Percutaneous thoracic duct embolisation for persistent chyle leak

Evidence-based recommendations on percutaneous thoracic duct embolisation for persistent chyle leak. In this procedure, under general anaesthesia, ultrasound and X-rays are used to create an image of the thoracic duct and find the leak. Then, using a needle, a tube is inserted through the abdominal wall (percutaneous) and guided into the thoracic duct. Small metal coils and medical glue are inserted through the tube and used to plug the leak (embolisation). The aim is to stop the leak.

# Recommendations
Evidence on the safety and efficacy of percutaneous thoracic duct embolisation for persistent chyle leak is limited in quantity and quality. Therefore, this procedure should only be used with special arrangements for clinical governance, consent, and audit or research. Find out what special arrangements mean on the NICE interventional procedures guidance page.
Clinicians wanting to do percutaneous thoracic duct embolisation for persistent chyle leak should:
Inform the clinical governance leads in their healthcare organisation.
Give people (and their families and carers, as appropriate) clear written information to support shared decision making, including NICE's information for the public.
Ensure that people (and their families and carers, as appropriate) understand the procedure's safety and efficacy, and any uncertainties about these.
Audit and review clinical outcomes of everyone having the procedure. The main efficacy and safety outcomes identified in this guidance can be entered into NICE's interventional procedure outcomes audit tool (for use at local discretion).
Discuss the outcomes of the procedure during their annual appraisal to reflect, learn and improve.
Healthcare organisations should:
Ensure systems are in place that support clinicians to collect and report data on outcomes and safety for everyone having this procedure.
Regularly review data on outcomes and safety for this procedure.
Patient selection should be done by a team experienced in managing the condition, including a dietitian.
The procedure should only be done in specialist centres by clinicians with specific training and experience in this procedure.
NICE encourages further research into percutaneous thoracic duct embolisation for persistent chyle leak. Research should include details of patient selection, size and position of the leak, approaches used, and short- and long-term efficacy and safety outcomes.# The condition, current treatments and procedure

# The condition
Chyle leak or discharge can occur as a result of thoracic duct injury (injury to the structure that returns lymph and chyle from the lower half of the body). Injury can happen during surgery, from trauma or from disease such as cancer. Chyle leak can cause delayed wound healing, dehydration, malnutrition, electrolyte imbalance, breathing problems and immunosuppression.

# Current treatments
Small chyle leaks are usually treated with medicines and by managing nutrition (including by modifying diet or with total parenteral nutrition) to reduce chyle secretion and relieve symptoms. Persistent high-volume leaks may need drainage or percutaneous or open surgical repair (such as thoracic duct ligation).

# The procedure
Thoracic duct embolisation is a percutaneous image-guided closure of the thoracic duct and is done under general or local anaesthesia. It is a 3step process consisting of intranodal inguinal lymphangiography followed by percutaneous transabdominal catheterisation of the thoracic duct or cisterna chyli and then embolisation of the thoracic duct.
Under fluoroscopic or ultrasound guidance, an oil-based contrast medium is injected into inguinal lymph nodes. This progresses slowly through the network of pelvic and retroperitoneal lymphatic vessels and allows the thoracic duct and cisterna chyli to be visualised. Then, through transabdominal access under imaging guidance, the target thoracic duct or cisterna chyli is accessed with a guidewire using a needle. A microcatheter is advanced over the guidewire into the thoracic duct, then the guidewire is removed. Contrast medium is injected through the catheter to define the source of the leak and the thoracic duct anatomy. The target thoracic duct and its branches are embolised proximally to the leak with a combination of microcoils and cyanoacrylate glue.