VATS thoracic-duct division for aortic surgery-related chylous leakage

Traumatic chylothorax is a serious morbidity due to aortic surgery. We treated this complication successfully by supradiaphragmatic thoracic-duct division in five adults (three men, two women, aged 61.5+/-19.5 years) and a 3-year-old male infant after an average interval of 4.1+/-1.8 days following initial aortic surgery: graft-replacement of subclavian or descending aortic aneurysm in the adults, and correction of aortic coarctation in the infant. A right thoracoscopic approach was used in the adults and the left thoracotomy was re-used in the infant. Individual exposure and division of the thoracic duct was accomplished using an ultrasonic coagulator. The operating time was 22+/-5.5 min for the thoracoscopy cases, and 70 min for the infant. There was no mortality and no procedure-related morbidity, and chylous leakage ceased immediately in all patients. There was no recurrence of chylothorax during a mean follow-up period of 17+/-9.7 months. Despite our limited experience, we conclude that the present supradiaphragmatic thoracic duct division technique (right thoracoscopy in adults) is safe and perfectly effective, and therefore prompt application of this method is recommendable for treatment of aortic surgery-related traumatic chylo-leakage, particularly in vulnerable elderly or infant patients.

Thoracic duct cysts: a rare differential diagnosis

OBJECTIVE

Cysts of the thoracic duct located in the supraclavicular region are uncommon. To date only 12 cases in this topographic area have been described in the literature. Between 1998 and 2002, 5 patients presented to our department with the primary symptom of a palpable soft left-supracavicular swelling that could be displaced relative to adjacent structures.

SETTING

In each case, sonography showed a hypoechogenic, almost echo-free, distinctly outlined polycyclic structure with distal echo enhancement at the junction of the left internal jugular vein and the subclavian vein. All 5 patients underwent surgery, the cysts were extirpated, and the numerous communicating lymph vessels localized and meticulously ligated. Pathohistologic analysis of the milky, yellowish fluid obtained by intraoperative puncture confirmed the initial suspicion of a thoracic duct cyst in all patients.

CONCLUSION

In the case of left supraclavicular masses, the rare differential diagnosis of a thoracic duct cyst must be considered as a possibility. Sonography as the imaging method of choice is sufficient for primary diagnosis. In addition, a thorax x-ray should be performed in order to exclude an intrathoracic involvement. Surgical extirpation marks the therapy of choice in treating such cysts.

The Effect of Cisterna Chyli Ablation Combined with Thoracic Duct Ligation on Abdominal Lymphatic Drainage

OBJECTIVE

To evaluate the effect of cisterna chyli ablation (CCA) and thoracic duct ligation (TDL) on abdominal lymphatic drainage in normal dogs.

STUDY DESIGN

Experimental study.

ANIMALS

Nine female beagle dogs.

METHODS

TDL was performed in 3 dogs and was combined with CCA (CCA-TDL) and local omentalization in 6 dogs. Contrast lymphangiography was attempted in all dogs immediately before and after TDL. Dogs were reanesthetized at 31-37 days for lymphatic studies by new methylene blue (NMB) injection into a mesenteric lymph node and by contrast lymphangiography.

RESULTS

In 6 CCA-TDL dogs, 2 had direct shunting of contrast from the lymphatic system into major abdominal veins, 3 had contrast material that dissipated into abdominal vessels within the mesenteric root, and 1 had shunting into the azygous vein. NMB was not observed within the omental pedicle after CCA-TDL. Chylous drainage was by the azygous vein in all 3 TDL dogs.

CONCLUSIONS

CCA-TDL disrupted chylous drainage to the thoracic duct and resulted in direct intraabdominal lymphaticovenous anastomoses identified by shunting of lymphatic flow directly into the abdominal vasculature in 5 of 6 CCA-TDL dogs. Omentalization of the cisternal ablation site was not beneficial in augmenting extrathoracic lymphatic drainage and is not recommended with CCA-TDL.

CLINICAL RELEVANCE

CCA-TDL represents a novel approach to surgical redirection of chylous drainage to the venous circulation outside of the thorax and may be useful in the treatment of spontaneous chylothorax in the dog.

Combined Late Diagnosed Right Main Bronchial Disruption and Chylothorax From Blunt Chest Trauma

Both main bronchial disruption and chylothorax are uncommon injuries associated with blunt thoracic trauma. We report the case of a patient who presented late after traumatic rupture of the right main bronchus who also had a traumatic chylothorax.

