Chylothorax complicating pulmonary resection

Outcomes of Chylothorax Nonoperative Management After Cardiothoracic Surgery: A Systematic Review and Meta-Analysis

INTRODUCTION

Chylothorax after thoracic surgery is a severe complication with high morbidity and mortality rate of 0.10 (95% confidence interval [CI] 0.06 - 0.02). There is no agreement on whether nonoperative treatment or early reoperation should be the initial intervention. This systematic review and meta-analysis aimed to evaluate the outcomes of the conservative approach to treat chyle leakage after cardiothoracic surgeries.

METHODS

A systematic review was conducted in PubMed®, Embase, Cochrane Library Central, and LILACS (Biblioteca Virtual em Saúde) databases; a manual search of references was also done. The inclusion criteria were patients who underwent cardiothoracic surgery, patients who received any nonoperative treatment (e.g., total parenteral nutrition, low-fat diet, medium chain triglycerides), and studies that evaluated chylothorax resolution, length of hospital stay, postoperative complications, infection, morbidity, and mortality.

CENTRAL MESSAGE

Nonoperative treatment for chylothorax after cardiothoracic procedures has significant hospital stay, morbidity, mortality, and reoperation rates.

RESULTS

Twenty-two articles were selected. Pulmonary complications, infections, and arrhythmia were the most common complications after surgical procedures. The incidence of chylothorax in cardiothoracic surgery was 1.8% (95% CI 1.7 - 2%). The mean time of maintenance of the chest tube was 16.08 days (95% CI 12.54 - 19.63), and the length of hospital stay was 23.74 days (95% CI 16.08 - 31.42) in patients with chylothorax receiving nonoperative treatment. Among patients that received conservative treatment, the morbidity event was 0.40 (95% CI 0.23 - 0.59), and reoperation rate was 0.37 (95% CI 0.27 - 0.49). Mortality rate was 0.10 (95% CI 0.06 - 0.02).

CONCLUSION

Nonoperative treatment for chylothorax after cardiothoracic procedures has significant hospital stay, morbidity, mortality, and reoperation rates.

Analysis of the unplanned reoperation following surgical treatment of pulmonary tumor

BACKGROUND

In this study, we aimed to summarize the extremely important lesson and experience in the whole process of surgical treatments of lung tumors for the benefit of steps taken to prevent against unplanned reoperation.

METHODS

Demographical and clinical information of 7732 patients were retrospectively retrieved and reviewed, who were diagnosed with pulmonary tumor and underwent surgical treatments from January 2016 to March 2021. Those patients who underwent unplanned reoperation for the treatment of severe complications were focused carefully and analyzed meticulously.

RESULTS

A total of forty-one patients (41/7732) received 44 unplanned reoperations. Among them, eight and thirty-three patients were diagnosed with benign and malignant tumor, respectively. The incidence of unplanned reoperations seemed to be similar on both sides (Left vs. Right: 12/3231 vs. 29/4501, p = 0.103). Lobectomy plus segmentectomy is prone to reoperation (2/16, 12.5%) as compared to the other types of surgery. The complications leading to reoperation was hemothorax, including active hemorrhage (23/44, 52.3%) and clotted hemothorax (6/44, 13.6%), chylothorax (8/44, 18.2%), and the others (7/44, 15.9%) including bronchopleural fistula, torsion, or injury of right middle bronchus and pulmonary bulla rupture. The morbidity and mortality after unplanned reoperation were 17.1% (7/41) and 12.2% (5/41), respectively.

CONCLUSIONS

Bronchi or vessel stumps, the surgical edges of the lung parenchyma, and pleural adhesions should be checked to avoid postoperative bleeding. Prophylactic ligation of the thoracic duct should be recommended in case of the suspected oily-like exudation in the lymph node bed. Smooth expansion of the middle lobe is important to avoid narrowing and torsion before transection of the bronchus.

Multidisciplinary Management of Chylothorax

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

Chylothorax after pulmonary resection and lymph node dissection for primary lung cancer; retrospective observational study

Background

Pulmonary resection with mediastinal lymph node dissection for treating primary lung cancer could sometimes causes chylothorax as a postoperative complication. This study examined the validity of treatments for chylothorax in our hospital.

