneous drain. In visceral surgery CLs mostly occur after pancreatic and esophageal surgery but rarely occur after colorectal, liver or gastric surgery. Treatment often consists of a diet rich in medium chain triglycerides (MCT) to reduce the lymphatic flow, while ensuring a sufficient nutrient supply. If the CL does not cease, total parenteral nutrition is usually carried out. A reoperation, lymphography sometimes with percutaneous intervention or short-term irradiation for CL are rarely necessary. A CL frequently results in a prolonged hospital stay and can be accompanied by other complications but is rarely associated with a poorer prognosis.

Conventional x‑ray transpedal lymphangiography enables the diagnosis of a variety of lymphatic diseases through detailed visualization of the lymphatic vessels, in particular those of the lower extremities. Today, it is employed primarily to visualize peripheral lymphatic leakage such as lymphoceles. Its application in lymphoma, lymph node metastases or lymphedema nowadays-with rare exceptions-is only of historical interest.

To present the basic technical principles of transpedal lymphangiography and the interventional treatment options for peripheral lymphatic leakage.

Transpedal x‑ray lymphangiography has a technical success rate of 75-100% when performed by an experienced interventionalist. Pathological findings are visualized in 58-95% of cases. Additionally, a therapeutic effect on postsurgical lymphatic leakage can be expected in about 50% of patients. Additional interventional procedures such as sclerotherapy and lymph vessel embolization are available for the treatment of peripheral lymphatic leaks, whereby the clinical success rates reach 80-100%. Complications are generally rare.

Transpedal x‑ray lymphangiography is a safe and effective procedure for visualizing lymph vessel anatomy. In patients with peripheral lymphatic leaks and consecutive fistulas and/or lymphoceles, lymphangiography as well as percutaneous sclerotherapy or embolization are successful and increasingly used treatment alternatives to surgery.

Chylothorax development following blunt abdominal trauma is a rare event. While low volume chylothoraxes usually improve with conservative treatment, invasive interventions are required in high-volume chylothoraxes with daily drainage exceeding 1000 ml. We report a case of a 14-year-old boy who developed high-volume (>3 L/d) chylothorax on the left side following blunt abdominal trauma. The patient did not respond to conservative treatments. He underwent thoracic duct ligation three times, with percutaneous lymphatic interventions, and percutaneous Lipiodol-glue mixture injections under computed tomography (CT) guidance, but all treatments were unsuccessful. We describe the four-month multidisciplinary challenge in this case that was ultimately successfully treated by surgical ligation of aberrant and/or collateral lymphatics draining from the left abdomen to the left pleural cavity, with the help of the novel cone-beam computed tomography (CBCT) lymphangiography (LAG) technique.

To investigate the diagnostic value of CT lymphangiography (CTL) and non-contrast MR lymphangiography (MRL) in lymphatic plastic bronchitis.

The clinical and imaging data of 31 patients with lymphatic plastic bronchitis diagnosed by clinical, imaging and pathological results were retrospectively analyzed. All patients underwent CTL and MRL. The imaging findings of patients include: (i) abnormal lymphatic reflux of the bronchial mediastinal trunk, the subclavian trunk, the cervical trunk, the thoracic duct and the right lymphatic duct; Abnormal CTL reflux refers to abnormal iodide deposition outside the normal lymphatic reflux pathway; If the MRL can observe abnormal lymphatic dilatation, hyperplasia, or morphological abnormalities, it is assumed that abnormal lymphatic reflux may be present.; (ii) abnormal morphological changes of lymphatic vessels at the extremity of the thoracic duct, the extremity of the right lymphatic duct and the mediastinum, such as spot-like or tubular, cystic changes; (iii) abnormal CTL and MRL signs in the lungs. The Mcnemar test was used to compare the parameters between CTL and MRL. P< 0.05 was statistically significant. The Kappa test was used to evaluate the consistency of CTL and MRL in evaluating lymphatic plastic bronchitis.