Could a simple surgical intervention eliminate HIV infection?

BACKGROUND

Human Immunodeficiency Virus (HIV) infection is a dynamic interaction of the pathogen and the host uniquely defined by the preference of the pathogen for a major component of the immune defense of the host. Simple mathematical models of these interactions show that one of the possible outcomes is a chronic infection and much of the modelling work has focused on this state.

BIFURCATION

However, the models also predict the existence of a virus-free equilibrium. Which one of the equilibrium states the system selects depends on its parameters. One of these is the net extinction rate of the preferred HIV target, the CD4+ lymphocyte. The theory predicts, somewhat counterintuitively, that above a critical extinction rate, the host could eliminate the virus. The question then is how to increase the extinction rate of lymphocytes over a period of several weeks to several months without affecting other parameters of the system.

TESTING THE HYPOTHESIS

Proposed here is the use of drainage, or filtration, of the thoracic duct lymph, a well-established surgical technique developed as an alternative for drug immunosuppression for organ transplantation. The performance of clinically tested thoracic duct lymphocyte depletion schemes matches theoretically predicted requirements for HIV elimination.

Management of Chyle Fistula Utilizing Thoracoscopic Ligation of the Thoracic Duct

OBJECTIVES

To document the treatment of refractory chyle leaks using thoracoscopic thoracic duct ligation and provide systematic guidelines to manage chyle leaks.

METHODS

The medical records of 2 patients with chyle leaks are reviewed, followed by a review of the literature on chyle leaks and their thoracoscopic management.

CONCLUSIONS

Initial treatment of chyle fistula is aimed at conservative medical management. Persistent high-output fistulas (>500 cm(3)) should be considered for neck reexploration as conservative management is likely to fail. Thoracoscopic thoracic duct ligation provides a safe and efficient means of treating chyle leaks refractory to repeated surgical and medical intervention. It should also be considered as a primary surgical intervention for patients with: (1) chyle output exceeding 500 cm(3)/day where prior intraoperative attempts at ligation have failed, (2) severe metabolic and nutritional complications, (3) coexisting chylothorax with respiratory compromise, and (4) low-output fistulas (<500 cm(3)/day) of long duration (>14 days).

Thoracic duct ligation and pericardectomy for treatment of idiopathic chylothorax

Chylothorax is a devastating disease, and the success rates from either medical or surgical management are less than satisfactory. In some animals with chylothorax, a thickening of the pericardium occurs that is associated with chronic irritation induced by chyle. We hypothesized that pericardial thickening would lead to increased right-sided venous pressures and that abnormal venous pressures would act to impede the drainage of chyle via lymphaticovenous communications after thoracic duct (TD) ligation. We also hypothesized that serosanguineous effusions that occurred after TD ligation could effectively be treated or prevented by pericardectomy in affected animals. TD ligation plus pericardectomy was performed in 17 animals, and pericardectomy alone was performed in an additional 3 animals that presented during a 5.5-year period to the Texas A&M University (College Station, TX). Nineteen animals presented for an evaluation of idiopathic chylothorax (9 dogs and 10 cats), and 1 dog presented for serosanguineous pleural fluid after TD ligation that had been performed elsewhere. Echocardiography was normal in all animals, except for a subjectively thickened pericardium in 7 cats and 6 dogs. Clinical signs of pleural fluid accumulation resolved in 10 of 10 dogs and in 8 of 10 cats after surgery. The overall success rate for the surgical treatment of chylothorax (ie, the resolution of pleural fluid accumulation) in this study was 90% (100% in dogs and 80% in cats). These data suggest that TD ligation in conjunction with pericardectomy has a favorable outcome in animals with idiopathic chylothorax.

Management of chylothorax via percutaneous embolization

PURPOSE OF REVIEW

The purpose of this review is to present a novel radiologic percutaneous transabdominal technique for treating high-output chylothorax by thoracic duct embolization, and to demonstrate that it can be potentially safer than the traditional treatment by surgical open-chest thoracic duct ligation.

RECENT FINDINGS

Pedal lymphography is initially performed to opacify large retroperitoneal lymph channels; a suitable duct more than 2 mm in diameter is then punctured transabdominally to allow catheterization and embolization of the thoracic duct under fluoroscopic guidance. If feeding lymphatic channels are too small for catheterization, they can often be occluded by needle disruption. This percutaneous interventional technique, which has been used in 60 patients with mostly high-output chylothorax caused by thoracic surgery, resulted in a 65% cure rate with no morbidity. Back-up surgical thoracic duct ligation was performed promptly on suitable lower risk patients when the percutaneous procedure failed.

