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PubMed1977

Effects of anti-microtubular agents and cycloheximide on the metabolism of chylomicron cholesteryl esters by hepatocyte suspensions.

1. Post-heparin plasma that promoted rapid hydrolysis of about 90% of the triacylglycerol markedly stimulated the uptake or binding of chylomicron cholesteryl ester by suspended hepatocytes. The net hydrolysis of chyle cholesteryl ester after the uptake by the cells was, however, slower than in vivo. 2. The cholesteryl ester uptake in the presence of post-heparin plasma was larger if the cells had been preincubated for 2h. It was inhibited by the presence of colchicine, vinblastine or cycloheximide during the preincubation, and by mild trypsin treatment of the preincubated cells. 3. The results suggested that the anti-microtubular agents, but not cycloheximide, also inhibited the hydrolysis of chyle cholesteryl ester after uptake or binding to the cells. 4. The uptake of isolated chylomicron remnant particles was more efficient than that of native chyle lipoproteins. It was, however, still stimulated by heparin alone and by post-heparin plasma. The heparin-stimulated uptake was markedly decreased if cycloheximide was present during the preincubation period.

Animals↗
PubMed2001

Chylothorax.

Chylothorax or chylous pleural effusion occurs when chyle accumulates in the pleural space usually secondary to disruption of thoracic lymphatics. Chyle is a milky, white, opalescent fluid that is formed when long-chain triglycerides in the diet are transformed into chylomicrons and very-low-density lipoproteins, which are then secreted into intestinal lacteals. These lymphatic channels coalesce to form the thoracic duct, which transports chyle and ultimately drains it into the left subclavian vein. Any injury to the duct (or its major tributaries) as it courses through the thoracic cavity can lead to a chylous effusion. Diagnosis depends on direct analysis of the fluid by assaying the triglyceride content and, at times, lipid electrophoretic pattern (chylomicrons). Management depends on the underlying cause and the individual clinical circumstances. Nonoperative options include observation, treatment of the underlying disease, dietary modification employing strict medium-chain triglyceride diet or total parenteral nutrition, therapeutic thoracentesis, tube thoracostomy with chemical pleurodesis, and embolization of the thoracic duct. Surgical management may include pleurectomy, talc poudrage, pleuroperitoneal shunting, and repair or ligation of the thoracic duct via thoracoscopy or thoracotomy.

Journal Article↗
PubMed1983

Treatment of postsurgical chylothorax with fibrin glue.

The treatment of postsurgical chylothorax with fibrin glue is reported. Chylothorax developed in a 3 1/2-month-old infant 2 days after extrapleural ligation of a patent ductus arteriosus. At rethoracotomy the chyle leak could not be located. To stop chyle effusion, the region of the presumed leakage was sealed with fibrin glue and a pleural flap. It is suggested that early reoperation and closure of the chyle leak with fibrin adhesive should be considered in cases of postsurgical chylothorax in infants.

Chylothorax↗
PubMed2001

Treatment of symptomatic primary chylous disorders.