MRL was superior to CTL in detecting abnormal lymphatic reflux in the right lymphatic vessel, thoracic duct, cervical trunk and subclavian trunk (P< 0.05).and the diagnostic consistency was general (Kappa < 0.40). There was no significant difference between MRL and CTL in the detection of abnormal lymphatic reflux in the bronchial mediastinal trunk (P> 0.05), and the diagnostic consistency was good (Kappa > 0.60). MRL was superior to CTL in detecting lymphatic abnormalities such as cystic changes at the extremity of the thoracic duct, spot-like or tubular changes at the extremity of the right lymphatic duct, cystic changes at the extremity of the right lymphatic duct, and cystic changes in the mediastinum (P< 0.05), and the diagnostic consistency was poor, fair, fair, and moderate (Kappa < 0.60), respectively. MRL and CTL showed abnormal signs in the lung: CTL was superior to MRL in showing the thickening of interlobular septum, lung nodules and airway stenosis (P< 0.05), and the diagnostic consistency was moderate, moderate and poor (Kappa < 0.60). There was no significant difference between CTL and MRL in atelectasis, consolidation in lobar and segmental distribution, consolidation in non-lobar and segmental distribution, and the thickening of the bronchovascular bundle (P> 0.05), and the diagnostic consistency was very good, very good, good, good (Kappa > 0.60). There was no significant difference between CTL and MRL in ground glass opacity, airway wall thickening and intralobular interstitial thickening (P> 0.05), and the diagnostic consistency was average, fair and poor (Kappa < 0.40).

The MRL is superior to CTL in showing the abnormalities of the thoracic duct, the right lymphatic duct and other abnormal lymphatic vessels. CTL is superior to MRL in the detection of pulmonary abnormalities. The combination of CTL and MRL can provide more comprehensive imaging information for diagnosing and treating lymphatic plastic bronchitis.

This study presents an evaluation of the computed tomography lymphangiography (CTL) features of lymphatic plastic bronchitis (PB) and primary chylothorax to improve the diagnostic accuracy for these two diseases.

To improve the diagnosis of lymphatic PB or primary chylothorax, a retrospective analysis of the clinical features and CTL characteristics of 71 patients diagnosed with lymphatic PB or primary chylothorax was performed.

The clinical and CTL data of 71 patients (20 with lymphatic PB, 41 with primary chylothorax, and 10 with lymphatic PB with primary chylothorax) were collected retrospectively. CTL was performed in all patients. The clinical manifestations, CTL findings, and conventional chest CT findings of the three groups of patients were compared. The chi-square test or Fisher's exact test was used to compare the differences among the three groups. A difference was considered to be statistically significant when P < 0.05.

(1) The percentages of abnormal contrast medium deposits on CTL in the three groups were as follows: Thoracic duct outlet in 14 (70.0%), 33 (80.5%) and 8 (80.0%) patients; peritracheal region in 18 (90.0%), 15 (36.6%) and 8 (80.0%) patients; pleura in 6 (30.0%), 33 (80.5%) and 9 (90.0%) patients; pericardium in 6 (30.0%), 6 (14.6%) and 4 (40.0%) patients; and hilum in 16 (80.0%), 11 (26.8%) and 7 (70.0%) patients; and (2) the abnormalities on conventional chest CT in the three groups were as follows: Ground-glass opacity in 19 (95.0%), 18 (43.9%) and 8 (80.0%) patients; atelectasis in 4 (20.0%), 26 (63.4%) and 7 (70.0%) patients; interlobular septal thickening in 12 (60.0%), 11 (26.8%) and 3 (30.0%) patients; bronchovascular bundle thickening in 14 (70.0%), 6 (14.6%) and 4 (40.0%) patients; localized mediastinal changes in 14 (70.0%), 14 (34.1%), and 7 (70.0%) patients; diffuse mediastinal changes in 6 (30.0%), 5 (12.2%), and 3 (30.0%) patients; cystic lesions in the axilla in 2 (10.0%), 6 (14.6%), and 2 (20.0%) patients; and cystic lesions in the chest wall in 0 (0%), 2 (4.9%), and 2 (4.9%) patients.

CTL is well suited to clarify the characteristics of lymphatic PB and primary chylothorax. This method is an excellent tool for diagnosing these two diseases.