SUMMARY

We have found that two thirds of patients presenting with life-threatening chylothorax can be safely treated by percutaneous transabdominal thoracic duct blockage. When successful, this novel interventional procedure can obviate repeat major thoracic surgery and shorten hospital stays.

Thoracic duct injury during esophagectomy: 20 years experience at a tertiary care center in a developing country

Thoracic duct injury is an uncommon complication of esophagectomy. Experience in managing these cases is limited to large centers performing esophagectomies in good numbers. We analyzed the prospectively maintained esophageal diseases database of patients presenting to a surgical unit between 1982 and 2002. Among 552 esophagectomies during this period we had encountered 14 cases of chylothorax (2.54%). We analyzed the type and site of lesion and the impact of neoadjuvant therapy on the incidence of thoracic duct injury. Among 459 patients of transhiatal esophagectomy, 11 developed postoperative chylothorax (2.40%). In 93 transthoracic resections, there were three cases of chylothorax (3.23%; (P = 0.9185)). The incidence following preoperative radiotherapy was 2.17%. None of the 31 patients, who had undergone esophagectomy for benign diseases had developed chylothorax. In the carcinoma group the incidence in middle third lesions was 5.85% and in lower third lesions was 0.80% (P = 0.0018). Seven patients were managed conservatively. Two of these patients, for whom surgery had been planned, died before they could be taken up for surgery. In the remaining seven patients transthoracic ligation of the thoracic duct was performed. Two patients in this group died. The average hospital stay was 20 days in the conservative group and 12 days in the surgery group. Among the factors studied, patients with middle third lesions were at increased risk of developing postoperative chylothorax, when compared to upper or lower third lesions.

Lymph sampling and lymphangiography via EUS-guided transesophageal thoracic duct puncture in a swine model

BACKGROUND

The thoracic duct plays an important role in fluid balance, lipid absorption, and transport of immunologically active cells. The thoracic duct is difficult to access but is readily identified by EUS. The present study assessed the feasibility of EUS identification and EUS-guided puncture of the thoracic duct in a swine model.

METHODS

Transesophageal EUS-guided thoracic duct puncture was attempted in 3 animals under fluoroscopy. In two animals, the thoracic duct was identified by cutdown in the neck; in the third animal, EUS-guided puncture was performed under fluoroscopy alone. In one animal, the thoracic duct was opacified by injecting contrast medium. In the second animal, thoracic duct was injected with patent blue and contrast medium.

OBSERVATIONS

Thoracic duct was identified and punctured successfully in all 3 animals. In the first animal, contrast medium containing lymph was aspirated. In the second animal, lymph containing patent blue was aspirated, and, in the third animal, successful puncture was confirmed by obtaining a lymphangiogram.

CONCLUSIONS

This pilot study in an animal model demonstrates that transesophageal EUS-guided puncture of the thoracic duct is feasible and that the technique can be used for lymph sampling and/or lymphangiography.

[Surgery for chylothorax]

Chyle is lymph fluid of intestinal origin containing fat digestion products. Chylothorax is produced by leaks from the thoracic duct or from one of its collaterals subsequent to valve incompetence. These leaks may be due to trauma (post-surgical chylothorax, the most frequent) or to spontaneous rupture of a lymph vessel distended by chyle reflux, the thoracic duct itself being pathological. When the thoracic duct is interrupted (obstruction, agenesis), chylothorax may occur from leakage due to reflux within substitution collateral pathways diverting the flow of chyle into the venoux confluents of the neck. Medical treatment is always attempted first: evacuation of chylothorax by drainage and fat-free diet or parenteral nutrition. Recently, treatment with octreotide has been found to be beneficial. Surgery consists in thoracic duct ligation or suture of leaking collaterals. In difficult cases, when the chyle leakage cannot be identified, pleurodesis is the only option.

A stepwise surgical procedure to investigate the lymphatic transport of lipid-based oral drug formulations: Cannulation of the mesenteric and thoracic lymph ducts within the rat

INTRODUCTION

A number of animal models have been described for the assessment of intestinal lymphatic drug transport. Lymphatic transport studies are commonly first conducted in the laboratory rat, with larger more complicated models (i.e., dog or pig) subsequently investigated. However, the utility of lymph fistulation in large animals is limited by considerable logistical and economic constraints.

