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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.
In conclusion, chylothorax after esophagectomy is a devastating complication with high mortality rates if not corrected. A heightened awareness of this complication with early diagnosis and aggressive reoperation leads to excellent outcome. Reoperation is not indicated only when medical therapy significantly slows the daily loss of chyle and there are no metabolic consequences. The early decision to reoperate avoids the high morbidity of a persistently unchecked chylothorax. Reoperation should be based on the approach initially used for the esophagectomy, the location of the leak, and the side that has the chylothorax. The conduit should be handled carefully at the time of reoperation, the leak identified, the duct or the leaking nodal basin clipped and glued, and a pleurodesis performed. Following these principles minimizes the morbidity of a serious postoperative complication.
Chylothorax is a rare but serious postoperative complication of thoracic surgical procedures. We report the case of a 77-year-old man who underwent a coronary artery bypass procedure using a left internal mammary artery pedicle graft. A permanent pacemaker was required postoperatively. A persistent postoperative chylothorax developed necessitating continuous drainage and conservative management. Somatostatin was instituted when after 1 week this management failed to resolve the chylothorax. This led to rapid cessation of chyle production. Enteral feeding was reinstituted without complication and surgical intervention was avoided.
BACKGROUND: Chylothorax is a challenging clinical problem. Untreated, it carries a high mortality and morbidity. Traditional surgical management for cases refractory to conservative treatment is thoracic duct ligation through a right open thoracotomy. METHODS: We describe 4 patients treated successfully by video-assisted thoracic surgery, using ports and no thoracotomy, and precise ligation and division of the thoracic duct just above the diaphragm. A pericardial window was made in the patient with chylopericardium, as in the patient with end-stage renal disease. Pleurodesis was used in the patient with esophageal carcinoma and the patient with jugular and subclavian vein thrombosis. RESULTS: There were 2 women aged 18 and 42 years and 2 men, aged 61 and 65 years. No procedure-related mortality or morbidity occurred. In patients 1, 2, 3, and 4, the postoperative duration of drainage was 5, 7, 7, and 5 days, respectively (mean duration, 6 days) and the hospital stay, 5, 9, 10, and 5 days, respectively (mean stay, 7 days). There was no recurrence of chylothorax or chylopericardium during follow-up (range, 2 to 24 months; mean follow-up, 9 months). One patient died of esophageal carcinoma 4 months after operation. CONCLUSIONS: Video-assisted thoracic surgery without a thoracotomy is an effective way of treating chylothorax and carries minimal morbidity.
We report a 15-year-old boy with bilateral chylothorax complicating Gorham's syndrome. Thoracic duct ligation failed to prevent fluid reaccumulation. The patient died of lymphocytopenia. Autopsy revealed vascular proliferation in the parietal and visceral pleura as well as in the ribs, which seemed to cause persistent chylothorax responsible for the poor prognosis of this patient. We reviewed treatments provided to 22 patients reported in the literature with Gorham's syndrome and chylothorax.
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.
Chylothorax is a rare complication following cavo-pulmonary connection and can lead to significant morbidity in infants and young children. We report here the case of a 3-month-old infant who underwent bilateral cavo-pulmonary connections, and developed severe chylothorax refractory to the usual conservative and surgical treatments. His chylothorax resolved after using a combination of parenteral octreotide (Sandostatin, Novartis Pharmaceuticals, East Hanover, NJ) and low-fat breast milk.
Thirteen patients required pleural drainage for postoperative chylothorax with an average duration of leakage of 36.9 days. Total protein and albumin levels, body weight, and peripheral lymphocyte counts all decreased substantially during the period of chylous leakage. Only 3 chylothoraces resolved with tube drainage and dietary management alone. Six patients required eight operations for control of chylothorax, and 4 patients, all of whom had cancer, died with a persistent leak. chylothorax is a debilitating postoperative complication resulting in an impaired immune system and nutritional state. Because it is associated with a 50% mortality in patients with cancer, early reoperation should be considered. Patients with benign underlying disease can be managed conservatively for longer periods. Control of potential chylous leaks at the time of original operation is vital, especially in patients with malignancies who have a predisposition toward leakage from sites other than the main thoracic duct.
BACKGROUND: Traditional therapy for refractory chylothorax in the pediatric population has included pleurodesis and thoracic duct ligation. These procedures are associated with high morbidity and questionable success rates. METHODS: We retrospectively reviewed our experience with 15 patients who underwent treatment for chylous effusions using pleuroperitoneal shunts with exteriorized pump chambers. Mean patient age at time of shunt placement was 2.1 (0.1 to 11.5) years and the most common indication (7 of 15) was refractory chylothorax following surgical correction of congenital heart disease. Mean chylothorax duration before shunt placement was 76 (5 to 810) days and shunts were in place for an average of 104 (12 to 365) days. A total of 19 chylous effusions (pleural or pericardial) were treated with shunts. RESULTS: Nine of 11 right-sided chylothoraces, 5 of 6 left-sided chylothoraces, and 2 of 2 chylopericardia resolved with shunt therapy (84% total). Pleuroperitoneal shunting failed to clear the effusion in 3 children. There were six episodes of shunt malfunction that were repaired and two episodes of infection. Inguinal or umbilical hernia developed in 4 patients. CONCLUSIONS: Externalized pleuroperitoneal shunting is a safe, effective, and minimally invasive treatment for children with refractory chylous effusions.
