Endovascular Lymphatic Decompression via Thoracic Duct Stent Placement for Refractory Ascites in Patients with Cirrhosis: A Pilot Study

PURPOSE

To evaluate the technical and clinical success of endovascular lymphatic decompression via thoracic duct (TD) stent placement in patients with cirrhosis with refractory ascites.

MATERIALS AND METHODS

Nine patients (6 men and 3 women; median age, 66 [interquartile range {IQR}, 65-68] years; range, 62-78 years) who underwent TD stent placement for refractory ascites with contraindications for liver transplantation and transjugular intrahepatic portosystemic shunt creation were included in this retrospective study. TD stent placement was performed under local anesthesia using retrograde access from the venous system. Self-expanding stents from 5 to 8 mm in diameter were used and extended into the subclavian vein by approximately 1 cm. Technical (correct positioning of the stent) and clinical success (no more requirement of paracentesis) were evaluated. In addition, the safety of the procedure and TD pressure evolution were evaluated.

RESULTS

The technical success rate was 100%, and 3 (33%) patients reported clinical success. Five (56%) patients reported 7 minor adverse events (Grade I), among which 2 TD perforations were induced by stent angioplasty, with no clinical manifestation or treatment required. The median TD pressure decreased from 19 mm Hg (IQR, 11-24 mm Hg) at the beginning of the procedure to 6 mm Hg (IQR, 5-11 mm Hg) after TD stent placement. The median survival time after the procedure was 7.1 months.

CONCLUSIONS

Endovascular lymphatic decompression via TD stent placement is feasible and safe and was effective on ascites in some patients with cirrhosis with refractory ascites.

Clinical implications of chyle leakage following esophagectomy

The clinical consequences of chyle leakage following esophagectomy are underexposed. The aim of this study was to investigate the clinical implications of chyle leakage following esophagectomy. This retrospective study of prospectively collected data included patients who underwent transthoracic esophagectomy in 2017-2020. Routinely, the thoracic duct was resected en bloc as part of the mediastinal lymphadenectomy. Chyle leakage was defined as milky drain fluid for which specific treatment was initiated and/or a triglyceride level in drain fluid of ≥1.13 mmol/L, according to the Esophagectomy Complications Consensus Group (ECCG) classification. Primary endpoints were the clinical characteristics of chyle leakage (type, severity and treatment). Secondary endpoints were the impact of chyle leakage on duration of thoracic drainage and hospital stay. Chyle leakage was present in 43/314 patients (14%), of whom 24 (56%) were classified as severity A and 19 (44%) as severity B. All patients were successfully treated with either medium chain triglyceride diet (98%) or total parental nutrition (2%). There were no re-interventions for chyle leakage during initial admission, although one patient needed additional pleural drainage during readmission. Patients with chyle leakage had 3 days longer duration of thoracic drainage (bias corrected accelerated (BCa) 95%CI:0.46-0.76) and 3 days longer hospital stay (BCa 95%CI:0.07-0.36), independently of the presence of other complications. Chyle leakage is a relatively frequent complication following esophagectomy. Postoperative chyle leakage was associated with a significant longer duration of thoracic drainage and hospital admission. Nonsurgical treatment was successful in all patients with chyle leakage.

Multidisciplinary Management of Chylothorax

Chylothorax, the accumulation of chyle in the pleural space, is usually caused by the disruption of the thoracic duct or its tributaries. Etiologies are broadly divided into traumatic, including postsurgical, and nontraumatic, most commonly in the setting of malignancy. The management of chylothorax largely depends on the cause and includes dietary modification and drainage of the pleural space. A definitive intervention, whether surgical or a percutaneous lymphatic intervention, should be considered in patients with a persistently high volume of chylous output and in those with a prolonged leak, before complications such as malnutrition ensue. No methodologically robust clinical trials guiding management are currently available. In this article, we review the current literature and propose a stepwise, evidence-based multidisciplinary approach to the management of patients with both traumatic and nontraumatic chylothorax.