METHODS

This paper describes a stepwise surgical procedure for cannulating the thoracic and mesenteric lymph ducts in male Sprague-Dawley rats.

RESULTS

Following surgery, thoracic and mesenteric lymph flow rates during the 24-h period immediately following surgery averaged 12.5+/-2.5 and 2.4+/-1.1 ml/h, respectively. This flow rate is greater than that obtained with previously described methods, which require restraint of the animals and/or a 24-h recovery period and are reported to produce average intestinal lymph flow rates of 2 ml/h.

DISCUSSION

This animal model can be utilized for the assessment of drug transport by the lymphatics and for determining what percentage of lymphatic transport is a result of only intestinal lymphatics.

Thoracoscopic management of thoracic duct injury: Is there a place for conservatism?

Thoracic duct injury is a rare but serious complication following chest surgeries and major neck dissections. Clinically, it can present as cervical chylous fistula, chylothorax or chylopericardium. Without treatment, the mortality is up to 50% and thus, early aggressive therapy is indicated. Traditional conservative management includes low-fat diet, parenteral nutrition, careful monitoring of fluid and electrolytes, and drainage of the neck wound or chylothorax. Patients with failed conservative management require definitive treatment in the form of ligation of the thoracic duct, which has traditionally been done by thoracotomy. The advent of Video-Assisted-Thoracoscopic-Surgery (VATS) over the last decade has changed the approach towards the management of numerous chest diseases. Thoracoscopic ligation of the thoracic duct has also been reported. We report herein a case of postoperative cervical chylous fistula managed successfully by VATS thoracic duct ligation and present a systematic analysis of the English literature to highlight the current trends in the management of thoracic duct injury.

One technique, two approaches, and results: thoracic duct cannulation in small laboratory animals

Experimental studies in immunology, pharmacology, or hematology require the sampling of the total thoracic duct lymph in awake and unrestrained rats or mice. Several approaches have been described for cannulation of the thoracic duct, but they are characterized by a modest reproducibility and a low lymph flow rate. An improved technique for obtaining thoracic duct lymph is described here, emphasizing the similarities and differences concerning both rats and mice (average weights of 305 and 15 g, respectively). Rats yielded a mean of 55.6 ml/day thoracic duct lymph, while lymph output in mice reached unexpected volumes of 29.3 ml/day. The use of an operating microscope and silicone cannula, and maintenance of mobility of the animals during lymph collection, offer a reliable method for a high and constant output of thoracic duct lymph. Relevant aspects of the murine thoracic duct anatomy are also identified.

Ligation of the thoracic duct for the treatment of chylothorax in heart diseases

In children, chylothorax occurs mainly after cardiac and thoracic surgeries. One of the recommended postsurgery treatments is ligation of the thoracic tract, when all other conservative treatments have failed. We report 4 cases of chylothorax in patients who were successfully treated with this approach, which resulted in a decrease in pleural drainage without recurrent chylothorax.

[Surgical anatomy of superior and mid-thoracic areas of the thoracic duct]

To investigate the peculiarities of surgical anatomy of superior and mid-thoracic portions of the thoracic duct, 70 human corpses of adults of both sexes were studied using modern anatomical and experimental methods. Some regularities of the changes of syntopy of the mediastinal organs and vessels and the connection of these changes with the individual features of thoracic structure are described. The relation between these peculiarities with the quantitative parameters of surgical procedures performed in superior and mid-thoracic portions of the thoracic duct is demonstrated.

Advantage of earlier thoracoscopic clipping of thoracic duct for post-operation chylothorax following thoracic aneurysm surgery

We report that an earlier thoracoscopic clipping of the thoracic duct was advantageous in a case of post-operation chylothorax that occurred following thoracic aneurysm surgery. A 61-year-old man developed chylothorax on postoperative day 2 following graft replacement of the descending thoracic aorta using a left-sided thoracotomy. Since a replaced graft infection is lethal, earlier thoracoscopic clipping of the thoracic duct through the right side chest wall was indicated. The patient underwent thoracoscopic clipping on postoperative day 7 and was successfully treated. The duration of drainage was 2 days and oral intake was started on the seventh day. From our results, we recommend a thoracoscopic procedure through the opposite (right) side chest wall in the early stage of chylothorax development following thoracic aneurysm surgery.