PURPOSE: Primary chylous disorders (PCDs) are rare. Rupture of dilated lymph vessels (lymphangiectasia) may result in chylous ascites, chylothorax, or leakage of chyle through chylocutanous fistulas in the lower limbs or genitalia. Chyle may reflux through incompetent lymphatics, causing lymphedema. To assess the efficacy of surgical treatment, we reviewed our experience. METHODS: The clinical data of 35 patients with PCDs treated between January 1, 1976, and August 31, 2000, were reviewed retrospectively. RESULTS: Fifteen men and 20 women (mean age, 29 years; range, 1 day-81 years) presented with PCDs. Sixteen (46%) patients had chylous ascites, and 19 (54%) had chylothorax (20 patients), and of these, 10 (29%) had both. In 16 patients, reflux of chyle into the pelvic or lower limb lymphatics caused lymphedema (14, 88%) or lymphatic leak through cutaneous fistulae (11, 69%). Presenting symptoms included lower-limb edema (19, 54%), dyspnea (17, 49%), scrotal or labial edema (15, 43%), or abdominal distention (13, 37%). Primary lymphangiectasia presented alone in 23 patients (66%), and it was associated with clinical syndromes or additional pathologic findings in 12 (yellow nail syndrome in 4, lymphangiomyomatosis in 3, unknown in 3, Prasad syndrome (hypogammaglobulinemia, lymphadenopathy, and pulmonary insufficiency) in 1, and thoracic duct cyst in 1). Twenty-one (60%) patients underwent 26 surgical procedures. Preoperative imaging included computed tomography scan in 15 patients, magnetic resonance imaging in 3, lymphoscintigraphy in 12, and lymphangiography in 14. Fifteen patients underwent 18 procedures for chylous ascites or pelvic reflux. Ten (56%) procedures were resection of retroperitoneal/mesenteric lymphatics with or without sclerotherapy of lymphatics, 4 (22%) were lymphovenous anastomoses or grafts, 3 (17%) were peritoneovenous shunts, and 1 (6%) patient had a hysterectomy. Six patients underwent eight procedures for chylothorax, including thoracotomy with decortication and pleurodesis (4 procedures), thoracoscopic decortication (1 patient), ligation of thoracic duct (2 procedures), and resection of thoracic duct cyst (1 patient). Postoperative mean follow-up was 54 months (range, 0.3-276). Early complications included wound infections in 3 patients, elevated liver enzymes in 1, and peritoneovenous shunt occlusion with innominate vein occlusion in 1. All patients improved initially, but four (19%) had recurrence of symptoms at a mean of 25 months (range, 1-43). Three patients had postoperative lymphoscintigraphy confirming improved lymphatic transport and diminished reflux. One patient died 12 years postoperatively, from causes unrelated to PCD. CONCLUSIONS: More than half of the patients with PCDs require surgical treatment, and surgery should be considered in patients with significant symptoms of PCD. Lymphangiography is recommended to determine anatomy and the site of the lymphatic leak, especially if lymphovenous grafting is planned. All patients had initial benefit postoperatively and two thirds of patients demonstrated durable clinical improvement after surgical treatment.

Adult↗
PubMed1998

Management of chylous ascites following laparoscopic presacral neurectomy.

Chylous ascites is an extremely rare complication of laparoscopic presacral neurectomy (LPSN), and treatment is still controversial. Four patients undergoing LPSN for dysmenorrhoea or chronic pelvic pain were complicated with chylous ascites. Two were successfully treated with bipolar cauterization and one, after the failure of initial treatment by bipolar cauterization, was then effectively managed by compression with Gelform and closure of the peritoneum of the presacral area by suture through laparoscopy. The fourth patient had persistent chyle leakage from the drainage tube after electrocauterization and was finally cured by conservative management including removal of the drainage tube and a low-fat diet for 3 weeks. Chylous ascites has not been reported in laparoscopic presacral neurectomy. Management that is quick, effective and subjects the patients to the least amount of suffering is still unresolved. Repeated laparoscopy can be considered to identify the possibility of injury to lymphatic vessels, to relieve abdominal distention due to chyle accumulation, and to apply electrocauterization or compression with Gelform and closure of the peritoneum. Conservative treatment with a low-fat diet may need a longer time. The use of a drainage tube may provide negative pressure allowing a continuous leakage of chyle. However, more controlled study is required to identify the most proper and effective management.

Adult↗
PubMed2003

Octreotide as a therapeutic option for management of chylothorax.

OBJECTIVE: To report a case of post-cardiac surgery-induced chylothorax treated with octreotide and review the literature on octreotide efficacy. CASE SUMMARY: A 5-month-old boy with Down syndrome was admitted for atrioventricular canal repair. On admission, he was taking captopril and furosemide. On postoperative day 4, he exhibited signs of chest wheezing and crackles, but was without cough or fever. Chest X-ray revealed a moderate right-sided pleural effusion. Accordingly, a pleural catheter was inserted and drained an average of 7.14 mL/h of chylous fluid that day. Laboratory analysis of the pleural fluid revealed a triglyceride level of 89 mg/dL, without bacterial growth. Based on those findings, the diagnosis was chylothorax. Because of the continuous extensive tube drainage, octreotide 3.5 micro g/kg/h was begun. The average daily chyle drainage was reduced from 7.14 one day before octreotide initiation to 0.83 mL/h on day 4 of octreotide therapy. After 4 days of therapy (postoperative day 8), octreotide was discontinued because of the satisfactory response and the pleural catheter was removed. DISCUSSION: In our case and the other few cases reported, octreotide showed acceptable efficacy in the management of chylothorax. The mechanism by which octreotide decreases chyle production includes reducing the intestinal absorption of fats, mainly triglycerides, and increasing fecal fat excretion. CONCLUSIONS: Octreotide may have reduced chyle production in our patient. Further reports and studies assessing octreotide efficacy in the management of chylothorax are warranted.

