Hepatic hydrothorax: pathophysiology, diagnosis, and management

Hepatic hydrothorax occurs in approximately 5 to 12% of patients with cirrhosis and portal hypertension. Various therapeutic modalities ranging from dietary and pharmacologic interventions to surgical approaches are available for the management of this condition. Treatment must be individualized based on the patient's response to conservative management as well as the severity of the underlying liver disease. Hepatic hydrothorax may be complicated by spontaneous bacterial empyema, which portends a poor prognosis with a mortality rate of up to 20%. All patients with hepatic hydrothorax should be evaluated for possible liver transplantation.

The medical management of idiopathic chylothorax in a domestic long-haired cat

A 3-year-old, spayed female domestic long-hair was evaluated for a 2-week history of progressive tachypnea. Chylothorax was diagnosed through radiographic and pleural fluid evaluation. No primary cause was identified and the cat was managed medically. Thoracocentesis, dietary management, and oral rutin therapy resulted in substantial improvement of this idiopathic condition.

Resolution of chylothorax after resection of rib chondroma in a dog

A six-year-old, male dobermann was presented with a history of dyspnoea and bouts of coughing. Radiography and computed tomography of the thorax showed pleural effusion and a well-circumscribed, calcified mass of 10 cm in diameter, appearing to originate from the left first rib. Thoracocentesis revealed that the pleural fluid was chylous in nature. An incisional biopsy was performed, which gave a histological diagnosis of chondroma. Resolution of the chylothorax after en-bloc surgical removal of the tumour suggested that the rib tumour was the initiating cause of the chylothorax. Seventeen months later, rib neoplasia recurred without pleural effusion, and was removed successfully. To the authors' knowledge, rib chondroma, which is an unusual tumour in dogs, has not been previously documented as a cause of chylothorax.

[Chylous effusions]

This paper presents 4 patients with chylothorax, and one patient with bilateral chylothorax and chyloperitoneum. The chylous effusions were of benign etiology, developed as a complication of miliary tuberculosis (1 patient), after L-2 vertebral body fracture (1 patient), and idiopathic (2 patients). The diagnosis was confirmed by the presence of chylomicrons and high content of triglycerides in the effusion, ranged 11.9-29.1 mmol/l. Lymphangiography showed multiple abnormalities of lymphatic system, the obstruction of ductus thoracicus, dilatation and convulsion of lymphatic channels, but the site of lymphatic leak was not detected. The treatment included an extended period of pleural and peritoneal drainage with total parenteral nutrition (1 patient), pleurodesis using Corynebacterium parvum (2 patients), and surgical partial parietal pleurectomy with continuous drainage (1 patient). The treatment was successful in all patients.

Comparison of Magnetic Resonance Imaging and Ultrasonography in the Prenatal Diagnosis of Congenital Thoracic Abnormalities

OBJECTIVES

To evaluate prenatal MRI in the diagnosis of fetal thoracic abnormalities and to determine whether MRI provides useful information in addition to that of ultrasonography (US).

METHODS

Ultrafast MR scanning was performed in 7 pregnant women in whom US was suspicious of fetal congenital anomalies of the thorax [3 cases of congenital diaphragmatic hernia (CDH), 3 cases of chylothorax and 1 case of congenital cystic adenomatoid malformation (CCAM) type III]. The presence, position, size and characteristics of the congenital lesions were determined and compared with postnatal diagnoses.

RESULTS

The MRI diagnoses were 3 cases of CDH, 2 of chylothorax and one each of esophageal atresia and CCAM type III. The results of MRI were in agreement with those of US in 6 cases and in disagreement in 1 case of esophageal atresia. Final diagnoses were confirmed at surgery or autopsy in all fetuses. Combined use of MR and US imaging enabled a correct diagnosis in 5 cases and led to an error in the diagnosis of 1 fetus with bronchial stenosis, which had been diagnosed as CCAM type III by US and MRI. MRI led to a correct diagnosis in 1 fetus with esophageal atresia, in whom US had been equivocal in the prenatal diagnosis.