Methods

We evaluated 2019 patients who underwent lobectomy, bilobectomy, or pneumonectomy with mediastinal lymph node dissection for primary lung cancer at Shizuoka Cancer Center Hospital, Shizuoka, Japan, between September 2002 and March 2018. The diagnostic criteria for postoperative chylothorax were that the drainage from the pleural drain was evidently white and turbid, or the pleural effusion contained a triglyceride level of > 110 mg/dL. The clinical courses and treatments were retrospectively reviewed.

Results

Postoperative chylothorax occurred in 37 patients (1.8%), 20 men and 17 women, with a median age of 70 years (33–80). A low-fat diet was instituted to all patients; 35 cases improved with conservative treatment, and 2 cases required reoperation. Nine cases had a drainage volume ≥ 500 mL one day following the low-fat diet commencement, which was resolved with conservative treatment and decreased drainage was observed on the third day of treatment in seven of those cases. Two cases with excessive drainage of ≥ 1000 mL in one day and systemic symptoms associated with chyle loss needed surgery.

Conclusions

Even when the daily drainage volume exceeds 500 mL following a low-fat diet, there were many cases that could be cured conservatively. The indication for surgery needs to be carefully considered.

Chylothorax associated with lymphatic reflux in a thoracic duct tributary after lung cancer surgery

Chyle leaks are attributed to damage to the thoracic duct itself or its tributaries during surgery. Chylothorax after lung cancer surgery can occur due to damaged thoracic duct tributaries; however, little is known of the mechanism involved. A 71-year-old female underwent a left upper lobectomy with hilar and mediastinal lymphadenectomy for a 1.8-cm primary squamous cell carcinoma, and developed a chylothorax a day later. Catheter lymphangiography revealed high-flow chyle leaks from a damaged thoracic duct tributary, known as a bronchomediastinal lymph trunk, due to a lymphatic reflex from the thoracic duct. Subsequently, catheter embolization of the tributary repaired the chylothorax. The potential for persistent chylothorax after lung cancer surgery and successful lymphatic intervention should be noted.

Thoracic duct embolization in treating postoperative chylothorax: does bail-out retrograde access improve outcomes?

OBJECTIVES

To evaluate clinical outcomes of thoracic duct embolization (TDE) for the management of postoperative chylothorax with the aid of the bail-out retrograde approach for thoracic duct cannulation (TDC).

MATERIALS AND METHODS

Forty-five patients with postoperative chylothorax underwent Lipiodol lymphangiography (LLG) between February 2016 and November 2019. If targetable central lymphatic vessels were identified in LLG, TDC, a prerequisite for TDE, was attempted. While the conventional antegrade transabdominal approach was the standard TDC method, the retrograde approach was applied as a bail-out method. Embolization, the last step of TDE, was performed after confirming leakages in the trans-TDC catheter lymphangiography. Technical and clinical success rates were determined retrospectively.

RESULTS

TDC was attempted in 40 among 45 patients based on LLG findings. The technical success rate of TDC with the conventional antegrade approach was 78% (31/40). In addition, six more patients were cannulated using the bail-out retrograde approach, which raised the technical success rate to 93% (37/40). While 35 patients underwent embolization (TDE group), ten patients did not (non-TDE group) for the following reasons: (1) lack of targetable lymphatics for TDC in LLG (n = 5), (2) technical failure of TDC (n = 3), and (3) lack of discernible leakages in the transcatheter lymphangiography (n = 2). The clinical success of the TDE group was 89% (31/35), compared with 50% (5/10) of the non-TDE group. One major procedure-related complication was bile peritonitis caused by the needle passage of the distended gallbladder.

CONCLUSIONS

Bail-out retrograde approach for TDC could improve the overall technical success of TDC significantly.

KEY POINTS

• Bail-out retrograde thoracic duct access may improve the overall technical success of thoracic duct access, thus improving the clinical success of thoracic duct embolization.

Treatment of Chylothorax complicating pulmonary resection with hypertonic glucose Pleurodesis

BACKGROUND

To retrospectively assess the efficacy of hypertonic glucose pleurodesis for treatment of chylothorax after pulmonary resection.