Cardiac Surgical Procedures↗
PubMed1999

Chylothorax in children: guidelines for diagnosis and management.

STUDY OBJECTIVE: To establish guidelines for the diagnosis and management of chylothorax in children. DESIGN: Retrospective study. PATIENTS: Fifty-one patients with a diagnosis of chylothorax. Twelve patients were excluded because of incomplete data or incorrect diagnosis. The following parameters were analyzed: triglyceride level, total cell number, and lymphocyte percentage; amount of pleural effusion on day of diagnosis, day 5, and day 14; and total time of pleural effusion. Prospectively, the same parameters were analyzed in a control group of 10 patients with pleural drainage. INTERVENTION: Patients with chylothorax were treated primarily with fat-free oral nutrition; if chyle did not stop, total parenteral nutrition with total enteric rest was started. If conservative therapy was not successful, pleurodesis was performed. RESULTS: In children with chylothorax triglyceride, triglyceride content ranged from 0.56 to 26.6 mmol/L; all values except one were > 1.1 mmol/L. In 36 of 39 patients (92%), the cell count was > 1,000 cells/microL. In 33 of 39 patients (85%), lymphocytes were > 90%. In patients without chylothorax triglyceride, triglyceride levels ranged from 0.1 to 0.71 mmol/L (median, 0.38 mmol/L) and cell count was from 20 to 1400 cells/microL (median, 322 cells/microL), with a maximum of 60% lymphocytes. With fat-free nutrition, chyle disappeared in 29 of 39 patients. Five patients died, and five required pleurodesis. CONCLUSIONS: Pleural effusion in children is chyle when it contains > 1.1 mmol/L triglycerides (with oral fat intake) and has a total cell count > or 1,000 cells/microL, with a lymphocyte fraction > 80%. Chylous effusions usually last long; however, after 6 weeks, the majority of the effusions (29 of 39 patients) had ceased. Late surgical interventions reduce the number of thoracotomies substantially, but can lead to very long hospitalization times. Early surgical interventions (after < 3 weeks) lead to a high number of thoracotomies, but certainly reduce hospitalization time.

Cell Count↗
PubMedDate not supplied

Thoracoscopic ligation of the thoracic duct.

OBJECTIVE: When nonoperative treatment of chylothorax fails, thoracic duct ligation is usually performed through a thoracotomy. We describe two cases of persistent chylothorax, in a child and an adult, successfully treated with thoracoscopic ligation of the thoracic duct. METHODS: A 4-year-old girl developed a right chylothorax following a Fontan procedure. Aggressive nonoperative management failed to eliminate the persistent chyle loss. A 72-year-old insulin-dependent diabetic man was involved in a motor vehicle accident, in which he sustained multiple fractured ribs, a right hemopneumothorax, a right femoral shaft fracture, and a T-11 thoracic vertebral fracture. Subsequently, he developed a right chylothorax, which did not respond to nonoperative management. Both patients were successfully treated with thoracoscopic ligation of the thoracic duct. RESULTS: The child had significant decrease of chyle drainage following surgery. Increased drainage that appeared after the introduction of full feedings five days postoperatively was controlled with the somatostatin analog octreotide. The chest tube was removed two weeks after surgery. After two years' follow-up, she has had no recurrence of chylothorax. The adult had no chyle drainage following surgery. He was maintained on a medium-chain triglyceride diet postoperatively for two weeks. The chest tube was removed four days after surgery. After six months' follow-up, he has had no recurrence of chylothorax. CONCLUSIONS: Thoracoscopic ligation of the thoracic duct provides a safe and effective treatment of chylothorax and may avoid thoracotomy and its associated morbidity.