Invasive treatment of persistent postoperative chylothorax secondary to thoracic duct variation injury: Two case reports and literature review

RATIONALE

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.

PATIENT CONCERNS

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.

DIAGNOSIS

Postoperative chylothorax.

INTERVENTIONS

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.

OUTCOMES

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

LESSONS

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.

Survival Analysis of Patients with Thoracic Duct Ligation during Thoracoscopic Esophagectomy

OBJECTIVE

To determinate the effect of thoracic duct ligation during thoracoscopic esophagectomy on esophageal cancer patients survival.

STUDY DESIGN

A descriptive study.

PLACE AND DURATION OF STUDY

Tai'an City Central Hospital, Tai'an, Shandong, China, from June, 2016 to June, 2021.

METHODOLOGY

All cT1b-3N0M0 stage esophageal cancer patients were randomly divided into thoracic duct ligation group and non-ligation group. In addition to thoracoscopic esophagectomy, thoracic duct ligation was also performed in the experimental group. The general data of two groups were compared by Chi-square test, with statistical significance at p <0.05. The effect of thoracic duct ligation on disease-free survival (DFS) and overall survival (OS) was analysed by Kaplan-Meier and Cox regression.

RESULT

There was no significant difference in gender, age, tumor location, depth of invasion, degree of differentiation and presence of tumor thrombus between the ligation group (33 cases, 47.8%), and the non-ligation group (36 cases, 52.2%). Cox regression analysis showed that depth of invasion (p = 0.0014), degree of differentiation (p = 0.0036), presence of tumor thrombus (p = 0.0367) and thoracic duct ligation (p = 0.0057) were independent factors affecting DFS. Meanwhile, the depth of invasion (p <0.0001), presence of tumor thrombus (p = 0.0073) and age (p = 0.0129) were independent factors affecting OS.

CONCLUSION

Thoracic duct ligation during thoracoscopic esophagectomy can affect DFS in patients with pT1b-3N0M0 esophageal squamous cell carcinoma, and the thoracic duct ligation, depth of invasion, degree of differentiation and presence of tumor thrombus are independent factors. Meanwhile, the depth of invasion, presence of tumor thrombus and age were independent factors affecting OS. Key Words: Esophageal cancer, VATS, Esophagectomy, Thoracic duct ligation, DFS, OS.

Thoracoscopic approach in the treatment of thoracic duct injuries - case reports and review of the literature

Thoracic duct injuries are very rare due to its protected location. Duct is most often injured in polytraumas and during operations in his vicinity. Treatment is primarily conservative, based on a low-fat diet or parenteral nutrition and adequate chest drainage. If the conservative management fails, a surgical duct ligation via thoracotomy, or more conveniently thoracoscopic approach, is necessary. The presented case reports describe the surgical treatment of isolated injury of the thoracic duct via thoracoscopic approach.

[Surgery for chyloptysis]

Chyloptysis is a rare disease characterized by formation of bronchial casts containing chyle and repeating bronchial tree branching. The authors report a 56-year-old woman with chyloptysis accompanied by cough and expectoration of milky bronchial casts, as well several episodes of asphyxia. Stages of diagnosis and successful treatment including thoracic duct ligation and skeletonization of the root of the left lung are described. The authors also analyze literature data on etiology, pathogenesis and feasibility of conservative and surgical treatment of these patients.