METHODS

Out of a total of 8252 patients who underwent pulmonary resection (at least lobectomy) at department of thoracic surgery, between June 2008 and December 2015, 58 patients (0.7%) developed postoperative chylothorax. All patients received conservative treatment, including thoracic closed drainage, oral fasting, and total parenteral nutrition.

RESULTS

Conservative treatment was successful in 50 (86.2%) patients, while eight patients [mean age: 58.0 years (range, 45-75)] were treated with hypertonic glucose pleurodesis. All eight patients had undergone operation for lung cancer (four squamous cell carcinomas and four adenocarcinomas). The bronchial stump was covered by pleural flap in three patients. After pleurodesis, three patients developed fever but without empyema; thoracentesis was performed in two patients. The mean time interval between pleurodesis and operation was 4.3 days (range,3-5) days. The average length of stay was 23.1 days (range, 18-31). No recurrent pleural effusion was observed over a mean follow-up duration of 28 months.

CONCLUSION

Hypertonic glucose pleurodesis performed via the chest drainage tube is a viable treatment option for chylothorax after lung resection, prior to resorting to a thoracoscopic or thoracotomic ductus thoracicus ligation of the thoracic duct leak. It is a simple, safe and efficient modality associated with rapid recovery and less pain.

Evaluation of treatment options for postoperative and spontaneous chylothorax in adults

 

OBJECTIVES

Both postoperative and spontaneous chylothorax remain therapeutic challenges without recommendations for a standardized treatment approach. Regardless of its aetiology, patients with chylothorax experience prolonged hospitalization and suffer from the associated complications or the invasive therapy administered.

METHODS

We conducted a retrospective, observational review of adult patients with chylothorax treated between January 2010 and September 2019. The primary end point was successful management with sustained cessation and/or controlled chylous output. Therapy duration, inpatient stay and the incidence of complications were evaluated as secondary end points.

RESULTS

Of the 36 patients included (22 men; median age 63 years), 24 patients (67%) suffered from a postoperative accumulation of chylous fluid in the pleural space; in the remaining 12 (33%) patients, chylothoraces occurred spontaneously. Initial conservative treatment was successful in 42% (n = 15); in the other 20 cases (56%) additional invasive therapeutic strategies were followed. A complicated course requiring more than 1 treatment was seen in 54% (n = 13) of the postoperative and in 58% (n = 7) of the spontaneous cases. The median length of hospitalization was significantly longer in the postoperative group (37.5 vs 15.5 days; P = 0.016). Serious complications were observed only in the postoperative group (P = 0.28). There were no in-hospital deaths.

CONCLUSIONS

Basic treatment of both postoperative and spontaneous chylothorax should include dietary measures in all patients. Additional sclerosing radiotherapy and interventional or surgical therapy are often necessary. The choice of therapeutic approach should be indicated, depending on the aetiology and development of the chylothorax. Early, multimodal treatment is recommended.

Chylothorax after Lung Cancer Surgery: A Key Factor Influencing Prognosis and Quality of Life

Chylothorax is caused by the accumulation of chylous fluid in the pleural cavity due to the injury of the thoracic duct or its tributaries. Chylothorax following lung cancer surgery, especially pulmonary resection and mediastinal lymph node dissection, is a raw potential postoperative complication as previously reported. Chylothorax might lead to a high mortality rate if not addressed in a timely fashion. This article reviews the anatomy of the thoracic duct, risk factors of postoperative chylothorax, diagnoses and management with chylothorax, and intraoperative prevention of chylothorax. With the development of researches on postoperative chylothorax, more effective treatment and prevention measures need to be proposed to better solve this clinical problem.

[Postoperative complications after major lung resection]

INTRODUCTION

The advent of the minimally invasive techniques has allowed an expansion of the indications for thoracic surgery, particularly in older patients and those with more comorbidities. However, the rate of postoperative complications has remained stable.

