We present a case of a 58 year-old woman with primary chylopericardium associated with chylothorax. Chylopericardium is a condition in which chylous fluid containing a high concentration of triglycerides accumulates in the pericardial cavity, and it can form for many different reasons. 3D computed tomography with lymphography precisely depicted the specific location of the lymphatic leak in this patient, which was successfully repaired using targeted video assisted thoracic surgery (VATS).
Background A side-effect of axillary lymph node excision and radiotherapy for breast cancer is arm lymphedema in about 25% patients (ranging from 13 to 52%). Sentinel lymph node (SLN) biopsy has reduced the severity of swelling to nearly 6% patients (from 2 to 7%) and, in case of positive SLN, complete axillary dissection (AD) is still required. That is why Axillary Reverse Mapping method (ARM) was developed aiming at identifying and preserve lymphatics draining the arm. Leaving in place lymph nodes related to arm lymphatic drainage would decrease the risk of arm lymphedema, but not retrieving all nodes, the main risk is to leave metastatic disease in the axilla. Based on long term experience in lymphatic-venous anastomoses (LVA) for lymphedema treatment, Authors conceived and carried out preventive LVA during nodal dissection (Lymphatic Microsurgical Preventing Healing Approach - LY.M.P.H.A. technique). Methods 78 patients underwent axillary nodal dissection for breast cancer treatment and in 74 of them LY.M.P.H.A. procedure was performed. Indications to LY.M.P.H.A. technique were based on clinical and lymphoscintigraphic parameters. All blue nodes were resected and 2 to 4 main afferent lymphatics from the arm could be prepared and used for anastomoses. Lymphatics were introduced inside the vein cut-end by a U-shaped stitch. Volumetry was performed preoperatively in all patients and after 1, 6, 12 months and once a year. Lymphoscintigraphy was performed in 45 patients preoperatively and in 30 also postoperatively after at least over 1 year. Results Seventy-one patients had no sign of lymphedema. In 3 patients, lymphedema occurred after 8-12 months postoperatively. The incidence of secondary arm lymphedema after LY.M.P.H.A. technique was therefore 4.05%. ConclusionLVA proved not only to prevent lymphedema but also to reduce early lymphatic complications (i.e. lymphorrhea, lymphocele). LY.M.P.H.A. technique is also useful in patients with melanoma of the trunk and vulvar cancer, in whom it is possible to perform preventive LVA simultaneously with inguinal lymphadenectomy. Lymphedema is a consequence of cancer treatment. The use of the blue dye and of LVA helps to solve the problem of preventing secondary arm and leg lymphedema. LY.M.P.H.A. represents a rational approach to the prevention of lymphedema following axillary and groin surgery in the therapy of breast cancer, melanoma, vulvar cancer and other tumors.
This study aimed to report new clinical approaches to the treatment of lymphatic disorders by microsurgical techniques based on histological and immunohistochemical findings. The authors’ wide clinical experience in the treatment of patients with peripheral lymphedema by microsurgical techniques is reported. Microsurgical methods included derivative lymphatic-venous anastomoses and lymphatic reconstruction by interpositioned vein grafted shunts. In all patients, lymphatic and lymph nodal tissues were sent for histological assessment, together with specimen of the interstitial matrix. Diagnostic investigations consisted in venous duplex scan and lymphoscintigraphy. Results were assessed clinically by volumetry performed preoperatively and postoperatively at 3 to 6 months and at 1, 3, and 5 years. The outcome obtained in treating lymphedemas at different stages was analyzed for volume reduction, stability of results with time, reduction of dermatolymphangioadenitis attacks, necessity of wearing elastic supports, and use of conservative measures postoperatively. Microsurgical lymphatic derivative and reconstructive techniques allow bringing about positive results in the treatment of peripheral lymphedema, above all in early stages when tissular changes are slight and allow almost a complete restore of lymphatic drainage.