Plastic bronchitis: A rare complication following a motor vehicle collision

Plastic bronchitis, more appropriately termed chyloptysis, is a rare and potentially fatal condition caused by chylous coating of the airways. These cast coating can dislodge and become an obstructive mass in the patient's airway, necessitating rapid intervention. PB is well described to occur following single ventricle physiology heart disease corrective procedures, particularly following Fontan procedures. It is less commonly seen in traumatic settings. We present the youngest known case of a traumatic injury induced plastic bronchitis. A 19-year-old man was involved in a motor vehicle accident with airbag deployment. The airbags struck him in the chest; however, the patient felt well at the time and did not seek medical attention. Several months later the patient began coughing up milky white masses identified as casts. He was initially diagnosed with asthma but did not respond to therapy. He ultimately was found to have evidence of thoracic duct injury. Options for therapy were discussed, including possible thoracic duct ligation. The patient opted to continue a lowfat diet and has remained cast free. This case highlights the importance of considering plastic bronchitis in patients with cast production and a history of trauma to the chest.

Recurrent thoracic duct cyst of the left supraclavicular fossa: A retrospective study of 6 observational case series and literature review

ABSTRACT

The transient occlusion of the terminal thoracic duct is a rare disease responsible for renitent supraclavicular cysts. The aim of this study was to describe the clinical characteristics, evolution, and treatment.A retrospective multicenter study and literature review was carried out. The literature search (PubMed) was conducted including data up to 31 December 2020 and PRISMA guidelines were respected.This study identified 6 observational cases between September 2010 and December 2020. The search results indicated a total of 24 articles of which 19 were excluded due to the lack of recurrent swelling or the unavailability of full texts (n = 5). Fourteen patients (8 from literature) mostly reported a noninflammatory, painless renitent mass in the supraclavicular fossa which appeared rapidly over a few hours and disappeared spontaneously over an average of 8 days (range: from about 2 hours to 10 days). Anamnesis indicated a high-fat intake during the preceding days in all cases and 7 from literature found in the Medline databases. Recurrences were noted in 10 patients. Thoracic duct imaging was performed in all cases to detect abnormalities or extrinsic compression as well as to eliminate differential diagnoses.A painless, fluctuating, noninflammatory, and recurrent swelling of the left supraclavicular fossa in patients evoking an intermittent obstruction of the terminal portion of the thoracic duct was identified. A low-fat diet was found as safe and effective treatment.

Near infra-red fluorescence identification of the thoracic duct to prevent chyle leaks during oesophagectomy

Background

Chyle leaks following oesophagectomy are a frustrating complication of surgery with considerable morbidity. The use of near infra-red (NIR) fluorescence in surgery is an emerging technology and the use of fluorescence to identify the thoracic duct has been demonstrated in animal work and early human case reports. This study evaluated the use mesenteric and enteral administration of indocyanine green (ICG) in humans to identify the thoracic duct during oesophagectomy.

Methods

Patients undergoing oesophagectomy were recruited to the study. Administration of ICG via an enteral route or mesenteric injection was evaluated. Fluorescence was assessed using a NIR fluorescence enabled laparoscope system with a visual scoring system and signal to background ratios. Visualisation of the thoracic duct under white light and NIR fluorescence was compared as well as any identification of active chyle leak. Patients were followed up post-operatively for adverse events and chyle leak.

Results

20 patients received ICG and were included in the study. The enteral route failed to fluoresce the thoracic duct. Mesenteric injection (17 patients) identified the thoracic duct under fluorescence prior to white light in 70% of patients with a mean signal to background ratio of 5.35. In 6 participants, a possible active chyle leak was identified under fluorescence with 4 showing active chyle leak from what was identified as the thoracic duct.

Conclusion

This study demonstrates that ICG administration via mesenteric injection can highlight the thoracic duct during oesophagectomy and may be a potential technology to reduce chyle leak following surgery.

Clinical trial registration

Clinical trials.gov (NCT03292757).