STATE OF THE ART

Postoperative complications are defined as any variation from the normal course. They occur in 30% but majority of them are minor. The 30-day mortality rate for lung resection varies range between 2 % and 3% in the literature. Complications can be classified as: (1) early (occurring in the first 24hours) including both "generic" surgical complications (especially postoperative bleeding) and complications more specific to lung surgery (Acute respiratory syndrome, atelectasis); (2) in-hospital complications and those occurring during the first 3 months; these are dominated by infectious events in particular pneumonia but also bronchial (bronchopleural fistula), pleural (pneumothorax, hydrothorax) or cardiac complications; (3) late complications are dominated by chronic pain, affecting 60% of patients having a thoracotomy at three months. Lobectomy is the most common lung resection. Pneumonectomy is a distinct procedure requiring a specific peri- and postoperative management. Right pneumonectomy is associated with a higher risk with a treatment related-mortality ranging between 7 and 10%.

CONCLUSION

Major lung resection has benefited from minimally invasive approaches and fast track to surgery. However, it is important to note the occurrence of new and specific complications related to those news surgical access.

Lymphatic Interventions for Chylothorax: A Systematic Review and Meta-Analysis

PURPOSE

To perform a systematic review and meta-analysis of published studies to evaluate the efficacy of lymphatic interventions for chylothorax.

MATERIALS AND METHODS

The MEDLINE, EMBASE, and Cochrane databases were searched for English-language studies until March 2017 that included patients with chylothorax treated with lymphangiography (LAG), thoracic duct embolization (TDE), or thoracic duct disruption (TDD). Exclusion criteria were as follows: a sample size of less than 10 patients, no extractable data, or data included in subsequent articles or duplicate reports.

RESULTS

The cases of 407 patients from 9 studies were evaluated. The pooled technical success rates of LAG and TDE were 94.2% (95% confidence interval [CI], 88.4%-97.2%; I² = 46.7%) and 63.1% (95% CI, 55.4%-70.2%; I² = 37.3%), respectively. The pooled clinical success rates of LAG, TDE, and TDD, on a per-protocol basis, were 56.6% (95% CI, 45.4%-67.2%; I² = 5.4%), 79.4% (95% CI, 64.8%-89.0%; I² = 68.1%), and 60.8% (95% CI, 49.4%-71.2%; I² = 0%), respectively. The pooled major complication rate of LAG and TDE was 1.9% (95% CI, 0.8%-4.3%; I² = 0%) and 2.4% (95% CI, 0.9%-6.6%; I² = 26.4%), respectively. The pooled overall clinical success rate of lymphatic interventions, on an intention-to-treat basis, was 60.1% (95% CI, 52.1%-67.7%; I² = 54.3%). Etiology of chylothorax was identified as a significant source of heterogeneity for the pooled clinical success rate of TDE and overall clinical success rate.

CONCLUSIONS

Lymphatic interventions have a respectable efficacy for the treatment of chylothorax.

Risk factors and consequences of perioperative reoperation in patients undergoing pulmonary resection surgery

BACKGROUND

Perioperative reoperation is generally agreed to be necessary for the management of particular, severe complications. Understanding the incidence and predictors of perioperative reoperation enables surgeons to improve surgery quality. The objective of this study is to investigate the incidence, risk factors, and consequences of perioperative reoperation after pulmonary resection.

METHODS

Data from patients who underwent perioperative reoperation after pulmonary resection surgery over the past 6 years in our department were reviewed retrospectively. A propensity score-matched analysis was performed to identify the association between reoperation and clinical outcomes. Univariate and multivariate analysis were used to analyze independent risk factors for the occurrence of reoperation.

RESULTS

Overall, 19,304 patients with various lung diseases who underwent pulmonary resection surgeries were analyzed retrospectively, in which 195 patients (1.01%) required reoperation for severe perioperative complications. The leading cause for reoperation was hemorrhage in 143 (73.33%) patients, followed by bronchopleural fistula in 22 patients (11.28%). Further indications for reoperation were chyle leak, bronchial esophageal fistula, empyema, pulmonary congestion, air leak, and femoral artery embolism. The mortality of reoperation was 5.13% (10/195), with the highest (33.33%) among bronchial esophageal fistula and empyema. Patients undergoing reoperation had a higher mortality at hospital discharge, a longer duration of hospital stay, and a lesser incidence of postoperative transfusion (P < .05). Logistic regression indicated that patients with comorbidity, operative approach of open thoracotomy, and location of upper lobe were independent risk factors for the occurrence of early reoperation that performed within 24 hours (P < .05); however, operative approach showed no significance in terms of reoperation that happened beyond 24 hours (P = .087).

