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Motas N, Manolache V, Rus O, Davidescu M, Cioalca‑iliescu M, Socea B, Ceausu M, Trifanescu O. Tensioned space after pneumonectomy for cancer with mediastinal shift and cardiac tamponade‑causes and treatment (Review). Exp Ther Med 2022; 24:548. [PMID: 35978935 PMCID: PMC9366286 DOI: 10.3892/etm.2022.11485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 06/09/2022] [Indexed: 11/28/2022] Open
Abstract
Regarding the pleural space after pneumonectomy for malignancy, a vast number of studies have assessed early drop in the fluid level, suggesting a broncho-pleural fistula, but only a small number of studies reported on the abnormal increase in the fluid level-a potentially lethal complication. In the present study, the available databases worldwide were screened and 19 cases were retrieved, including 14 chylothorax and 3 hydrothorax cases, 1 pneumothorax and 1 haemothorax case. Tension chylothorax is caused by mediastinal lymph node dissection as an assumed risk in radical cancer surgery. For tensioned haemothorax, the cause has not been elucidated, although lymphatic stasis associated with deep venous thrombosis was suspected. Tensioned pneumothorax was caused by chest wall damage after extrapleural pneumonectomy combined with low aspiration pressure on the chest drain. No cause was determined for none of the tensioned hydrothorax-all 3 cases had the scenario of pericardial resection in addition to pneumonectomy in common. Tensioned space after pneumonectomy for cancer manifests as cardiac tamponade. Initial management is emergent decompression of the heart and mediastinum. Final management depends on the fluid type (chyle, transudate, air, blood) and the medical context of each case. Of the 19 cases, 12 required a major surgical procedure as the definitive management.
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Affiliation(s)
- Natalia Motas
- Clinic of Thoracic Surgery, Institute of Oncology ‘Prof. Dr. Al. Trestioreanu’, Bucharest RO‑022328, Romania
| | - Veronica Manolache
- Clinic of Thoracic Surgery ‘Prof. Dr. Al. Trestioreanu’, University of Medicine and Pharmacy Carol Davila, Bucharest RO‑020021, Romania
| | - Ovidiu Rus
- Clinic of Thoracic Surgery, Institute of Oncology ‘Prof. Dr. Al. Trestioreanu’, Bucharest RO‑022328, Romania
| | - Mihnea Davidescu
- Clinic of Thoracic Surgery, Institute of Oncology ‘Prof. Dr. Al. Trestioreanu’, Bucharest RO‑022328, Romania
| | - Madalina Cioalca‑iliescu
- Clinic of Thoracic Surgery, Institute of Oncology ‘Prof. Dr. Al. Trestioreanu’, Bucharest RO‑022328, Romania
| | - Bogdan Socea
- Clinic of General Surgery, Emergency Clinical Hospital Sf. Pantelimon, Bucharest RO‑021659, Romania
| | - Mihail Ceausu
- Department of Pathology, Institute of Oncology ‘Prof. Dr. Al. Trestioreanu’, Bucharest RO‑022328, Romania
| | - Oana Trifanescu
- Clinic of Oncology, Institute of Oncology ‘Prof. Dr. Al. Trestioreanu’, Bucharest RO‑022328, Romania
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Petrella F, Casiraghi M, Radice D, Bertolaccini L, Spaggiari L. Treatment of Chylothorax after Lung Resection: Indications, Timing, and Outcomes. Thorac Cardiovasc Surg 2020; 68:520-524. [PMID: 32492713 DOI: 10.1055/s-0040-1710071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Chylothorax following pulmonary resection and lymphadenectomy for cancer is a potential severe complication in thoracic surgery. In the present study, we investigated the efficacy of the nonsurgical approach as well as the need for reoperation after conservative approach failure. METHODS Chylothorax was diagnosed when chylous leakage from the chest drainage was observed and confirmed by the presence of triglycerides in the pleural fluid. We initially treated all the patients conservatively with complete oral intake cessation and total parenteral nutrition; if drainage output remained more than 800 mL/d after the first 5 days or major pleural effusion was observed at chest X-ray after chest tube removal, surgical treatment of chylothorax was indicated. RESULTS Between January 1998 and December 2018, 5,072 patients underwent standard anatomical resection and mediastinal lymph node dissection for cancer at our institution. Among them, 30 patients (0.6%) developed chylothorax: 20 patients were effectively treated only by nil per os and low-fat diet, while 10 patients (33.3%) required surgical treatment. Mean age was 63 years; there were 24 male patients (80%); right-sided chylothorax was more frequent than left-sided chylothorax (22 vs. 8, respectively) although not statistically significant (p = 0.38); the only factor that seems to influence the need for reoperation is chylothorax flow rate during conservative treatment (p = 0.06). CONCLUSION Conservative treatment is effective in the case of low flow-rate chylothorax (< 800 mL/d); in the case of a higher flow rate, surgical exploration is needed and thoracic duct ligation-with or without lymphatic sites clipping-provides definitive lymphostasis.