CONCLUSION

MRI helped further characterize the fetal thoracic lesions and confirmed or changed the prenatal diagnosis based on US. MRI seems to be powerful in the prenatal diagnosis of thoracic lesions that are atypical or complicated by multiple abnormalities.

Kaposi sarcoma with upper airway obstruction and bilateral chylothoraces

A 3-year-old boy infected with HIV presented with progressive dyspnea and upper airway obstruction necessitating airway stenting. Chest radiography revealed bilateral alveolar opacification and chylothoraces. Post,mortem examination confirmed disseminated Kaposi sarcoma with infiltration of the thoracic duct.

Hennekam syndrome presenting as nonimmune hydrops fetalis, congenital chylothorax, and congenital pulmonary lymphangiectasia

We report a female infant with congenital lymphedema, facial anomalies, intestinal lymphangiectasia consistent with a diagnosis of Hennekam syndrome. At birth the patient presented with severe respiratory distress due to nonimmune hydrops fetalis, a congenital chylothorax (CC), and pulmonary lymphangiectasia. Hydrops fetalis may be present in newborns with the Hennekam syndrome. Lymphoscintigraphy can be useful in explaining pleural-pulmonary involvement of this generalized lymph vessel malformation syndrome.

Chylothorax nach Anlage eines zentralvenösen Katheters

The authors report on a chylothorax, a rare, although classical complication of left internal jugular vein cannulation. The anatomy of major lymphatic vessels including variations is illustrated. The mechanisms of central venous catheter associated chylothorax are discussed. Likewise described are pathophysiology, signs, clinical features, and differential diagnosis with special consideration of the triglyceride content as well as treatment options.

Left cervical chyloma following right thyroidectomy

Cervical chylomas are rare entities, as only four cases have been previously reported. All of these previous cases involved the left side, all were related to the thoracic duct, and all occurred following trauma or surgery. We report a new case of a left-sided chyloma that was unusual because it arose following a right-sided subtotal thyroidectomy. The chyloma arose as a left supraclavicular mass within 3 months of the thyroidectomy, and it slowly enlarged over a period of 9 years. Following evaluation by computed tomography, the mass was excised, and the patient recovered uneventfully. We also review what is known about the diagnosis and treatment of cervical chylomas.

Does V-A ECMO increase the likelihood of chylothorax after congenital diaphragmatic hernia repair?

BACKGROUND

The authors noticed a relatively large number of patients with congenital diaphragmatic hernia (CDH) repair after extracorporeal membrane oxygenation (ECMO) who had a chylothorax (CT). The data are reviewed.

METHODS

The charts of patients from 1990 until 2000 with CDH, treated with or without ECMO, together with the charts of patients treated with ECMO for other reasons and patients with esophageal atresia (EA) repair were reviewed. The diagnosis of CT was made if aspirated fluid appeared chylous and contained more than 90% lymphocytes or if the triglyceride level was more than 1.50 mmol/L.

RESULTS

Eighty-nine patients with CDH were analyzed. Postoperatively, 10% had a CT-21% in CDH patients with ECMO treatment and 6% in CDH patients without ECMO treatment. This difference appeared to be significant (P <.05). The presence of a patch as independent variable for the development of CT also showed significance (P <.05).

CONCLUSIONS

Chylothorax presented in almost all cases as a left-sided fluid accumulation, and a patch was present in the majority of patients with CDH. Therefore, CT should be considered the result of the severity of the defect rather than the consequence of ECMO as a therapeutic modality.

[Chylothorax: an unexpected complication of artificial ventilation in severe acute asthma]

INTRODUCTION

Complications of mechanical ventilation for severe acute asthma are common and are related essentially to barotrauma. However, the incidence has declined in recent years thanks to different techniques of ventilation.