Aged↗
PubMed2000

[Thoracoscopic clipping of thoracic duct in a woman with persisting chylothorax].

A 78-year-old female had chest pain, radiating to the back, caused by a thoracic aneurysm of the aorta. A vascular prosthesis was sutured into place through a left-sided thoracotomy. Six days after the operation she developed chylothorax on the right side. Following 14 days of conservative management, chyle leakage persisted at a rate of 1500 ml per 24 hours. By thoracoscopy the thoracic duct was dissected and clipped, which stopped the chyle leakage. The patient recovered moderately well. Conservative measures, such as adjusted nutrition, are successful in 50% of patients. Clipping of the thoracic duct by thoracoscopy is a definitive and minimally invasive procedure to treat persistent chyle leakage.

Aged↗
PubMed1989

Intraoperative determination of thoracic duct injury with 131I-fat. An experimental study on dogs.

The creation of an experimental animal model of traumatic chylothorax was verified by 131I labelled fat (peanut oil). 15 dogs of 3 groups were administered 131I labelled oil via a gastric tube. The results were compared between the two experimental groups and a control group with nonchylous pleural effusion. Dynamic radioactive studies on the blood and pleural fluid showed that the absorption curve of the dog's blood and chyle to 131I labelled oil was identical regardless of different attitudes, and was also similar to that of the human blood because the peak appeared 4 hours after the administration of 131I labelled oil, at which the radioactivity of chyle reached its maximum, more powerful than that of the blood collected at the same time (P less than 0.01). The 99% confidence limitation of radioactivity of the pleural fluid, and the radioactivity ratio of the pleural fluid to blood in the experimental groups were 1.8-10.5 and 493-2340 cpm respectively. The specific characteristics of chyle was then determined qualitatively according to the quantitative norms. We conclude that the technique is parallel with the normal physiological pattern and seems to be more simple and reliable than the conventional methods for detection of intraoperative injury of the thoracic duct and early diagnosis of postoperative chylothorax.

Animals↗
PubMed1995

[Early reoperation in chylothorax after thoracic surgery].

Chylothorax is a rare complication of thoracic surgery. The chyle leak can induce serious metabolic and immunological disorders. The ideal treatment of chylothorax has not been clearly established, and opinions are still divided between medical treatment and early or late surgical reoperation after prolonged medical treatment. Out of a total of 1.750 thoracic operations performed at the Centre Chirurgical du Val d'Or over the last 10 years, six cases of chylothorax were reoperated early, an average of five days after the initial operation. The chyle leak was easy to localize in every case. The second operation was performed via the same initial incision. All six patients has an uneventful postoperative course and only one case had a persistent chyle leak which gradually resolved. The mean total hospital stay was 18 days. No systemic infections or deaths were recorded. Early reoperation avoids the complications of prolonged medical treatment, is technically easy and decreases the length of hospital stay.

Adult↗
PubMed1997

Chylothorax.

BACKGROUND: Chylothorax is a condition that is debilitating to the point of threatening life. There is controversy over its management, in particular the relative merits of conservative measures and the timing of surgical intervention. METHOD: The literature is reviewed from the basic sciences of chyle composition and flow, to diagnostic approaches, the complications of chyle loss and appropriate management strategies. RESULTS AND CONCLUSION: Prompt diagnosis is essential to institute an effective therapeutic regimen. Surgery achieves fast, safe and effective reversal of this dire situation. Minimally invasive thoracoscopic techniques are gaining wide recognition. Early intervention, which should be aggressive and complete to avoid the immune and nutritional consequences of extended chyle depletion, is recommended.

Chylothorax↗
PubMed1997

[Direct approach to the site of injury of the thoracic duct in treatment of chylothorax after pulmonary resection].