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Affiliation(s)
- Francesco Petrella
- Department of Thoracic Surgery, IRCCS European Institute of Oncology, Milan, Lombardia, Italy.,Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | - Monica Casiraghi
- Department of Thoracic Surgery, IRCCS European Institute of Oncology, Milan, Lombardia, Italy
| | - Davide Radice
- Division of Epidemiology and Biostatistics, IRCCS European Institute of Oncology, Milan, Lombardia, Italy
| | - Luca Bertolaccini
- Department of Thoracic Surgery, IRCCS European Institute of Oncology, Milan, Lombardia, Italy
| | - Lorenzo Spaggiari
- Department of Thoracic Surgery, IRCCS European Institute of Oncology, Milan, Lombardia, Italy.,Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
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Abstract
AIM to improve the results and current pathogenetic treatment of chylorrhea. MATERIAL AND METHODS Thirty seven patients with chylothorax have been treated for the period 2004-2014. In 34 cases traumatic chylothorax developed after surgery and in 3 cases - after intensive care for therapeutic diseases and great veins catheterization. Chylothorax was predominantly diagnosed by X-ray method. Herewith, hydrothorax was established and its nature was defined using laboratory survey. Presence of neutral fat in pleural drainage is the sign of chylothorax. Pathogenetic treatment was often delayed (up to 4.5 months) due to poor awareness of physicians about this pathological process. 6 patients underwent thoracic duct ligation above diaphragm due to ineffective therapy. RESULTS Medical therapy had good clinical effect in 83.8% of cases. Postoperatively 1 patient died for single lung inflammation on background of postoperative chylothorax after right-sided pneumonectomy. In other cases chylothora was eliminated with no recurrence in remote postoperative period. It is difficult to recognize injury of thoracic duct or its great branches during surgery. In these cases prolonged thoracic duct ligation above diaphragm is indicated.
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Affiliation(s)
- V D Parshin
- Sechenov First Moscow State Medical University of Ministry of Health, Moscow, Russia
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Gómez-Caro AA, Moradiellos Diez FJ, Marrón CF, Larrú Cabrero EJ, Martín de Nicolás JL. Conservative Management of Postsurgical Chylothorax with Octreotide. Asian Cardiovasc Thorac Ann 2016; 13:222-4. [PMID: 16112992 DOI: 10.1177/021849230501300306] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Postsurgical chylothorax after lung resection has an important associated rate of morbidity and mortality, and a large proportion of cases require re-exploration. The most desirable and least aggressive option is conservative treatment. The use of octreotide seems to be associated with a higher rate of resolution without the need for surgical intervention. We present 4 cases in which this drug showed excellent efficacy and minimal adverse effects in the resolution of postsurgical chylothorax.
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Affiliation(s)
- Abel A Gómez-Caro
- Department of Thoracic Surgery, 12 de Octubre University Hospital, Andalucía Ctra KM 5.400, Madrid 28004, Spain.