Lymphatic imaging and interventional therapies of disorders affecting the lymphatic vascular system have evolved rapidly in recent years. Although x-ray lymphangiography had been all but replaced by the advent of cross-sectional imaging and the scientific focus shifted to lymph node imaging (eg, for detection of metastatic disease), interest in lymph vessel imaging was rekindled by the introduction of lymphatic interventional treatments in the late 1990s. Although x-ray lymphangiography is still the mainstay imaging technique to guide interventional procedures, several other, often less invasive, techniques have been developed more recently to evaluate the lymphatic vascular system and associated pathologies. Especially the introduction of magnetic resonance, and even more recently computed tomography, lymphangiography with water-soluble iodinated contrast agent has furthered our understanding of complex pathophysiological backgrounds of lymphatic diseases. This has led to an improvement of treatment approaches, especially of nontraumatic disorders caused by lymphatic flow abnormalities including plastic bronchitis, protein-losing enteropathy, and nontraumatic chylolymphatic leakages. The therapeutic armamentarium has also constantly grown and diversified in recent years with the introduction of more complex catheter-based and interstitial embolization techniques, lymph vessel stenting, lymphovenous anastomoses, as well as (targeted) medical treatment options. The aim of this article is to review the relevant spectrum of lymphatic disorders with currently available radiological imaging and interventional techniques, as well as the application of these methods in specific, individual clinical situations.

To present a preclinical in vivo approach for standardization and training of lymphangiography and lymphatic interventions using a pictorial review.

Different lipiodol- and gadolinium-based lymphangiography and lymphatic interventions were performed in twelve (12) landrace pigs with a mean bodyweight of 34 ± 2 kg using various imaging and guiding modalities, similar to the procedures used in humans. The techniques used were explicitly introduced and illustrated. The potential applications of each technique in preclinical training were also discussed.

By applying visual, ultrasonography, fluoroscopy, CT, cone-beam CT, and/or MRI examination or guidance, a total of eleven techniques were successfully implemented in twelve pigs. The presented techniques include inguinal postoperative lymphatic leakage (PLL) establishment, interstitial dye test, five types of lymphangiography [incl. lipiodol-based translymphatic lymphangiography (TL), lipiodol-based percutaneous intranodal lymphangiography (INL), lipiodol-based laparotomic INL, lipiodol-based interstitial lymphangiography, and interstitial magnetic resonance lymphangiography (MRL)], and four types of percutaneous interventions in the treatment of PLL [incl. thoracic duct embolization (TDE), intranodal embolization (INE), afferent lymphatic vessel sclerotherapy (ALVS), and afferent lymphatic vessel embolization (ALVE)].

This study provides a valuable resource for inexperienced interventional radiologists to undergo the preclinical training in lymphangiography and lymphatic interventions using healthy pig models.

Postoperative chylothorax is a rare complication after pulmonary resection. Thoracic duct variations may play a key role in postoperative chylothorax occurrence and make treatment difficult. No studies in the literature have reported the successful treatment of chylothorax second to thoracic duct variation by lipiodol-based lymphangiography.

A 63-year-old male and a 28-year-old female with primary lung adenocarcinoma were treated by video-assisted thoracoscopic cancer resection, and suffered postoperative chylothorax. Conservative treatment was ineffective, including nil per os, persistent thoracic drainage, fatty food restriction, and somatostatin administration.

Postoperative chylothorax.

Patients received lipiodol-based lymphangiography under fluoroscopic guidance. Iatrogenic injuries were identified at thoracic duct variations, including an additional channel in case 1 and the lymphatic plexus instead of the thoracic duct in case 2.

Thoracic duct variations were identified by lipiodol-based lymphangiography, and postoperative chylothorax was successfully treated by lipiodol embolizing effect.

Thoracic duct variations should be considered after the failure of conservative treatment for postoperative chylothorax secondary to pulmonary resection. Lipiodol-based lymphangiography is valuable for identifying the thoracic duct variations and embolizing chylous leakage.

Chyle leak is a common complication following pancreatic surgery. After failure of conservative treatment, lymphography is one of the last therapeutic options. The objective of this study was to evaluate whether lymphography represents an effective treatment for severe chyle leak (International study Group on Pancreatic Surgery, grade C) after pancreatic surgery.