Chylothorax, a rare complication after pulmonary resection, has no single established treatment. Generally, conservative therapy is tried first, but surgery should be done without delay if chyle leakage is severe. A 73-year-old woman underwent upper left lobectomy for lung cancer. Two days later, chylothorax was diagnosed, and because chyle leakage was great, emergency re-thoracotomy was done on day 4 after the first operation. With the preoperative ingestion of 200 ml of milk and 20 g of margarine, chyle leakage from the injured thoracic duct was readily located in the upper mediastinum. Closure of the trunk of the thoracic duct may be undertaken, but a direct approach to the site of injury is more preferable, because the trunk may have collateral.

Aged↗
PubMed1986

Xerostomia. A treatment feasibility study in dogs.

An acute study was performed in dogs to test the feasibility of using another bodily fluid in place of saliva in patients with xerostomia. Chyle was routed from the thoracic duct to the oral cavity via a vein graft using the external jugular vein. While technically challenging, the vein conduit worked well in delivering chyle to the oral cavity.

Animals↗
PubMed1980

"How I do it"--head and neck. A targeted problem and its solution. Chylous fistula prevention and management.

Prevention of chylous fistulae involves a careful search at the time of surgery for any possible chyle leaks. These should be ligated and the surgeon should be aware of the possible anatomical variations of both the thoracic duct and right lymphatic duct when he is searching for the leak. Treatment of the postoperative chyle fistula consists of elimination of long chain triglycerides from the diet and use of a medium chain triglyceride diet (Portagen), or oral feedings may be discontinued and intravenous fluids used exclusively. The supraclavicular area is treated with aspiration and pressure dressing. If the above measures are unsuccessful then surgical re-exploration is necessary.

Chyle↗
PubMed1979

A chylous mesenteric cyst and a study of its contents.

A case of a patient with a large chylous cyst in the mesentery of the small intestine is presented. After excision of the cyst, the chyle was analyzed with special reference to its protein and lipid content. The composition of the chyle compared with that of intestinal lymph of experimental animals suggests that the fluid in the cyst has undergone concentration in terms of protein.

Adult↗
PubMed1981

Digestion and absorption of a sulphoxide analogue of triacylglycerol in the rat.

The stereochemistry of fat digestion and absorption was studied by feeding a triacylglycerol analogue to rats with a thoracic duct cannula. The analogue, rac-1,2-dioleoyl-3-S-tetradecyl-3-thioglycerol-S-oxide was chosen since its enantiomers exhibited high rotation in optical rotary dispersion (ORD) and circular dichroism (CD). In the chyle, triacylglycerol was the major lipid but X-1,2-diacyl-3-S-tetradecyl-3-thioglycerol-S-oxide constituted 8% of lipid weight. It was resolved by thin-layer chromatography (TLC) into two diastereomers. Each of the diastereomers were analyzed for the proportions of 1-thio-sn-glycerol/3-thio-sn-glycerol isomers by ORD and CD. The 1-thio-sn-glycerol isomers dominated for both compounds indicating that they were enriched during the absorption processes, since a racemic compound was fed. The stereospecificities are probably exerted by acyltransferase(s) during chyle lipid synthesis. The methods used will be valuable tools in studies on the metabolism of enantiomeric glycerides and also for characterization of naturally occurring sulphur-containing lipids.

Animals↗
PubMed1990

Pressure within the thoracic duct modulates lymph composition.

The amount of lymph received by the thoracic duct depends on each contributing organ's ability to produce interstitial fluid and generate a pressure differential moving lymph into the central lymphatic circulation. It has been reported that varying the pressure within the thoracic duct could alter each organ's contribution to thoracic duct flow. The thoracic duct above the diaphragm was cannulated to obtain lymph from the liver, gut, and lower body. Pressure within the thoracic duct was elevated serially by increasing the lymphatic cannula outflow height. This caused lymph protein concentration to increase while chyle concentration (measured by absorbance) decreased. The data demonstrate that as thoracic duct pressure increases, the percentage contribution of gut lymph flow (as represented by chyle concentration) decreases while the contribution of lymph originating within the liver (as indicated by higher protein concentration) increases. We conclude that pressure variation within the central lymphatic system affects the amount of lymph or edema fluid leaving any given organ.

Animals↗