CONCLUSION

The incidence of perioperative reoperation after pulmonary resection surgery is low and is mainly related to technical issues from the initial operation. The most common complication is hemorrhage, and the mortality of reoperation in bronchial esophageal fistula and empyema is higher than in others. Patients undergoing reoperation had a higher mortality at hospital discharge, a longer duration of hospital stay, and a lesser incidence of postoperative transfusion. Preoperative comorbidity, operative approach of open thoracotomy, and location of upper lobe were independent risk factors for the occurrence of early perioperative reoperation that was performed within 24 hours; approach of surgery was not significant in terms of reoperation that happened beyond 24 hours.

Chylothorax complicating pulmonary resection for lung cancer: effective management and pleurodesis

BACKGROUND

Chylothorax associated with pulmonary resection for lung cancer, although rare, must be considered as a potential complication during thoracic surgery. In the present study, we investigated the effectiveness of a conservative approach (diet or pleurodesis) to the management of chylothorax.

METHODS

Between January 2000 and December 2010, 3,120 consecutive patients underwent pulmonary resection and mediastinal lymph node dissection at our institution. Among them, 67 patients with confirmed chylothorax were retrospectively reviewed.

RESULTS

Right-sided chylothorax was more common than left-sided chylothorax (p=0.033). All patients were initially treated with nil per os (NPO; n=46) or a low long-chain triglyceride (LCT) diet (n=21). In the NPO group, 24 patients were successfully treated with diet alone and 20 underwent pleurodesis. In the LCT group, 10 patients were successfully treated with diet alone; of the 11 remaining patients, 4 patients improved after NPO. The 7 patients who did not improve with NPO underwent pleurodesis. No significant differences in chest tube output before and after initial treatment, length of stay, or success rate were observed between patients initially treated with NPO and those receiving low LCT. All 32 pleurodeses performed in 27 patients were successful. Two patients underwent surgery without pleurodesis after dietary treatment failure. Postoperative air leakage or drainage for 5 days greater than 21.6 mL/kg were independent risk factors for dietary treatment failure.

CONCLUSIONS

Conservative treatment, including pleurodesis, should be the first choice of treatment for chylothorax complicating pulmonary resection.

[Lymphangioma and lymphangiectasia]

Primary thoracic lymphatic diseases are both infrequent and probably under diagnosed. The two major forms are lymphangiomas and lymphangiectasias. Lymphangiomas are focal proliferation of well-differentiated lymphatic vessels. Childhood lymphangiomas may follow embryologic disorders. Adult lymphangiomas are more likely secondary to lymphatic obstruction. When associated with typical CT and MRI features, their surgical resection is not mandatory, whereas in case of diagnostic difficulties or related complications, surgical resection is the rule. Lymphangiectasias are congenital or acquired pathologic lymphatic dilatation from pleura and interlobular septa without any proliferation. These diseases can be limited to one pulmonary lobe, or can involve the whole lymphatic network. In case of communication between the lymphangiectasias and the thoracic duct, symptoms may include chyloptysis, chylothorax, and chylopericardium. Lymphangio MRI allows visualisation of the lymphangiectasis and thoracic duct. Surgical treatment may be required in case of resistance to medical treatment.

Radiotherapy in the treatment of postoperative chylothorax

Background

Chylothorax is characterized by the presence of chyle in the pleural cavity. The healing rate of non-operative treatment varies enormously; the maximum success rate in series is 70%. We investigate the efficacy and outcomes of radiotherapy for postoperative chylothorax.

Methods

Chylothorax was identified based on the quantity and quality of the drainage fluid. Radiation was indicated if the daily chyle flow exceeded 450 ml after complete cessation of oral intake. Radiotherapy consisted of opposed isocentric portals to the mediastinum using 15 MV photon beams from a linear accelerator, a single dose of 1–1.5 Gy, and a maximum of five fractions per week. The radiation target area was the anatomical region between TH3 and TH10 depending on the localization of the resected lobe. The mean doses of the ionizing energy was 8.5 Gy ± 3.5 Gy.