[A Case of Refractory Chylothorax after Surgery for Esophageal Cancer in Which Lymphangiography and Thoracic Duct Ligation Was Useful]

Chylothorax after esophagectomy is a relatively rare complication that can be difficult to manage. Here, we report a case of refractory chylothorax after surgery for esophageal cancer treated with lymphatic duct lipiodol imaging by inguinal lymph node puncture to confirm patency of the thoracic duct and thoracic duct ligation. A 71-year-old female with esophageal cancer(cT3N0M0)underwent video-assisted thoracoscopic esophagectomy with 2-field lymph node dissection, intrathoracic gastric tube reconstruction, and an enterostomy. A chylothorax appeared when we started enteral nutrition on the day after surgery. She became markedly dehydrated due to over 2,000 mL/day of drainage from the chest drain, and we managed her general condition in the ICU. We started octreotide acetate on postoperative day(POD)6 and etilefrine on POD 8, but neither was effective. Lymphatic duct lipiodol imaging by bilateral inguinal lymph node puncture was performed, and we confirmed leakage from the main thoracic duct. On POD 11, a thoracic duct ligation performed via a thoracotomy revealed that the volume of the chylothorax was remarkably decreased. The chest tube was removed on re-POD 12.

[Reoperation for Chylothorax after Lung Resection]

Chylothorax is not a rare complication of lung surgery. Diagnosis is easy in most cases, but treatment is sometimes difficult. Dietary restriction is effective in reducing the chyle but does not always cease the lymph and chyle. Two surgical procedures for postoperative chylothorax are well known:direct closure of the ruptured lymph vessel and ligation of the thoracic duct. Direct closure often fails. It is difficult to detect lymphatic leakage pre- and peri-reoperation. Early reoperation decisions are important for successful direct closure. Thoracic duct ligation is ordinarily performed using the right thoracoscopic approach because the thoracic duct runs in front of the vertebrae along the azygos vein near the diaphragm in the right pleural cavity. The effect of the ligation should be shown immediately. Unfortunately, even if the thoracic duct is confirmed to have been ligated, it sometimes fails to cease the chyle pleural effusion. This may be due to the existence or formation of lymphatic bypass routes.

Prophylactic ligation of the opacified thoracic duct in minimally invasive esophagectomy - feasibility and safety

BACKGROUND

Chyle leak is a rare but morbid complication of esophagectomy. We assessed the feasibility of visualization and prophylactic ligation of the opacified thoracic duct (TD) after administration of 50 ml of olive oil.

METHODS

This prospective single center study considered all patients with carcinoma of the middle and lower thirds of the thoracic esophagus including the gastroesophageal junction (GEJ), managed from January 2018 to December 2019, for inclusion. All patients underwent McKeown minimally invasive esophagectomy. After anesthesia and endotracheal intubation, 50 ml of olive oil was administered through a nasogastric (NG) tube. During thoracoscopic esophageal mobilization, the opacified thoracic duct was identified and ligated using Weck Hem-o-lok clips immediately above the diaphragmatic hiatus. Postoperatively, the nature, volume, and triglyceride levels of the fluid from the chest drain were recorded.

RESULTS

Forty-three patients with carcinoma of the esophagus were assessed for inclusion and eventually, 33 were enrolled. The median age of the study population was 55 years, and there were 20 males. The tumor site was the lower esophagus in 24 (72.7%) patients. The most common histolopathological finding was squamous cell carcinoma (97%). The opacified thoracic duct could be identified and ligated in 31 (93.9%) patients. The median duration from the administration of olive oil to the ligation of the thoracic duct was 100 min. The median chest drain output and triglyceride levels on postoperative day (POD) one were 250 ml and 48 mg% respectively. No patient developed postoperative chylothorax.

CONCLUSION

Opacification and visualization of the thoracic duct during thoracoscopy can be aided by administering olive oil. Ligation of this opacified duct is feasible and safe.

Anatomical study of the thoracic duct and its clinical implications in thoracic and pediatric surgery, a 70 cases cadaveric study

INTRODUCTION

Given the high variability and fragility of the thoracic duct, good knowledge of its anatomy is essential for its repair or to prevent iatrogenic postoperative chylothorax. The objective of this study was to define a site where the thoracic duct is consistently found for its ligation. The second objective was to define an anatomically safe surgical pathway to prevent iatrogenic chylothorax in surgery for aortic arch anomalies with vascular ring, through better knowledge of the anatomical relationships of the thoracic duct.