CASE REPORT

We report a case of spontaneous chylothorax occurring during the course of ventilation in a patient with severe acute asthma where the ventilatory parameters were in accordance with current recommendations. Recovery was straightforward with resolution of the chylothorax and no recurrence either immediately or later. Exhaustive clinical, biological and morphological investigations failed to find any cause other than the mechanical ventilation.

CONCLUSION

This case of chylothorax may be considered as a rare barotraumatic complication of severe acute asthma.

Chylothorax: case report and review of the literature

Chylothorax is a rare entity with both traumatic and non-traumatic etiologies. Chyle depletion has significant nutritional, metabolic and immunologic consequences. We present a case of a patient with chylothorax who presented to the Emergency Department on numerous occasions with complications related to his chylothorax.

Chylothorax in lymphangioleiomyomatosis

STUDY OBJECTIVE

Pulmonary lymphangioleiomyomatosis (LAM) is a rare, serious disorder characterized by proliferation of abnormal smooth-muscle cells and affects almost exclusively women of childbearing age. Optimal management of chylothorax, a well-recognized complication of LAM, in these patients has not been defined. This study was performed to characterize the clinical course and identify appropriate management options for chylothorax occurring in patients with LAM.

DESIGN

Identification and retrospective review of available medical records on patients with LAM and chylothorax.

SETTING

Tertiary-referral medical center.

PATIENTS

All patients with LAM seen at Mayo Clinic, Rochester, MN, from January 1, 1976, to December 31, 2000.

INTERVENTION

None.

MEASUREMENT AND RESULTS

Eight of 79 patients (10.1%) with LAM had chylothorax. All were women aged 33 to 51 years, and four patients had underlying tuberous sclerosis complex. These eight women represented 3.5% of the 229 patients with chylothorax seen over this 25-year period at Mayo Clinic Rochester. Six patients had unilateral pleural effusion and two patients had bilateral effusions at initial presentation. The size of the chylothorax varied and was not necessarily progressive. Management of chylothorax ranged from thoracentesis only to thoracotomy with thoracic duct ligation and parietal pleurectomy. When needed, pleurodesis by instillation of sclerosing agents or parietal pleurectomy appeared to be effective in controlling chylothorax.

CONCLUSIONS

Chylothorax occurring in patients with LAM has a variable clinical course. Although pleurodesis with or without thoracic duct ligation appears to be effective in controlling intractable chylothorax, less invasive treatments such as thoracentesis or observation may suffice in some cases. Management of chylothorax in patients with LAM should be individualized depending on the size and clinical effects of the chylous pleural effusion, as well as comorbid factors and local expertise.

Thoracic lymphangiectasis presenting with chyloptysis and bronchial cast expectoration

A 70-year-old man with recurrent undiagnosed episodes of bronchial cast expectoration and pulmonary infiltrates on chest radiography for 15 years is described. The diagnosis of chyloptysis was established by chemical analysis of the bronchial aspiration. We emphasize the radiological findings of this rare observation. The CT-associated lymphangiography showed mediastinal lymphangiectasis with retrograde opacification of mediastinal and hilar lymph nodes as well as submucosal lymphatic vessels protruding into the lumen of the tracheo-bronchial tree without evidence of thoracic duct obstruction as well as a "crazy-paving appearance." Congenital incompetence of the valves of the lymphatic vessels originating from the thoracic duct is held to be the cause. Chyloptysis and pulmonary lymphatic disorder should be sought in cases of bronchial cast expectoration.

Postoperative chylothorax

Chylothorax is an unusual complication of surgical procedures within the chest. Early recognition is important so that appropriate conservative measures can be applied. Operative intervention after a short course of supportive therapy will control most chyle fistulas. Methods of diagnosis in the postoperative setting and literature supporting various treatment options are the focus of this article.