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Misthos P, Kanakis MA, Lioulias AG. Chylothorax complicating thoracic surgery: conservative or early surgical management? Updates Surg 2012; 64:5-11. [DOI: 10.1007/s13304-012-0133-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2011] [Accepted: 01/04/2012] [Indexed: 11/30/2022]
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Jackson TA, Mehran RJ, Thakar D, Riedel B, Nunnally ME, Slinger P. Case 5-2007 postoperative complications after pneumonectomy: clinical conference. J Cardiothorac Vasc Anesth 2007; 21:743-51. [PMID: 17905288 DOI: 10.1053/j.jvca.2007.07.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Timothy A Jackson
- Department of Anesthesiology and Pain Medicine, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030-4009, USA.
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Abstract
Chylothorax, an uncommon cause of pleural effusion, is usually secondary to malignancy, trauma, congenital diseases, infections and superior vena cava thrombosis. The early diagnosis and treatment are important to prevent the most fearful consequence of chylothorax, the malnutrition with a compromised immunological status.
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Abstract
PURPOSE OF REVIEW This article reviews the current literature concerning the role of somatostatin and its synthetic analogue, octreotide, in the treatment of chylothorax. RECENT FINDINGS Management of chylothorax includes evacuation of the pleural cavity through a chest tube to alleviate dyspnoea, and dietary fat restriction aimed at reducing lymph flow. When these measures fail to control lymph flow, surgical interventions are employed to achieve definite closure of the thoracic duct leak. Several case reports and series have shown that octreotide is safe and probably effective in both children and adults with chylothorax of different origins. The property of somatostatin and octreotide to induce leak closure is attributed to a decelerating effect on lymph flow, although their exact mechanism of action is not well defined. In successful cases, a substantial reduction of lymph drainage through the chest tube is evident within the first few days of commencing the drug, and treatment lasts for 1-2 weeks. Treatment failure has been also reported, however. SUMMARY Accumulating evidence suggests that octreotide is a putative novel therapeutic intervention for chylothorax. It is imperative that randomized controlled studies are conducted in order to fully elucidate the efficacy and safety of this treatment.
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Affiliation(s)
- Ioannis Kalomenidis
- Department of Critical Care and Pulmonary Services, Athens Medical School, Evangelismos Hospital, Athens, Greece.
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Sugiura K, Tanabe Y, Ogawa T, Tokushima T. Localization of chyle leakage site in postoperative chylothorax by oral administration of I-123 BMIPP. Ann Nucl Med 2005; 19:597-601. [PMID: 16363625 DOI: 10.1007/bf02985053] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The authors present a 71-year-old woman who had a right chylothorax after right upper lobectomy for lung cancer. As the chylothorax was considered to be due to thoracic duct injury at the time of operation, lymphoscintigraphy was performed by oral administration of I-123 beta-methyl-iodophenyl pentadecanoic acid (BMIPP). After visualization of the stomach and intestine, abnormal accumulation of the radiotracer was found initially around the right pulmonary hilum and then spread laterally in the upper pleural cavity, indicating chyle leakage in the region of the right pulmonary hilum. Scintigraphic finding was well correlated with the subsequent thoracoscopic observation, showing chyle leakage from a lymphatic tributary near its confluence to the thoracic duct at the level of the azygos continuation. The disruption site was ligated by video-assisted-thoracoscopic-surgery procedure with successful termination of the chyle leakage. Lymphoscintigraphy by oral administration of I-123 BMIPP is thought to be a useful method for localization of chyle leakage in patients with chylothorax induced by thoracic surgery.
