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Clinical Characteristics of Patients with Primary Chylothorax Failed in Treatment of Thoracic Duct Ligation
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摘要:
目的 对胸导管结扎术(thoracic duct ligation, TDL)治疗原发性乳糜胸失败病例的临床特征进行总结。 方法 本研究为回顾性分析。研究对象为2007年5月至2021年10月首都医科大学附属北京世纪坛医院淋巴外科收治的经外院TDL治疗失败的原发性乳糜胸患者。对其入院后临床表现及直接淋巴管造影(结合淋巴管造影后CT影像学资料)结果进行总结。 结果 共入选38例符合纳入和排除标准的原发性乳糜胸患者。TDL治疗后, 50.0%(19/38)的患者胸腔积液引流量增加, 36.8%(14/38)的患者出现了新症状。直接淋巴管造影结果显示, 所有患者的胸导管结扎均较彻底, 但患者普遍存在不同程度的淋巴回流障碍, 表现为淋巴管扩张(94.7%, 36/38)和不同形式的淋巴管反流(92.1%, 35/38)。 结论 TDL治疗失败的原发性乳糜胸患者的渗漏点应位于乳糜池及其属支淋巴管与结扎点之间, 治疗失败的原因可能与胸导管结扎加重了原本存在的淋巴回流障碍有关。建议原发性乳糜胸患者于TDL术前均行淋巴管造影检查, 以指导治疗方案的制订。 Abstract:Objective To summarize the clinical characteristics of patients with primary chylothorax who failed in the treatment of thoracic duct ligation (TDL). Methods This study was a retrospective analysis. The subjects were patients with primary chylothorax who had failed in TDL treatment in other hospitals and were admitted to the Department of Lymphatic Surgery, Beijing Shijitan Hospital, Capital Medical University from May 2007 to October 2021. The clinical features and results of direct lymphangiography (combined with CT imaging data after lymphangiography) after admission were summarized. Results A total of 38 patients with primary chylothorax who met the inclusion and exclusion criteria were enrolled. After TDL treatment, 50.0%(19/38) patients had increased drainage of pleural effusion and 36.8% (14/38) patients developed new symptoms. The results of direct lymphangiography showed that the ligation of the thoracic duct was relatively complete in all patients. The patients generally had different degrees of lymphatic reflux disorder, and manifested lymphatic dilatation (94.7%, 36/38) and different forms of lymphatic reflux (92.1%, 35/38). Conclusions In this study, the leaking point of primary chylothorax may be located between the cisterna chylior its branching lymphatic vessels and the ligation point. The failure of TDL treatment may be related to the aggravation of the existing lymphatic reflux disorder caused by TDL. Lymphangiography before TDL is recommended for patients with primary chylothorax to guide the formulation of treatment. 作者贡献：安然负责数据收集、论文撰写；夏松、孙宇光负责淋巴管造影阅片、数据收集；常鲲、信建峰、王婷婷负责数据收集；沈文彬指导研究设计、修订论文。利益冲突：所有作者均声明不存在利益冲突 -
图 1 1例胸导管结扎术治疗失败的乳糜胸患者直接淋巴管造影图像，可见碘油上行至第10胸椎(a)，碘油反流至肋间淋巴管(b)，碘油向胸导管以外漏出(c)，腹部淋巴管明显扩张(d)
表 1 38例患者的一般临床资料
指标 数值 性别[n(%)] 男 19(50.0) 女 19(50.0) 年龄(x±s, 岁) 41.4±17.3 乳糜胸积液位置[n(%)] 左侧胸腔 10(26.3) 右侧胸腔 14(36.8) 双侧胸腔 14(36.8) 胸导管结扎术后引流量变化[n(%)] 增加 19(50.0) 减少 6(15.8) 不变 13(34.2) 胸导管结扎术后新症状[n(%)] 双侧乳糜胸 4(10.5) 乳糜腹 7(18.4) 血性乳糜胸 2(5.3) 腹泻 2(5.3) 会阴水肿和鞘膜积液 2(5.3) 腰背部水肿 1(2.6) 
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表 2 38例患者直接淋巴管造影特征
指标 例数[n(%)] 穿刺路径 足背淋巴管 37(97.4) 腹股沟淋巴结 1(2.6) 碘油最高到达部位 颈部 0(0) 肺门 1(2.6) 第6胸椎 4(10.5) 第8胸椎 3(7.9) 第9胸椎 2(5.3) 第10胸椎 6(15.8) 第11胸椎 10(26.3) 第12胸椎 6(15.8) 第1腰椎 1(2.6) 第2腰椎 2(5.3) 第5腰椎 1(2.6) 腹股沟下 1(2.6) 淋巴管扩张 36(94.7) 碘油外周入血 3(7.9) 淋巴管反流 35(92.1) 膈肌 19(50.0) 对侧腰干 15(39.5) 肺 3(7.9) 肾脏 9(23.7) 肠系膜 6(15.8) 胸壁、腹壁、臀部、对侧下肢 6(15.8) 肝脏 4(10.5) 肋间 4(10.5) 会阴 4(10.5) 盆腔淋巴管 2(5.3) 锁骨下干 0(0) 支气管纵隔干 0(0) 颈干 0(0) 胸腔漏出 8(21.1) 腹腔漏出 3(7.9) 颈部入血 0(0)
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