Concurrent occurrence of chylothorax, chylous ascites, and protein-losing enteropathy in systemic lupus erythematosus

We describe 2 patients with systemic lupus erythematosus (SLE) who presented with chylothorax, chylous ascites, and protein-losing enteropathy. Analysis of pleural or peritoneal fluid revealed a high level of triglyceride and elevated 24 h stool alpha1-antitrypsin clearance in keeping with protein-losing enteropathy. One patient failed to respond to high dose corticosteroid therapy but recovered after 3 cycles of monthly cyclophosphamide treatment. The other patient initially responded to high dose corticosteroid therapy, but succumbed to infectious complications. This is the first report of occurrence of chylothorax and chylous ascites associated with SLE.

[Neonatal chylothorax and conservative treatment]

Four cases of chylothorax are reported. Three cases were congenital and the fourth was secondary to surgical repair of esophageal atresia. Of the three cases of congenital chylothorax, two were diagnosed prenatally. In all three patients with congenital chylothorax, the clinical course was favorable and pleural effusion was resolved in 19-80 days. Treatment consisted of pleural taps when respiratory function was compromised, parenteral nutrition, and respiratory support as required. Enteral nutrition was started with a formula containing medium-chain triglycerides while some effusion remained. Weight gain during this period was slow. Follow-up oscillated between 12 months and 6 years with no recurrences. The case of postsurgical chylothorax appeared several days after the intervention. Pleural effusion increased to 705 ml/day and the patient received no enteral nutrition. The patient died from intestinal complications and multiorgan failure 8 days after the onset of chylothorax. The etiology and clinical features of this condition, as well as the short- and long-term outcome with conservative treatment, are reviewed.

Chylothorax and cirrhosis of the liver: a case report

Chylothorax occurring in the setting of a lymphoma or a surgical procedure involving the area around the thoracic duct is a well-known phenomenon. Less common is the occurrence of chylothorax in conjunction with cirrhosis of the liver. Due to the paucity of data, it is uncertain if chylothorax is an associated or an independent sign of cirrhosis. The case reports in the literature favor the former, as demonstrated in this case of a patient with cirrhosis of the liver who developed a chylothorax.

[Chylothorax]

PHYSIOLOGY: Chylothorax corresponds to the intrathoracic presence of chyle. Chyle is a lymph of intestinal origin containing the product of digested fat. This lymph joins the blood circulation through the thoracic duct. The thoracic duct receives a part of the lymphatic drainage from the viscera below the diaphragm, from the diaphragm and from the sterno-costal wall.

PHYSIOPATHOLOGY

Intrapleural chyle issue is explained by an acquired or spontaneous lesion of the thoracic duct or of one of its collaterals in the thorax. The iatrogenic or spontaneous lesions of the collaterals suggest that the latter are incontinent and have lost their valve capacity, and hence provoke a reflux of chyle from the thoracic duct. The anatomy of the chylothorax (occasionally pathological) can be specified by a pedal lymphography. FROM A THERAPEUTIC POINT OF VIEW: Treatment, essentially medical, can be completed by surgery. The medical treatment is based on re-nutrition and a diet excluding fat, supplemented by medium chain triglycerides. Surgery consists in pleural symphysis and/or suture of the damaged collaterals, or ligature of the thoracic duct. The indications depend on the severity of the chyle leakage and the type of original lesion. The indications therefore depend on the etiology and clinical evolution of each case. These different treatments, isolated or combined, lead to the regression of the effusion in nearly all cases.

Omentalization of the thorax for treatment of idiopathic chylothorax with constrictive pleuritis in a cat

A 6-year-old, spayed female Himalayan cat with idiopathic chylothorax, which failed to respond to medical management, was successfully treated by advancement of the omentum into the thorax. Exploratory thoracotomy revealed severe, constrictive pleuritis as a sequela to chylothorax. Because of the poor prognosis for recovery from chylothorax in cats with thoracic duct ligation alone, and the lack of success in performing thoracic duct ligation in this cat, the omentum was advanced into the thorax through a hole created in the diaphragm and sutured within the thoracic cavity. The cat recovered from surgery and is clinically normal 13 months postoperatively. Omental advancement may be an effective surgical management technique for this challenging disease in cats.