Thoracic duct cyst of the mediastinum

Thoracic duct cysts of the mediastinum are extremely rare. The etiology may be related to a congenital or degenerative weakness in the wall of the thoracic duct. They are generally asymptomatic but may sometimes cause pressure effects on adjacent structures. Imaging studies are supportive but not diagnostic. Excision of these cysts is required for diagnosis and to prevent complications. We describe a 49-year old man who presented to us with hoarseness and a fixed right vocal cord. Computed tomography (CT) showed a cystic posterior mediastinal mass in the right paratracheal region. We performed a posterolateral thoracotomy and found the cyst arising from the thoracic duct and contained chylous fluid with a high lipid concentration. We dissected the cyst from the surrounding structures and excised it. Histopathology revealed a cyst lined by a single layer of endothelial cells. He is asymptomatic now one year after surgery.

Influences of thoracic duct blockage on early enteral nutrition for patients who underwent esophageal cancer surgery

OBJECTIVES

We have previously reported the beneficial effects of immediate enteral nutrition (EN) after esophageal cancer surgery. This randomized control study was conducted to determine whether immediate EN is beneficial or not for patients whose thoracic ducts were ligated, as well as those whose thoracic ducts were preserved.

PATIENTS AND METHODS

Thirty-nine patients who underwent radical resection of the esophageal cancer entered this trial. After stratifying into two groups--patients whose thoracic ducts were preserved [D(+)] and those whose thoracic ducts were ligated [D(-)], they were randomly divided into two groups--the patients who received early EN and those who received parenteral nutrition (PN) followed by delayed enteral feeding. Thus, the number of patients in the D(+)-EN group, D(+)-PN group, D(-)-EN group and D(-)-PN group were 13, 12, 7 and 7, respectively. The mortality and morbidity rates, and several blood chemistries were compared between the EN groups and the PN groups.

RESULTS

Total lymphocyte count showed a significant early increase and serum c-reactive protein (CRP) was significantly decreased in the D(+)-EN group compared to the D(+)-PN group. However those differences were not observed between the D(-) groups. Serum total bilirubin was significantly decreased in the both EN groups compared to the PN groups. The mortality and morbidity rates were not different between the EN group and the PN group in the D(+) patients and also in the D(-) patients.

CONCLUSIONS

Patients whose thoracic ducts were ligated did not obtain any other benefit from early enteral feeding except for bilirubin metabolism. Early enteral feeding is not recommended for patients whose thoracic ducts are ligated during radical resection of a cancer in the thoracic esophagus.

[Significance of features of the projection of the cervical part of the thoracic duct onto the left sternocleidomastoid muscle for performing operations involving video support]

To work out practical recommendations for using videosupport projection of cervical part of the thoracic duct on sternoclaidomastoid muscle was determined in 158 corpses of adults. Surgical access to the thoracic duct is available using common macrosurgical equipment until the moment of visualization of major lymphatic corrector, although it is reasonable to involve videosupport at following stage with the camera of videoendosurgical kit adjusted in inferior margin of the wound. This allows to perform all the necessary actions to expose cervical part of the thoracic duct and to correct them according to video information on the monitor.

[En bloc ligation of the thoracic duct in twelve dogs with idiopathic chylothorax]

Twelve dogs with idiopathic chylothorax were treated by en bloc ligation of the thoracic duct. Six dogs recovered completely. Minimal follow-up in this group was 12 months. Five dogs were euthanized within 5 months of surgery because of persisting liquothorax: two with chylous and three with non-chylous effusions. One dog was euthanized 2 months after surgery because of a recurrence of dyspnoea. It is concluded that the results are comparable with those of a previously described surgical treatment; however, the technique described here is less complicated because it does not require mesenteric lymphangiography.

Spontaneous thoracic duct cyst

Spontaneous and asymptomatic supraclavicular thoracic duct cysts (lymphoceles ) are rare. Only five cases have been reported so far. They are more common after surgery or trauma and have been reported in the abdomen, mediastinum, pelvis and neck. They must be differentiated from other neck cysts as failure to recognise their attachment may result in the disastrous consequence of chylothorax. A high index of suspicion is necessary, and diagnosis usually can be established by fine-needle aspiration and suitable imaging. This case is reported along with a review of the literature and management options, including that of inadvertent damage to the thoracic duct.