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Affiliation(s)
- Kimihiko Sugiura
- Department of Radiology, Tottori University Hospital, Yonago, Tottori 683-8504, Japan
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Abstract
OBJECTIVES To characterize the etiology of chylothorax in patients encountered at a single tertiary referral center and to compare the findings with those from previous studies. PATIENTS AND METHODS The medical records of all patients with chylothorax seen at the Mayo Clinic in Rochester, Minn, over a 21-year period, from January 1, 1980, to December 31, 2000, were retrospectively reviewed to ascertain the underlying cause of their condition. RESULTS We identified 203 patients with chylothorax; 92 were females (male-female ratio, 1.21). The median age was 54.5 years (range, 21 weeks' gestation to 93 years). Dyspnea, the most common presenting symptom, occurred in 98 (56.6%) of 173 patients in whom initial symptoms were recorded, whereas 64 (37.0%) had no respiratory symptoms. Median duration of symptoms before diagnosis was 7.5 weeks (range, 1 day to 4.5 years). Causes of chylothorax included surgery or trauma in 101 patients (49.8%), various medical conditions in 89 (43.8%), and unknown in 13 (6.4%). Among surgical procedures, esophagectomy (29 patients) and surgery for congenital heart disease (28 patients) were the most common causes of chylothorax. Among medical conditions, lymphoma (23 patients), lymphatic disorders (19 patients), and chylous ascites (16 patients) were the most common causes. CONCLUSIONS Chylothorax has numerous causes. In contrast to previous studies, surgery or trauma was the most common cause of chylothorax at our institution, accounting for nearly 50% of cases. Lymphoma and other malignancies caused chylothorax in only 16.7% of cases. These numbers are possibly related to the high volume of cardiothoracic surgical procedures performed at our tertiary referral center.
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Affiliation(s)
- Clinton H Doerr
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine, Rochester, Minn 55905, USA
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Gómez-Caro Andrés A, Marrón Fernández C, Moradiellos Díez FJ, Díaz-Hellín Gude V, Pérez Antón JA, Martín de Nicolás JL. [Octreotide for conservative management of postoperative chylothorax]. Arch Bronconeumol 2005; 40:473-5. [PMID: 15491540 DOI: 10.1016/s1579-2129(06)60357-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Postoperative chylothorax after lung resection is a major problem leading to morbidity and mortality and requiring reoperation in a large number of cases. The most advisable and least aggressive option is conservative management in progressive stages: a diet rich in medium-chain fatty acids and/or total parenteral nutrition, in addition to chest tube drainage. Including octreotide in this regimen seems to be related to a higher success rate without the need for surgery. We report a case in which the effectiveness and safety of octreotide in the resolution of postoperative chylothorax was excellent.
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Shimizu K, Otani Y, Ibe T, Kawashima O, Kamiyoshihara M, Yasuo M. Late-onset chylothorax after pulmonary resection and systematic mediastinal lymph node dissection for lung cancer. ACTA ACUST UNITED AC 2005; 53:39-41. [PMID: 15724501 DOI: 10.1007/s11748-005-1007-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
Late-onset chylothorax occurred 49 days after right lower lobectomy for lung cancer in a 76-year-old man. Chylothorax was successfully managed by conservative treatment with chest tube drainage and an enteral low-fat diet. Chylothorax may occur in the late period after pulmonary resection and systematic mediastinal lymph node dissection for lung cancer, for which conservative management is the treatment of choice.
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Affiliation(s)
- Kimihiro Shimizu
- Second Department of Surgery, Gunma University Faculty of Medicine, Maebashi, Gunma, Japan
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Affiliation(s)
- Riyad Karmy-Jones
- Harborview Medical Center, University of Washington, Seattle, Washington, USA
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Gómez-Caro Andrés A, Marrón Fernández C, Moradiellos Díez F, Díaz-Hellín Gude V, Pérez Antón J, Martín de Nicolás J. Tratamiento conservador con octreótido del quilotórax posquirúrgico. Arch Bronconeumol 2004. [DOI: 10.1016/s0300-2896(04)75574-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Riedel BJCJ, Vaporciyan AA. Unusual cause of dyspnea after pneumonectomy. J Cardiothorac Vasc Anesth 2003; 17:131-3. [PMID: 12635076 DOI: 10.1053/jcan.2003.26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Bernhard J C J Riedel
- Department of Anesthesiology, The University of Texas M.D. Anderson Cancer Center, Houston, TX 77030, USA.