Results

The median start date of the radiation was the fourth day after chylothorax diagnosis. The patients’ mediastinum was radiated an average of six times. Radiotherapy, in combination with dietary restrictions, was successful in all patients. The median time between the end of the radiation and the removal of the chest tube was one day. One patient underwent wound healing by secondary intention. The median time between the end of radiation and discharge was three days, and the overall hospital stay between the chylothorax diagnosis and discharge was 18 days (range: 11–30 days). After a follow-up of six months, no patient experienced chylothorax recurrence.

Conclusions

Our results suggest that radiotherapy in combination with dietary restriction in the treatment of postoperative chylothorax is very safe, rapid and successful. This novel interventional procedure can obviate repeat major thoracic surgery and shorten hospital stays and could be the first choice in the treatment of postthoracotomy chylothorax.

[Primitive thoracic lymphatic disease in adults]

Primary thoracic lymphatic diseases are both infrequent and probably under diagnosed. Current classification distinguishes lymphangioma (solitary tumor), lymphangiectasies (dilatation), lymphangiomatosis (proliferation) and lymphatic dysplasia syndrome (dysplasia). Classifications' efforts and radiologic progress may lead to an improvement in the management of these patients.

Ultrasonic scalpel for sealing of the thoracic duct: evaluation of effectiveness in an animal model

To verify the usefulness of an ultrasonic scalpel for the sealing of lymphatic ducts, a Harmonic Ace scalpel (Ethicon Endo-Surgery, Inc, Cincinnati, OH) was tested, using the thoracic ducts in pigs. Indocyanine green was injected into the abdominal lymphatic ducts in two pigs, and the stained thoracic ducts were identified. The thoracic ducts were then divided and sealed into seven sections with a Harmonic Ace scalpel, used at a power setting of level 3. The cut ends of the thoracic ducts were evaluated macroscopically, histologically, and by measuring bursting pressure. The whole length of thoracic duct of each pig was clearly imaged by pigment. Each stump divided by the ultrasonic scalpel was completely sealed, and there was no pigment leakage from the cut end macroscopically. Histologic examination revealed that the cut end was sealed by homogenous degenerative coagulation. Bursting pressures could be determined at three cut ends of thoracic ducts and were 195 mmHg, 188 mmHg, and 203 mmHg, respectively. The thoracic ducts were reliably divided and sealed by an ultrasonic scalpel in pigs. This device is expected to be a useful tool for the surgical treatment of chylothorax.

Tension chylothorax: a rare life threatening entity after pneumonectomy

Chylothorax is an accumulation of chyle in the pleural space due to disruption or blockage of the thoracic duct or its lymphatic tributaries. The thoracic duct carries chyle, which is defined as lymphatic fluid of intestinal origin, to the bloodstream. Chylothorax can occur due to traumatic or non-traumatic a etiologies. Chylothorax is a known complication of thoracic surgery and can occur after significant trauma. However, tension chylothorax is an extremely rare and life threatening complication after thoracic surgery. We describe a patient who developed tension chylothorax 2 weeks after a left pneumonectomy was performed. Early recognition and prompt treatment of this life threatening entity are essential.

Treatment of chylothorax by robotic thoracic duct ligation

This is the first report describing the use of robotic technology for the treatment of chylothorax. We present a 22-year-old with mixed embryonal cell and seminoma germ cell cancer refractory to medical and surgical treatment. The patient had rising markers and a growing left lower lung lobe metastasis. After left lower lobectomy, left-sided chylothorax developed. Conservative management failed, and a robotic right-sided thoracic duct ligation was performed. Other treatment options are reviewed.

Tension chylothorax

Thoracic duct injury resulting in chylothorax is a well-known and documented complication of thoracic surgery. However, chylothorax under tension is a rarely reported complication that results in respiratory and hemodynamic collapse. Early recognition and treatment of this entity are essential for optimal patient outcome. Herein we present two cases of postoperative tension chylothorax followed by a review of the diagnostic work-up and therapy for this complication.