Treatment of symptomatic primary chylous disorders

PURPOSE

Primary chylous disorders (PCDs) are rare. Rupture of dilated lymph vessels (lymphangiectasia) may result in chylous ascites, chylothorax, or leakage of chyle through chylocutanous fistulas in the lower limbs or genitalia. Chyle may reflux through incompetent lymphatics, causing lymphedema. To assess the efficacy of surgical treatment, we reviewed our experience.

METHODS

The clinical data of 35 patients with PCDs treated between January 1, 1976, and August 31, 2000, were reviewed retrospectively.

RESULTS

Fifteen men and 20 women (mean age, 29 years; range, 1 day-81 years) presented with PCDs. Sixteen (46%) patients had chylous ascites, and 19 (54%) had chylothorax (20 patients), and of these, 10 (29%) had both. In 16 patients, reflux of chyle into the pelvic or lower limb lymphatics caused lymphedema (14, 88%) or lymphatic leak through cutaneous fistulae (11, 69%). Presenting symptoms included lower-limb edema (19, 54%), dyspnea (17, 49%), scrotal or labial edema (15, 43%), or abdominal distention (13, 37%). Primary lymphangiectasia presented alone in 23 patients (66%), and it was associated with clinical syndromes or additional pathologic findings in 12 (yellow nail syndrome in 4, lymphangiomyomatosis in 3, unknown in 3, Prasad syndrome (hypogammaglobulinemia, lymphadenopathy, and pulmonary insufficiency) in 1, and thoracic duct cyst in 1). Twenty-one (60%) patients underwent 26 surgical procedures. Preoperative imaging included computed tomography scan in 15 patients, magnetic resonance imaging in 3, lymphoscintigraphy in 12, and lymphangiography in 14. Fifteen patients underwent 18 procedures for chylous ascites or pelvic reflux. Ten (56%) procedures were resection of retroperitoneal/mesenteric lymphatics with or without sclerotherapy of lymphatics, 4 (22%) were lymphovenous anastomoses or grafts, 3 (17%) were peritoneovenous shunts, and 1 (6%) patient had a hysterectomy. Six patients underwent eight procedures for chylothorax, including thoracotomy with decortication and pleurodesis (4 procedures), thoracoscopic decortication (1 patient), ligation of thoracic duct (2 procedures), and resection of thoracic duct cyst (1 patient). Postoperative mean follow-up was 54 months (range, 0.3-276). Early complications included wound infections in 3 patients, elevated liver enzymes in 1, and peritoneovenous shunt occlusion with innominate vein occlusion in 1. All patients improved initially, but four (19%) had recurrence of symptoms at a mean of 25 months (range, 1-43). Three patients had postoperative lymphoscintigraphy confirming improved lymphatic transport and diminished reflux. One patient died 12 years postoperatively, from causes unrelated to PCD.

CONCLUSIONS

More than half of the patients with PCDs require surgical treatment, and surgery should be considered in patients with significant symptoms of PCD. Lymphangiography is recommended to determine anatomy and the site of the lymphatic leak, especially if lymphovenous grafting is planned. All patients had initial benefit postoperatively and two thirds of patients demonstrated durable clinical improvement after surgical treatment.

Interstitial MR lymphography with gadoterate meglumine: initial experience in humans

Magnetic resonance (MR) lymphography was performed in five healthy volunteers and three patients (two adults and one infant). Subcutaneous administration of gadoterate meglumine in the foot allowed visualization of draining lymph vessels and nodes. In one patient, an inguinal fluid collection could be characterized as a lymphocele. In the infant, a chylothorax was diagnosed. The authors conclude that interstitial MR lymphography with commercially available compounds is feasible.