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Shimizu K, Yoshida J, Nishimura M, Takamochi K, Nakahara R, Nagai K. Treatment strategy for chylothorax after pulmonary resection and lymph node dissection for lung cancer. J Thorac Cardiovasc Surg 2002; 124:499-502. [PMID: 12202866 DOI: 10.1067/mtc.2002.124386] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE We reviewed our experience with iatrogenic chylothorax after pulmonary resections for lung cancer to evaluate our treatment strategy and to identify factors that predict the need for reoperation. METHODS From July 1992 through February 2000, a total of 1110 patients underwent pulmonary resection (at least lobectomy) and systematic mediastinal lymph node dissection for lung cancer at our division. Twenty-seven patients (2.4%) had postoperative chylothorax develop. We initially treated 26 of these patients conservatively with complete oral intake cessation and total parenteral nutrition, and these patients constituted the subjects in this study. RESULTS There were 21 men and 5 women with a median age of 62 years (range 44 to 80 years). The initial procedures were pneumonectomy in 2 cases, bilobectomy in 1 case, and lobectomy in 23 cases. Twenty-one patients (81%) had the condition cured with conservative treatment. These patients resumed a normal diet at a median of 8 days after chylothorax diagnosis (range 4-35 days). The remaining 5 patients (19%) underwent reoperation at a median of 14 days after diagnosis (range 5-35 days). Chest tube drainage of less than 500 mL during the first 24 hours after complete oral intake cessation and total parenteral nutrition predicted a cure with conservative treatment. CONCLUSION Although most cases of chylothorax after pulmonary resection with systematic mediastinal lymph node dissection can be cured with a conservative strategy, early surgical intervention may be indicated if chest tube drainage is more than 500 mL during the first 24 hours after complete oral intake cessation and total parenteral nutrition.
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Affiliation(s)
- Kimihiro Shimizu
- Division of Thoracic Surgery, National Cancer Center Hospital East, Kashiwanoha, Kashiwa Chiba, Japan.
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Abstract
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.
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Affiliation(s)
- David W Johnstone
- Department of Cardiothoracic Surgery, University of Rochester School of Medicine & Dentistry, 601 Elmwood Avenue, Box Surgery, Rochester, NY 14642, USA.
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Abstract
BACKGROUND Chylothorax complicating pulmonary resection (CCPR) is infrequent and surgical treatment is for the most part avoided. The purpose of this study is to analyze the clinical and therapeutic characteristics of this complication. METHODS From March 1981 to June 2001, 26 cases of CCPR (24 men and 2 women; mean age 57 years) were treated in two departments of thoracic surgery. Twenty-five cases complicated lung resection for lung cancer (lobectomy n = 14, bilobectomy n = 3, pneumonectomy n = 8) and 1 case followed lobectomy for a benign lesion. Medical history, location, and characteristics of the chylothorax, lymphography, and clinical evolution after medical or surgical therapy were studied. RESULTS Medical history was never predictive of CCPR. Chylothorax was right sided in 18 cases and left sided in 8 cases. The total amount of chyle ranged from 1.9 L to 27.9 L per patient with a mean of 7.9 L (pneumonectomy 12.3 L and lobectomy 6.3 L). In 15 patients (pneumonectomy n = 2 and lobectomy n = 13) mean quantity of daily chyle was 0.3 L. All these patients recovered with conservative therapy except for 2 patients who underwent drainage and talc slurry (n = 1) and video-assisted lysis of adhesions (n = 1). In the remaining 11 patients (pneumonectomy n = 6 and lobectomy n = 5) mean quantity of daily chyle was 1 L. The chylous leak was seen at lymphography (n = 4), during reoperation (n = 2), or at lymphography and reoperation (n = 3). The location was clearly identified at the level of thoracic duct tributaries in all cases. In 4 postlobectomy cases (4 of 7), surgery was not performed because of the therapeutic usefulness of lymphography. Reoperation was necessary in 6 cases (postpneumonectomy n = 5, postlobectomy n = 1) and consisted of duct ligation (n = 2), leak/suture (n = 3), and fibrin glue (n = 1). CONCLUSIONS CCPR is rare and appears to respond well to medical treatment owing to the fact that the thoracic duct is generally patent as the leak is due to injury of its tributaries. When surgery is considered, lymphography may help to select cases in which conservative medical therapy should be continued. However, in a small number of cases, usually after pneumonectomy, surgery remains mandatory.