Chylothorax

Chylothorax is a rare complication of pulmonary resection. It requires prompt treatment, which is initially conservative. This treatment consists of drainage, nutritional support, and measures to diminish chyle flow. Surgical intervention is indicated when conservative management is ineffective. Delay in surgical intervention leads not only to serious metabolic, nutritional, and immunologic disturbances from the loss of chyle but also increases the risk for adhesion formation, loculation, organization, and infection of the chylothorax, making subsequent surgical attempts difficult and increasing postoperative morbidity and mortality. VATS provides a minimally invasive approach for the treatment of chylothorax complicating pulmonary resection. Clipping of the thoracic duct or chemical pleurodesis may be performed with minimal morbidity and mortality. Conservative treatment is expensive and fails in most patients who have high-output chylous fistulae. On the other hand, VATS is uniformly effective, is less expensive, and has low morbidity. Indeed, VATS is rapidly becoming the preferred approach for the management of chylothorax complicating pulmonary resection. The need to prevent the occurrence of a chylothorax by careful dissection techniques and liberal clipping of lymphatic vessels particularly in areas of high anatomic risk during the initial operation cannot be overemphasized.

Prise en charge des chylothorax post opératoires

INTRODUCTION

A chylothorax can occur following any intrathoracic procedure. It is generally straightforward to make the diagnosis but optimal management can be problematic.

METHODS

Between 1995 and 2002, three women and one man aged from 13 to 58 years were treated for chylothorax after thoracic surgery. Their initial illnesses were a right pulmonary hydatid cyst associated with hepatic disease, a tumour of the posterior mediastinum, an oesophageal carcinoma and metastases in the left lung.

RESULTS

These patients had: a pulmonary and hepatic cystectomies, a resection of the mediastinal tumor, an Akyama oesophagectomy and a resection of four left pulmonary metastases. Chylothorax became apparent post operatively between the 1st and the 4th day. All patients were treated with a medium-chain triglyceride diet. Two patients were re-explored with ligation of lymphatic vessels. One woman who did not have further surgery was treated with etilefrine. In the patient who had had an oesophagectomy, chylothorax persisted after re-operation. He was successfully treated by talc pleurodesis via a chest drain, which prevented further recurrence.

CONCLUSIONS

In the management of postoperative chylothorax, medical treatment must be started early but surgery should not be delayed as operative risk is increased by the development of malnutrition and immune deficiency.

Plasmatic [corrected] factor XIII reduces severe pleural effusion in children after open-heart surgery

Chylous effusions frequently occur after cardiac surgery due to severe damage to the lymphatic system, thus indicating that the insertion of a chest tube may be necessary. Factor XIII (FXIII) is discussed as being essential for wound healing. The aim of this retrospective study was to evaluate whether the application of a single dose of FXIII results in a reduced amount of pleural effusion, leading to an earlier release of patients from the hospital. The cases of 40 children with severe chylous effusions after open-heart surgery were examined. Twenty patients received FXIII and were compared to 20 age- and weight-matched patients who did not receive FXIII. Major parameters included the amount of effusion before and 1 and 3 days after the application of FXIII; the duration of chest tubes; the total amount of fluid loss via drainage; and the period of hospitalization. FXIII levels in plasma showed an inverse correlation with fluid loss. After application of a single dose of FXIII, a significant reduction of pleural effusion within the first 24 hours was detected. However, no difference was observed between the two groups when comparing the total amount of pleural effusions within the first 72 hours. Finally, the duration of hospitalization did not differ between the FXIII-treated and the control group. A single application of FXIII rapidly reduces the amount of chylous effusions in the early period after open-heart surgery. This effect is detectable only for 24 hours after the treatment and does not alter the further clinical outcome. Prospective clinical trials are warranted to determine if repeated application or a higher dose of FXIII may improve the clinical outcome of chylous leakages in children after open-heart surgery.

Localization of chyle leakage site in postoperative chylothorax by oral administration of I-123 BMIPP

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.

Late-onset chylothorax after pulmonary resection and systematic mediastinal lymph node dissection for lung cancer

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.

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.

[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.