METHODS

Seventy adult formalin-fixed cadavers were dissected. The anatomical relationships of the thoracic duct were reported at the postero-inferior mediastinum, at levels T3 and T4.

RESULTS

The thoracic duct was consistently situated between the left anterolateral border of the azygos vein and the right border of the aorta between levels T9 and T10, whether it was simple, double, or plexiform. It was located medially, anteromedially, or posteriorly to the left subclavian artery in 51%, 21%, and 28% of the cases, respectively, at the level of T3. At T4, it was posteromedial in 27% of the cases or had no direct relationship with the aortic arch.

CONCLUSION

These results favor mass ligation of the thoracic duct at levels T9-T10 between the right border of the aorta and the azygos vein, eventually including the latter. To prevent iatrogenic postoperative chylothorax in aortic arch anomalies with vascular ring surgery, we recommend remaining strictly lateral to the left subclavian artery at the level of T3 to reach the aortic arch anomalies with vascular ring at T4.

Isolated thoracic duct injury from blunt force trauma

Isolated thoracic duct injury is an uncommon clinical event and is rare in the setting of trauma. We describe a case of an isolated thoracic duct injury resulting in the development of bilateral chylothorax following a motor vehicle collision in the absence of any other definable injury. We outline the initial patient presentation and diagnosis. After failing a trial of conservative management the patient underwent lymphangiography followed by thoracic duct ligation with pleurodesis. This case highlights the importance of recognizing thoracic duct injury following trauma.

Embolization or disruption of thoracic duct and cisterna chyli leaks post oesophageal cancer surgery should be first line management for ECCG-defined type III chyle fistulae

Chyle leakage from the thoracic duct or cisterna chyli is a relatively rare complication of oesophageal cancer surgery. The majority of cases settle with conservative measures, but high volume leaks may be refractory and result in significant morbidity and require intervention with reoperation or embolization. In the experience of this high-volume centre over the last decade, 3 (0.5%) patients required reoperation and ligation of the thoracic duct; for the so-called type III leaks, interventional radiological approaches were not considered. This article is built around two recent cases, where interventional radiology to embolize and disrupt complex fistulae was successfully performed. The lessons from this experience will change practice at this centre to initial lymphangiography with a view to embolization or disruption of thoracic duct and cisterna chyli leaks as first line therapy for type III chyle leaks, with surgery reserved for where this fails.

Percutaneous Extra-Anatomic Lymphovenous Bypass Creation: Toward Treatment of Central Conducting Lymphatic Obstructions

INTRODUCTION

Protein-losing enteropathy manifests as a loss of serum proteins through the gastrointestinal tract, resulting in hypoproteinemia, extravascular fluid retention, and edema. Management consists of nutritional maintenance in conjunction with interventions targeted at treating the underlying etiology.

MATERIALS AND METHODS

This report describes a patient with protein-losing enteropathy from a central conducting lymphatic obstruction who was treated with percutaneous extra-anatomic lymphovenous bypass creation.

RESULTS

A modified gun-sight technique was used to create a lymphovenous bypass between an occluded terminal thoracic duct and the left internal jugular vein.

CONCLUSION

A percutaneous technique to reconstruct the terminal thoracic duct via lymphovenous bypass creation was feasible.

Lymphovenous Anastomosis for the Treatment of Thoracic Duct Lesion: A Case Report and Systematic Review of Literature

BACKGROUND

Chylous leak is an uncommon complication after head and neck surgery and typically results from a lesion of the thoracic duct (TD). Beside conservative treatment, different minimally invasive and surgical procedures exist, of which almost all lead to a total closure of the TD.

METHODS

We report on a rare case of microsurgical lymphovenous anastomosis to treat a TD lesion. An additional systematic review on surgical procedures to treat TD lesions with special attention to lymphovenous anastomoses was performed according to the PRISMA guidelines.

