[Surgery for chylothorax]

Thoracic Duct Injury Following Cervical Spine Surgery: A Multicenter Retrospective Review

STUDY DESIGN

Multicenter retrospective case series.

OBJECTIVE

To determine the rate of thoracic duct injury during cervical spine operations.

METHODS

A retrospective case series study was conducted among 21 high-volume surgical centers to identify instances of thoracic duct injury during anterior cervical spine surgery. Staff at each center abstracted data for each identified case into case report forms. All case report forms were collected by the AOSpine North America Clinical Research Network Methodological Core for data processing, cleaning, and analysis.

RESULTS

Of a total of 9591 patients reviewed that underwent cervical spine surgery, 2 (0.02%) incurred iatrogenic injury to the thoracic duct. Both patients underwent a left-sided anterior cervical discectomy and fusion. The interruption of the thoracic duct was addressed intraoperatively in one patient with no residual postoperative effects. The second individual developed a chylous fluid collection approximately 2 months after the operation that required drainage via needle aspiration.

CONCLUSIONS

Damage to the thoracic duct during cervical spine surgery is a relatively rare occurrence. Rapid identification of the disruption of this lymphatic vessel is critical to minimize deleterious effects of this complication.

Treatment of persistent congenital chylothorax with intrapleural injection of sapylin in infants

Test the therapeutic efficacy of Sapylin in resolving persistent Congenital Chylothorax (CC) in four infants who failed to respond to conservative medical therapy including Erythromycin and/or Octreotide management. All cases were cured and have no adverse reactions during follow-up. The result shows Sapylin is effective in reducing chylous production.

An idiopathic congenital chylothorax: surgery or conservative management?

A 3-month-old infant was admitted to the respiratory unit for dyspnoea and vomiting after her second DTaP-Polio vaccine shot. The chest X-rays showed a white right lung with a left mediastinal shift. A pleural aspiration assessed the diagnosis of chylothorax. A conservative treatment was initiated with a fat-free diet and pleural aspirations. As this treatment was ineffective, a total parenteral nutrition was started at day 11, plus increasing doses of Octreotide. As the chylothorax persisted at day 50, a pleuroperitoneal shunting was performed but a pleurodesis was finally necessary. The child was discharged from the hospital 6 weeks after the surgery. Ten months later, her physical and biological conditions were normal and her chest X-rays dramatically improved. This case highlights the difficult management of infant chylothorax. Although conservative treatment has to be tried first, surgical procedures as pleuroperitoneal shunting and rarely pleurodesis have to be discussed.

[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.

Idiopathic chylothorax in a young man

Chylothorax refers to the presence of chyle in the pleural space owing to disruption or obstruction of the thoracic duct or one of its tributaries. We present a case of non-traumatic, idiopathic chylothorax in an 18-year-old man. Lymphoscintigraphy was used to identify the site of leak. We tried the full armamentarium of available non-surgical therapy on him, including a modified diet, chest tube insertion, total parenteral nutrition and octreotide. Yet, despite optimal medical therapy, his effusion continued to persist. He eventually required thoracic duct ligation, which resulted in resolution of the effusion.

[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.

Congenital pulmonary lymphangiectasia

Congenital pulmonary lymphangiectasia (PL) is a rare developmental disorder involving the lung, and characterized by pulmonary subpleural, interlobar, perivascular and peribronchial lymphatic dilatation. The prevalence is unknown. PL presents at birth with severe respiratory distress, tachypnea and cyanosis, with a very high mortality rate at or within a few hours of birth. Most reported cases are sporadic and the etiology is not completely understood. It has been suggested that PL lymphatic channels of the fetal lung do not undergo the normal regression process at 20 weeks of gestation. Secondary PL may be caused by a cardiac lesion. The diagnostic approach includes complete family and obstetric history, conventional radiologic studies, ultrasound and magnetic resonance studies, lymphoscintigraphy, lung functionality tests, lung biopsy, bronchoscopy, and pleural effusion examination. During the prenatal period, all causes leading to hydrops fetalis should be considered in the diagnosis of PL. Fetal ultrasound evaluation plays a key role in the antenatal diagnosis of PL. At birth, mechanical ventilation and pleural drainage are nearly always necessary to obtain a favorable outcome of respiratory distress. Home supplemental oxygen therapy and symptomatic treatment of recurrent cough and wheeze are often necessary during childhood, sometimes associated with prolonged pleural drainage. Recent advances in intensive neonatal care have changed the previously nearly fatal outcome of PL at birth. Patients affected by PL who survive infancy, present medical problems which are characteristic of chronic lung disease.