Patients with grade C chyle leak after pancreatic surgery who received transpedal or transnodal therapeutic lymphography between 2010 and 2020 were identified from a prospectively maintained database. Clinical success of the lymphography was evaluated according to percent decrease of drainage output after lymphography (>50% decrease = partial success; >85% decrease = complete success).

Of the 48 patients undergoing lymphography, 23 had a clinically successful lymphography: 14 (29%) showed partial and 9 (19%) complete success. In 25 cases (52%) lymphography did not lead to a significant reduction of chyle leak. Successful lymphography was associated with earlier drain removal and hospital discharge [complete clinical success: 7.1 days (±4.1); partial clinical success: 12 days (±9.1), clinical failure: 19 days (±19) after lymphography; p = 0.006]. No serious adverse events were observed.

Therapeutic lymphography is a feasible, safe, and effective option for treating grade C chyle leak after pancreatic surgery.

Persistent lymphatic leakage from the surgical drain is a troubling complication occasionally encountered postoperatively. This study investigated lymphatic leaks after renal or liver transplantation, comparing the treatment efficacy of traditional catheter drainage vs. minimally invasive lymphatic interventions. We also discuss access and treatment targets considering the physiology of lymphatic flow.

Between September 2018 and September 2020, 13 patients with lymphatic leakage were treated with minimally invasive lymphatic interventions; 11 had received a renal transplant, and two received a liver transplant. The control group included 10 patients with post-renal transplant lymphatic leakage treated with catheter drainage. The treatment efficacy of catheter drainage, lymphatic interventions, and different targets of embolization were compared.

The technical success rate for lymphatic intervention was 100%, and the clinical success rate was 92%, with an 82.9% percent reduction in drain volume on the first day after treatment. The duration to reach clinical success was 5.9 days with lymphatic intervention, and 33.9 days with conservative catheter drainage.

Lymphangiography and embolization are minimally invasive and efficient procedures for treating persistent lymphatic leaks after renal or liver transplantation. We suggest prompt diagnosis and embolization at upstream lymphatics to reduce the duration of drain retention, days of hospitalization and associated comorbidities. This article is protected by copyright. All rights reserved.

 Report of experience from a single institution in treating postoperative lymphatic leakage (PLL) applying conventional transpedal lymphangiography (TL).

 453 patients with the initial diagnosis of PLL receiving TL between 03/1993 and 09/2018 were identified in the database. Only patients with confirmed PLL were included in the study. The technical success, safety, and treatment success of TL were evaluated. Independent predictors of TL treatment failure were examined using univariate and multivariate logistic regression analysis.

 355 consecutive patients (218 men, 137 women; median age of 62 years) who underwent TL for PLL (e. g., chylothorax) after ineffective conservative treatment were included. The median time between causal surgery and TL was 27 days. The median technical success rate of TL was 88.5 %, with a median volume of Lipiodol of 10.0 ml. No complication of TL was recorded. Three groups were defined according to the different clinical courses: group A (41/355, 11.5 %) - TL with technical failure; group B (258/355, 72.7 %) - "therapeutic" TL alone with technical success; and group C (56/355, 15.8 %) - "diagnostic" TL with simultaneously invasive treatment (incl. surgical revision and percutaneous sclerotherapy). Treatment success rate and median time to treatment success were higher in group C than in group B, but without significant differences (64.3 % vs. 61.6 %, p = 0.710; six vs. five days, p = 0.065). Univariate and multivariate logistic regression analyses for group B confirmed drainage volume (> 500 ml/d) and Lipiodol extravasation as independent predictors of TL clinical failure (odds ratios [ORs] of 2.128 and 2.372 [p = 0.005 and p = 0.003, respectively]).

 TL is technically reliable, safe, and effective in treating PLL. When conservative treatment fails, TL can be regarded as the next treatment option.

  · TL is technically reliable, safe, and effective for treating PLL.. · When conservative treatment fails, TL can be regarded as the next treatment option.. · Drainage volume > 500 ml/day is an independent predictor of clinical failure after TL.. · Lipiodol extravasation is an independent predictor of clinical failure after TL..