Life-threatening anomalies of the thoracic duct: anatomic delineation dictates management

Congenital anomalies of the thoracic duct are rare, poorly characterized, and difficult to manage. The spectrum of pathophysiologic perturbations, presenting symptoms, radiographic findings, and interventions performed in 4 patients are shown. Accurate anatomic delineation of the malformation was only possible by direct injection contrast lymphangiography. Therapies tailored to address the anatomic aberrations included intralesional sclerotherapy, surgical excision and ligation, lymphovenous anastomosis, and omental interposition to interrupt dysfunctional collateral lymphatics to the lung. Accurate anatomic diagnosis of central lymphatic channel anomalies by contrast lymphangiography facilitates an individualized multidisciplinary approach to repair.

The effect of neck dissection on human fat transport

This study examines the effect of neck dissection and thoracic duct ligation on lipid metabolism. Included were 23 patients undergoing neck dissection with thoracic duct ligation. The results showed a temporary reduction in lipid metabolism in approximately half the patients who had a left neck dissection. This effect subsided within 6 months, possibly because of the development of alternative lymph channels. The reduction in fat metabolism in selected cases may have therapeutic effects on patients with morbid hypertriglyceridemia or those who receive chemopreventive regimens. To the best of our knowledge, no similar studies have been reported heretofore in humans.

Bilateral chylothorax following neck dissection: a new method of treatment

Chylothorax is a serious condition with a high rate of morbidity that may lead to death. Although it is encountered more frequently with certain thoracic procedures, it is considered to be a rare complication of neck dissection. Different forms of management have been postulated; however, no consensus of treatment has been achieved. A case of severe bilateral chylothorax that developed after bilateral neck dissection in a patient with laryngeal carcinoma is presented. Somatostatin injection was successful after total parenteral nutrition failed to control the chylothorax. On the basis of this case and the review of the literature discussed here, we advocate the use of somatostatin with other conservative measures in the management of chylothorax.

Neonatal chylothorax

ACHYLOTHORAX IS AN ACCUMULATION of lymphatic fluid that collects in the pleural space. It is the most common cause of a large pleural effusion in the newborn.1,2 Estimated incidences vary from 1 in 10,000 deliveries to 1 in 2,000 admissions to the NICU.2,3 Chylothorax may be unilateral or, infrequently, bilateral and can occur spontaneously or be acquired secondary to trauma or surgical procedures. The right lung is more commonly affected than the left.

Bilateral chylothorax caused by pleuropulmonary lymphangiomyomatosis: a challenging problem in thoracic surgery

Massive left-sided pleural effusion in a 35-year-old man was initially diagnosed as idiopathic spontaneous chylothorax and treated with serial thoracenteses and left thoracotomy. Six weeks later, a right thoracotomy was performed for contralateral chylothorax, and histologic examination revealed lymphangiomyomatosis. The patient survived this rare and potentially fatal disease. We have found no previously published case of bilateral lymphangiomyomatosis treated with separate thoracotomies because of bilateral chylothorax.

[Pseudochylothorax during the course of rheumatoid arthritis]

Psudochylothorax is uncommon among pleural fluids. It can be observed during tuberculosis or rheumatoid arthritis in majority. A case of a 62 years old man with chronic pleural fluid is presented. Patient had rheumatoid arthritis diagnosed 40 years ago. For last 13 years symptomsless bilateral pleural fluid was observed. Antituberculous drugs were used without success. Plural fluid obtained after puncture had high level of cholesterol with it[symbol: see text]s crystals, without chylomikrons and triglycerides. Diagnosis of pseudochylothorax in the course of rheumatoid arthritis was established. After plural puncture fluid was removed and did not appear later. Differential diagnosis of pleural fluids is presented.

[Spontaneous idiopathic chylothorax. Case report and review of the literature]

We present a new case of bilateral spontaneous idiopathic pneumothorax, occurring in a 52-year-old woman. A literature review of similar cases shows a quite reproducible picture, consisting in the occurrence of supraclavicular swelling and left or bilateral chylothorax after a mild effort in a woman in her fifties.

The treatment of chylothorax

OBJECTIVES

To understand and grasp the diagnosis and treatment of chylothorax caused by variou reasons.

METHOD

The treatment results of 31 cases of chylothorax in PUMC hospital from 1963 approximately 1997 were retrospectively analyzed.