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Riquet M, Le Pimpec Barthes F, Souilamas R, Hidden G. Thoracic duct tributaries from intrathoracic organs. Ann Thorac Surg 2002; 73:892-8; discussion 898-9. [PMID: 11899197 DOI: 10.1016/s0003-4975(01)03361-6] [Citation(s) in RCA: 85] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND The thoracic duct (TD) is the main collecting vessel of the lymphatic system. Little is known about the intrathoracic tributaries of the TD, which are named intercostal, mediastinal, and bronchomediastinal trunks. The purpose of the study was to identify the lymphatic tributaries from intrathoracic organs to the thoracic duct. METHODS The study was performed on 530 adult cadavers. The lymphatics of different organs were catheterized and injected with a dye: lungs (n = 360), heart (n = 90), esophagus (n = 50), and diaphragm (n = 30). The lymphatic tributaries draining the lymph from these organs to the thoracic duct were dissected along their course to the thoracic duct and classified. RESULTS The TD tributaries were observed in 147 cases: right lung (n = 46), left lung (n = 69), heart (n = 8), esophagus (n = 13), and diaphragm (n = 11). Connections with the TD were observed at its origin (n = 13), within the mediastinum (n = 87), and at the level of the TD arch (n = 47). Tributaries from the lung issued from lower paratracheal nodes 4 R (n = 14) and 4 L (n = 31), subaortic 5 (n = 4), subcarinal 7 (n = 18), pulmonary ligament 9 (n = 7), upper tracheal 2 L (n = 28), paraortic 6 (n = 11), and celiac nodes (n = 2). Tributaries from the heart connected with the TD in the mediastinum in 1 case (4 L) and with the TD arch in 7 cases. Tributaries from the esophagus connected with the thoracic duct within the mediastinum in 13 cases; anodal routes were frequent (n = 5). The TD tributaries from the diaphragm were observed in 11 cases, always connecting with the TD at its origin. CONCLUSIONS Injection of intrathoracic organs permits visualization of TD tributaries. These tributaries appear located at unchanging levels. Lymph of intrathoracic organs may thus drain into the general circulation through the TD. The tributaries may represent a potential route for tumor cells dissemination. When incompetent, due to valve insufficiency, they permit chylous lymph to backflow into the intrathoracic lymph nodes. Injury at this level may lead to intrathoracic chylous effusions.
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Affiliation(s)
- Marc Riquet
- Service de Chirurgie Thoracique, Hôpital Européen Georges Pompidou and Institut d'Anatomie, UER Biomédicale des Saints Pères, Paris, France.
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Gómez V, Álvarez L, González J, González E, Guijosa F, Rodríguez E. Manejo actual del quilotórax iatrogénico. Cir Esp 2001. [DOI: 10.1016/s0009-739x(01)71715-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Markham KM, Glover JL, Welsh RJ, Lucas RJ, Bendick PJ. Octreotide in the Treatment of Thoracic Duct Injuries. Am Surg 2000. [DOI: 10.1177/000313480006601215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
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 μg/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 m1/24-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.