RESULTS

A 52-year-old patient with a chylous fistula after modified radical neck dissection was successfully treated by a lymphovenous anastomosis of the TD and external jugular vein with additional coverage by sternocleidomastoid muscle flap. The patient showed a complete resolution of chylous leak with an uneventful postoperative course.The systematic search of literature yielded 684 articles with 4 case reports on lymphovenous anastomosis in chylous leak with a high success rate. Other surgical techniques include transcervical, thoracoscopic, or video-assisted thoracoscopic TD ligation, either alone or combined with a local muscle flap.

CONCLUSIONS

Lymphovenous anastomosis of the TD is a feasible and safe technique allowing for treatment of cervical TD lesions, especially if minimally invasive procedures fail. Compared with other techniques, lymphatic circulation can successfully be maintained.

Prone position thoracoscopic management of neck chyle leak following major head and neck surgery. A case series

Chyle leak is a major compication following head and neck surgery, with reported incidence of 0.5% up to 8.3% in published literature. Cervical chyle leak may be challenging to manage with significant morbidity, resulting from extensive fluid and nutritional losses. This manuscript presents four cases of cervical chyle leak after head and neck surgery. Cervical thoracic duct injury had been identified intra-operatively. Conservative treatment failed to reduce chylous output post-operatively. All patients were offered thoracocscopic thoracic duct ligation in prone position; thoracic duct was dissected above the right diaphragm and ligated. Immediate resolution of their symptoms followed, with no recurrence at the follow-up period. Intra-operative repair of cervical thoracic duct remains controversial, while when identified early reduces the following comorbidities. Conservative management addresses reduction of chylous output, while amplifying hydration and alimentation. Thoracoscopic thoracic duct ligation offers a safe and feasible treatment for cervival chyle leak following head and neck surgery with all the advances of minimally-invasive surgery. KEY WORDS: Chyle leak, Head and Neck Surgery, Thoracoscopic, Thorasic Duct, Ligation, Minimally-Invasive.

Thoracic duct stent-graft decompression with 3-month patency: Revisiting a historical treatment option for portal hypertension

This report introduces the rationale for thoracic duct stent-graft decompression in cirrhotic patients with portal hypertension and provides a case example with 3-month stentgraft patency. Thoracic duct flow and pressure are elevated in cirrhosis. Historically, complications of portal hypertension have been successfully treated with external drainage of the thoracic duct or surgical lymphovenous bypass. A 45-year-old woman with cirrhosis, chronic portosplenomesenteric thrombosis, and acute variceal hemorrhage underwent percutaneous thoracic duct stent-graft placement across the lymphovenous junction. The hemorrhage subsequently resolved and follow up endoscopy demonstrated decompression of the bleeding varices. Venography 40 days later demonstrated a partially patent stent-graft with fibrin sheath formation distally. The stent-graft was extended distally to the right atrium and was fully patent on venography 3 months later. The patient had no further episodes of hemorrhage.

Thoracic duct decompression: An idea whose time has come - again

[Editorial] Thoracic duct decompression (TDD) is an idea first proposed and applied as a novel therapeutic strategy by lymphologists in the 1960's. TDD is recently being reexamined and, in selected patients with portal hypertension from hepatic cirrhosis or with central venous hypertension from isolated right-sided heart failure, undertaken using advanced surgical and image-guided interventional radiologic approaches.

Abdominal lymphatic drainage after thoracic duct ligation and cisterna chyli ablation in clinically normal cats

OBJECTIVE

To characterize abdominal lymphatic drainage in cats after thoracic duct ligation (TDL) and cisterna chyli ablation (CCA).

ANIMALS

7 purpose-bred research cats.