· Pan F, Richter GM, Do TD et al. Treatment of Postoperative Lymphatic Leakage Applying Transpedal Lymphangiography - Experience in 355 Consecutive Patients. Fortschr Röntgenstr 2022; DOI: 10.1055/a-1717-2467.

Iodized oil-based lymphangiography (LAG) is a well-established diagnostic exam during the workup of postoperative lymphatic leaks. Computed tomography (CT) has been shown to be a useful complement to optimize treatment planning and can easily be performed after conventional LAG. The treatment options for lymphatic leaks include conservative dietary modification, sclerotherapy, embolization, and surgery. We present a case of a 48-year-old man who developed a symptomatic left retroperitoneal lymphatic fluid collection after left nephrectomy, complicated by postoperative retroperitoneal abscess. Retroperitoneal duct leak was confirmed via ultrasound-guided intranodal LAG and post-LAG CT. This leak was successfully managed with N-butyl cyanoacrylate glue embolization of the leaking lymphatics via fluoroscopic-guided catheterization of the leak via percutaneous access through the lymphatic fluid collection.

Postoperative lymphorrhea can occur after different surgical procedures and may prolong the hospital stay due to the need for specific treatment. In this work, the therapeutic significance of the radiological management of postoperative lymphorrhea was assessed and illustrated.

A standardized search of the literature was performed in PubMed applying the Medical Subject Headings (MeSH) term "lymphangiography." For the review, the inclusion criterion was "studies with original data on Lipiodol-based Conventional Lymphangiography (CL) with subsequent Percutaneous Lymphatic Intervention (PLI)." Different exclusion criteria were defined (e.g., studies with <15 patients). The collected data comprised of clinical background and indications, procedural aspects and types of PLI, and outcomes. In the form of a pictorial essay, each author illustrated a clinical case with CL and/or PLI.

Seven studies (corresponding to evidence level 4 [Oxford Centre for Evidence-Based Medicine]) accounting for 196 patients were included in the synthesis and analysis of data. Preceding surgery resulting in postoperative lymphorrhea included different surgical procedures such as extended oncologic surgery or vascular surgery. Central (e.g., chylothorax) and peripheral (e.g., lymphocele) types of postoperative lymphorrhea with a drainage volume of 100-4000 ml/day underwent CL with subsequent PLI. The intervals between "preceding surgery and CL" and between "CL and PLI" were 2-330 days and 0-5 days, respectively. CL was performed before PLI to visualize the lymphatic pathology (e.g., leakage point or inflow lymph ducts), applying fluoroscopy, radiography, and/or computed tomography (CT). In total, seven different types of PLI were identified: (1) thoracic duct (or thoracic inflow lymph duct) embolization, (2) thoracic duct (or thoracic inflow lymph duct) maceration, (3) leakage point direct embolization, (4) inflow lymph node interstitial embolization, (5) inflow lymph duct (other than thoracic) embolization, (6) inflow lymph duct (other than thoracic) maceration, and (7) transvenous retrograde lymph duct embolization. CL-associated and PLI-associated technical success rates were 97-100% and 89-100%, respectively. The clinical success rate of CL and PLI was 73-95%. CL-associated and PLI-associated major complication rates were 0-3% and 0-5%, respectively. The combined CL- and PLI-associated 30-day mortality rate was 0%, and the overall mortality rate was 3% (corresponding to six patients). In the pictorial essay, the spectrum of CL and/or PLI was illustrated.

The radiological management of postoperative lymphorrhea is feasible, safe, and effective. Standardized radiological treatments embedded in an interdisciplinary concept are a step towards improving outcomes.

A postoperative chylothorax is an uncommon but problematic surgical complication in 0.5-4.0% of surgical cases that nevertheless still plagues every busy thoracic surgeon. Fortunately, most chylothoraces are low-volume and are readily controlled by conservative measures. A high-volume chylothorax (>1 liter/24 hours) fortunately occurs in less than one-third of patients, usually responding to the published treatment algorithms and generally requiring invasive techniques. We report a case of a post-lobectomy high-volume, left-sided chylothorax refractory to all the usual recommended interventions that ultimately was successfully treated by novel CT lymphangiography-guided transabdominal surgical ligation of the aberrant left-sided lymphatics with complete, prompt chylothorax control.