RESULTS

Among 31 cases, 18 underwent surgery, 14 of 18 were cured, 2 died. In the 13 treated conservatively, 2 were cured, 3 died. Eleven cases were congenital, iatrogenic and traumatic chylothorax, 8 of them received surgical treatment and 6 of 8 were cured. The spontaneous chylothorax of unknown cause were 10 cases, 7 were treated by surgery and 6 were cured.

CONCLUSION

Surgical intervention should be aggressively recommended for the traumatic, congenital, and iatrogenic chylothorx. The definite reason must be found out for the spontaneous chylothorax, corresponding management will be given according to the reason. Surgical ligation of the thoracic duct will contribute good result for the chylothorax of unknown cause, but combination of multiple treatment measures will be necessary for a successful management.

Octreotide in the treatment of thoracic duct injuries

Anecdotal reports support the use of octreotide in the treatment of traumatic thoracic duct injuries and chylothorax, but no prospective studies have proved its efficacy. We evaluated the effects of octreotide in treating thoracic duct transection in a canine model. Eight mongrel dogs (27.8+/-5.1 kg) were fed one pint of 10.5 per cent milkfat 2 hours before operation. Through a left supraclavicular neck incision, the thoracic duct was identified and transected, producing free flow of chyle. A quarter-inch drain was tunneled subcutaneously from the wound and attached to closed suction. After wound closure dogs were randomized to a control group (n = 4) receiving sham injections of saline subcutaneously three times per day, or a treatment group (n = 4) given 3 microg/kg octreotide three times per day. Postoperatively all dogs were fed a standard low-fat (5-7%) crude fat diet. Drain output was measured each day, and on odd-numbered postoperative days the drainage was analyzed for cholesterol, triglycerides, albumin, and total protein. Fistula closure was defined as drainage <10 ml/24-hour period. Treated dogs achieved fistula closure significantly faster than controls: 3.5+/-1.3 days versus 7.8+/-1.0 days (P = 0.0037). Whereas equivalent amounts of drainage occurred on the day of surgery and on postoperative day one in both groups, by postoperative day 2 the treatment group had significantly less drainage over 24 hours: 63+/-69 ml versus 195+/-79 ml (P = 0.046); this significant difference persisted through postoperative day 5 when drainage began to decrease in the control group. No significant differences between groups were seen in levels of cholesterol, triglycerides, albumin, or protein in the drainage at any time point. We conclude that octreotide is effective in treating thoracic duct injury, leading to an early decrease in drainage and early fistula closure. The mechanism for this effect remains to be clarified.

Late presentation of tension chylothorax following blunt chest trauma

We describe the case of tension chylothorax in a 29-year-old man following blunt chest trauma sustained in a road traffic accident. This presented with respiratory and haemodynamic compromise. Conservative treatment was attempted but definitive surgical intervention was required.

Paragonimiasis miyazakii associated with bilateral pseudochylothorax

A 37-year-old man who suffered from bilateral pleural effusions, subcutaneous abdominal induration and blood eosinophilia, was admitted to our hospital. He had ingested raw crabs at a pub-restaurant before the onset of his symptoms. His pleural effusions were chyliform containing cholesterol crystals, and a high level of immunoglobulin E (36,580 IU/ml) and anti-Paragonimus miyazakii antibody were detected. He was effectively treated with praziquantel. This case suggests that paragonimiasis should be strongly suspected if blood eosinophilia, pseudochylothorax, and a high level of immunoglobulin E in pleural effusion are detected.