PROCEDURES

Baseline CT lymphangiography was performed. A popliteal lymph node was injected with iohexol, and images were acquired at 5-minute intervals for 15 minutes. Cats underwent TDL and CCA; methylene blue was used to aid in identifying lymphatic vessels. The CT lymphangiography was repeated immediately after and 30 days after surgery. All cats were euthanized and necropsied.

RESULTS

Results of baseline CT lymphangiography were unremarkable for all 7 cats. Only 5 cats completed the study. Leakage of contrast medium at the level of the cisterna chyli was seen on CT lymphangiography images obtained from all cats immediately after surgery. Evaluation of 30-day postoperative CT lymphangiography images revealed small branches entering the caudal vena cava in 2 cats, leakage of contrast medium into the caudal vena cava with no visible branches in 1 cat, and no contrast medium in the caudal vena cava in 2 cats. Contrast medium did not flow beyond the level of the cisterna chyli in any cat. Gross examination during necropsy revealed that all cats had small lymphatic vessels that appeared to connect to local vasculature identified in the region of the cisterna chyli.

CONCLUSIONS AND CLINICAL RELEVANCE

Abdominal lymphaticovenous anastomoses formed after TDL and CCA in cats. This would support use of these procedures for treatment of cats with idiopathic chylothorax, although additional studies with clinically affected cats are warranted.

Uniportal Thoracoscopic Thoracic Duct Clipping in Poirier's Triangle for Postoperative Chylothorax

Postoperative chylothorax is a rare but potentially life-threatening complication. Conservative treatment is usually unsuccessful in patients with high-output chylothorax, for whom early surgical thoracic duct ligation has been advocated to minimize morbidity and mortality. This report describes left uniportal thoracoscopic closure of persistent high-output chylothorax through Poirier's triangle in a patient undergoing thoracoscopic thymectomy. After resection of pleural adhesions, the mediastinal pleura was resected at the level of the aortic arch, left subclavian artery, and vertebral column, the anatomic limits of Poirier's triangle. The thoracic duct was then isolated from the esophagus and successfully clipped along its path.

[Energy Device and Soft Coagulation System in Thoracic Surgery]

While the recent emergence of energy-based surgical techniques and soft coagulation has made surgical procedures less invasive, the safety and proper use of such advances have yet to be investigated. Herein we review the experimental and clinical use of ultrasonically-activated coagulating shears, a vessel sealing system, incorporating ultrasonic and vessel sealing technology, and a soft coagulation system in thoracic surgery. All energy devices have been reported to be safe for use on pulmonary vessels, and use in combination with a ligature appears to be adequate. The thoracic duct has been reported to be sealed with sufficient pressure using energy devices, which are expected to prevent chylothorax formation. Bipolar scissors can be safely and efficiently applied for dissection of pulmonary vessels without damage to the vessel wall. Monopolar soft coagulation can be applied to shrink bullous changes and stop air leakage or bleeding within the lung.

Effect of Prophylactic Thoracic Duct Ligation in Reducing the Incidence of Postoperative Chylothorax during Esophagectomy: A Systematic Review and Meta-analysis

OBJECTIVES

There is no consensus on the effectiveness of prophylactic thoracic duct ligation (PLG) in esophagectomy for reducing the incidence of postoperative chylothorax. We performed a systemic review and meta-analysis to study its efficacy.

METHODS

A systemic review of the publications was performed on three databases to identify all the relevant literature on comparative outcomes of PLG and nonprophylactic thoracic duct ligation (NPLG). The primary end point was the incidence of postoperative chylothorax.

RESULTS

Seven studies with comparative data on PLG (n = 2,178) versus NPLG (n = 3,048) were identify from the current publications. Comparison showed no significant difference between PLG and NPLG on the incidence of postoperative chylothorax (relative risk = 0.431; 95% confidence interval, 0.186 to 1.002; p = 0.050).

CONCLUSIONS

Although some studies showed that PLG during the esophagectomy was effective to lower the incidence of postoperative chylothorax, no evidence was observed in the present meta-analysis. Further research is warranted to validate the findings.