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Affiliation(s)
- Kevin M. Markham
- Department of Surgery, William Beaumont Hospital, Royal Oak, Michigan
| | - John L. Glover
- Department of Surgery, William Beaumont Hospital, Royal Oak, Michigan
| | - Robert J. Welsh
- Department of Surgery, William Beaumont Hospital, Royal Oak, Michigan
| | - Robert J. Lucas
- Department of Surgery, William Beaumont Hospital, Royal Oak, Michigan
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Cerfolio RJ, Allen MS, Deschamps C, Trastek VF, Pairolero PC. Postoperative chylothorax. J Thorac Cardiovasc Surg 1996; 112:1361-5; discussion 1365-6. [PMID: 8911335 DOI: 10.1016/s0022-5223(96)70152-6] [Citation(s) in RCA: 249] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Between July 1987 and May 1995, 11,315 patients underwent general thoracic surgical procedures at our institution. In 47 of these patients (0.42%), postoperative chylothorax developed. There were 32 men and 15 women with a median age of 65 years (range 21 to 88 years). Initial operation was for esophageal disease in 27 patients, pulmonary disease in 13, mediastinal mass in six, and thoracic aortic aneurysm in one. All patients were initially treated with hyperalimentation, cessation of oral intake, medium chain triglyceride diet, or a combination. Nonoperative therapy was successful in 13 cases (27.7%), and oral intake was resumed a median of 7 days later (range 2 to 15 days). Reoperation was required in the remaining 34 cases. The reoperation rate varied according to the type of initial operation. Twenty-four of the 27 patients (88.9%) who had undergone an esophageal operation required reoperation, versus only five of 13 patients (38.5%) who had undergone pulmonary resection (p < 0.001). Lymphangiography was performed in 16 patients and identified the site of the leak in 13. The thoracic duct was ligated in 32 of the 34 patients who required reoperation (94%). The remaining two patients were treated with mechanical pleurodesis and fibrin glue. Reoperation was successful in 31 of the 34 patients (91.2%). The single death among the 47 patients (2.1%) occurred in the reoperated group. Complications occurred in 18 patients (38.3%). Factors that predicted the need for reoperation were initial esophageal operation and average daily postoperative drainage greater than 1000 ml/day for 7 days. We conclude that postoperative chylothorax is an infrequent complication. Some cases can be managed without operation; however, we recommend early reoperation when drainage is greater than 1000 ml/day or if the chylous fistula occurs after an esophageal operation. The fistula can usually be controlled by ligation of the thoracic duct.
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Affiliation(s)
- R J Cerfolio
- Section of General Thoracic Surgery, Mayo Clinic, Rochester, Minn 55905, USA
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Bin HR, Hsun CS, Sh CI, Chung CI, Hsien HS. Chylothorax after Operation for Congenital Heart Disease. Asian Cardiovasc Thorac Ann 1994. [DOI: 10.1177/021849239400200210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The management of chylothorax after operations for congenital heart diseases was reviewed retrospectively. Between 1986 and 1993, 5 cases were identified. During 1993, a total of 317 operations were performed for congenital heart disease and 3 patients developed chylothorax, with an incidence of 0.95%. Conservative treatment with dietary modification and chest tube drainage was successful in abolishing chylous leakage in 4 out of 5 cases. Re-exploration with oversewing the leaking lymphaticus was performed in 1 case after 2 weeks conservative treatment. The mean duration of treatment was 25.4 days (range 3–44 days). Hypoalbuminemia complicated 1 case and there was no mortality. There was no correlation between the initial drainage amount and the duration or severity of chylothorax. Venous hypertension (>10mmHg), present in 4 out of 5 cases, may be associated with the development of postoperative chylothorax and high-dose diuretic therapy may be beneficial in these patients.
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Affiliation(s)
- Hsu Ron Bin
- Department of Surgery National Taiwan University Hospital Taipei, Taiwan
| | - Chu Shu Hsun
- Department of Surgery National Taiwan University Hospital Taipei, Taiwan
| | - Chiu Ing Sh
- Department of Surgery National Taiwan University Hospital Taipei, Taiwan
| | - Chang I Chung
- Department of Surgery National Taiwan University Hospital Taipei, Taiwan
| | - Hou Shou Hsien
- Department of Surgery National Taiwan University Hospital Taipei, Taiwan
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