Nontraumatic chylothorax

Nontraumatic chylothorax is an uncommon condition of thoracic or abdominal origin caused by multiple disorders, of which malignancy is by far the most frequent one. Because gross appearance of pleural fluid is frequently misleading, pleural fluid and serum lipid analysis is required for its diagnosis. In addition to the presence of chylomicrons, chylothoraces are usually characterized by all three of the following: (1) a triglyceride level of more than 110 mg/dL; (2) a ratio of pleural fluid to the serum triglyceride level of more than 1.0; and (3) a ratio of the pleural fluid to serum cholesterol level of less than 1.0. In patients with lymphoma-related chylothorax refractory to chemotherapy and radiation therapy, medical thoracoscopic talc pleurodesis has an acceptable complication rate and a 100% success rate in the prevention of recurrences. Pleuroperitoneal shunting is considered a safe and effective treatment in the management of persistent chylothorax in children in the absence of chylous ascites.

Thoracoscopic ligation of the thoracic duct

OBJECTIVE

When nonoperative treatment of chylothorax fails, thoracic duct ligation is usually performed through a thoracotomy. We describe two cases of persistent chylothorax, in a child and an adult, successfully treated with thoracoscopic ligation of the thoracic duct.

METHODS

A 4-year-old girl developed a right chylothorax following a Fontan procedure. Aggressive nonoperative management failed to eliminate the persistent chyle loss. A 72-year-old insulin-dependent diabetic man was involved in a motor vehicle accident, in which he sustained multiple fractured ribs, a right hemopneumothorax, a right femoral shaft fracture, and a T-11 thoracic vertebral fracture. Subsequently, he developed a right chylothorax, which did not respond to nonoperative management. Both patients were successfully treated with thoracoscopic ligation of the thoracic duct.

RESULTS

The child had significant decrease of chyle drainage following surgery. Increased drainage that appeared after the introduction of full feedings five days postoperatively was controlled with the somatostatin analog octreotide. The chest tube was removed two weeks after surgery. After two years' follow-up, she has had no recurrence of chylothorax. The adult had no chyle drainage following surgery. He was maintained on a medium-chain triglyceride diet postoperatively for two weeks. The chest tube was removed four days after surgery. After six months' follow-up, he has had no recurrence of chylothorax.

CONCLUSIONS

Thoracoscopic ligation of the thoracic duct provides a safe and effective treatment of chylothorax and may avoid thoracotomy and its associated morbidity.

Disseminated lymphangiomatosis presenting with massive chylothorax

BACKGROUND

Lymphangiomatosis is a disease characterized by involvement of various body constituents and can involve the skeletal system, connective tissues, and visceral organs.

MATERIALS AND METHODS

We present a case of a 9-year-old girl where this entity presented with extensive right-sided chylothorax. Conventional imaging, including skeletal scintigraphy and contrast enhanced CT of the chest and abdomen, may have underestimated the extent of the disease, as seen on follow-up T2-weighted MR images of the chest and abdomen in our case.

RESULTS

MRI easily demonstrated additional bone lesions as well as multiple small splenic lesions, which were difficult to appreciate on prior CT examinations.

CONCLUSION

We suggest that MRI may be helpful to assess the extent of this disease more accurately.

Chylothorax

Chylothorax is defined as an accumulation of chyle in the pleural space caused by disruption of the thoracic duct or one of its major divisions. Chyle has a high content of triglycerides. The odorless fluid is turbid and milky due to the presence of fat containing particles, the chylomicrons. The etiology of chylothorax can be divided into four major categories: tumor, trauma, idiopathic and miscellaneous. Although chylothorax is uncommon, it is a serious and potentially hazardous disorder. Loss of chyle leads to metabolic disturbances, malnutrition and immunodeficiency. Treatment consists of treatment of the underlying disease, conservative treatment (medium chain triglyceride diet, parenteral nutrition) or surgical intervention. Appropriate timing of surgical intervention is essential. Since the ligation of the thoracic duct can be performed during thoracoscopy, this minimal interventional technique is the procedure of choice when conservative treatment fails.

[Pseudochylothorax]

Pseudochylothorax--a rare disease, occurring in prolonged persistence of exudate in the cavity of fibrotically changed pleura. Three observations of pseudochylothorax, including as the complication of viral hepatitis A, are adduced. Diagnosis was established after biochemical analysis of exudate, obtained during pleural puncture.