We here report the clinical findings and management of 9 consecutive cases of chylothorax, 5 of which occurred spontaneously. One cases followed cardiac surgery. Three cases occurred in low-birth-weight, premature infants concurrently with other symptoms of the superior vena cava syndrome secondary to central intravenous nutrition. To our knowledge, this is the first description of chylothorax as a possible complication of total parenteral nutrition in newborn babies. In our treatment of chylothorax in the newborn, we employed diagnostic thoracentesis followed by chest tube drainage and a medium chain triglyceride diet.
Chylothorax is an uncommon condition that may be associated with significant morbidity and mortality. The authors report a case of traumatic chylothorax attributed to child abuse and describe our management with tube thoracostomy and nutritional support with medium-chain triglycerides. Child abuse should be suspected in any case of chylothorax when no other etiology is evident and particularly when other signs of abuse are present.
We report a case of chylo-retroperitoneum and chylothorax following an uneventful left radical nephrectomy for renal cell carcinoma, and propose the mechanism of an infradiaphragmatic lymphatic injury with fistulous connection into the chest. Treatment with oral medium chain triglycerides was unsuccessful. Subsequently, total parenteral nutrition in conjunction with chest drainage, retroperitoneal drainage and sclerotherapy successfully treated the chylothorax. To our knowledge chylothorax following radical nephrectomy has not been reported previously in the literature.
BACKGROUND: Fetal chylothorax is associated with elevated perinatal mortality. Development of mediastinal shift with significant lung compression before 35 weeks' gestation needs treatment. CASE: A 24-year-old gravida 2, para 0 presented at 26 weeks' gestation with a fetal pleural effusion with a mediastinal shift and abnormal Doppler velocimetry indices in several vessels. Thoracentesis was successful but 3 days later, the fetal effusion had reaccumulated. Because of fetal position, a pleuro-amniotic shunt was difficult technically, so maternal medical treatment was initiated with a low-fat, high medium-chain triglyceride diet. After initial mild decrease, the estimated volume of the fetal chylothorax remained stable until 36 weeks' gestation, at which time we delivered by cesarean an infant with good Apgar scores. After aspiration of the remaining thoracic fluid and administration of a similar diet, the infant did well, with normal growth and development. CONCLUSION: Maternal dietary treatment might help delay the need for thoracentesis in cases of fetal chylothorax.
Chylothorax is defined as an accumulation of chyle in the pleural space caused by disruption of the thoracic duct or one of its major divisions. Chyle has a high content of triglycerides. The odorless fluid is turbid and milky due to the presence of fat containing particles, the chylomicrons. The etiology of chylothorax can be divided into four major categories: tumor, trauma, idiopathic and miscellaneous. Although chylothorax is uncommon, it is a serious and potentially hazardous disorder. Loss of chyle leads to metabolic disturbances, malnutrition and immunodeficiency. Treatment consists of treatment of the underlying disease, conservative treatment (medium chain triglyceride diet, parenteral nutrition) or surgical intervention. Appropriate timing of surgical intervention is essential. Since the ligation of the thoracic duct can be performed during thoracoscopy, this minimal interventional technique is the procedure of choice when conservative treatment fails.
Chylothorax is a rare entity with both traumatic and non-traumatic etiologies. Chyle depletion has significant nutritional, metabolic and immunologic consequences. We present a case of a patient with chylothorax who presented to the Emergency Department on numerous occasions with complications related to his chylothorax.
Chylothorax and chylous ascites are an accumulation of fluid containing a large proportion of triglycerides. The presence of these two effusions simultaneously is rare. A case of a patient with a known history of cirrhosis, hospitalized for an ascetic decompensation with left pleural effusion is herein presented. The woman was diagnosed as presenting both chylous ascites and chylothorax. Both fluids are transudate type fluids. After evacuation of the fluids and implementation of an adapted treatment neither effusion reappeared. The patient has been followed for the past year and has not shown any signs of relapse. Chylothorax, in cirrhotic patients is due to trans-diaphragmatic passage of fluid originating from the chylous ascites. Both extravasations have the same biological characteristics.
Chylothorax is defined as the presence of lymph in the pleural space. Congenital chylothorax is one of the most frequent causes of fetal pleural effusion. It may be primary or secondary. Careful assessment of the etiology and of possible associated anomalies is required. Main complications are pulmonary hypoplasia, hydrops fetalis and the risk of premature delivery. Management is still a mater of controversy, the diagnosis of fetal pulmonary hypoplasia being difficult in utero. Factors such as gestational age, evolution of pleural effusion on two weeks, signs of seriousness (hydrops fetalis), and pulmonary expansion after pleural puncture may help the physician to choose between abstention, pleural tapping or long-term in utero drainage. Post natal treatment consists of pleural drainage and assisted ventilation in cases of respiratory distress, correction of metabolic and immune disorders and exclusive parenteral nutrition. Once chylothorax is resolved, formula feeding without long-chain triglycerides is allowed. If pleural effusion persists despite a well conducted treatment, albumin infusion and diuretics may be used before considering surgical treatment.
Chylothorax is a potentially serious complication of lung and heart-lung transplantation. This article describes the clinical course of chylothorax in 3 heart-lung allograft recipients. We discuss management options, including dietary modifications, octreotide infusion, thoracic duct ligation and embolization, and surgical pleurodesis. In addition, we describe the novel use of aminocaproic acid to reduce lymph flow. We propose a multidisciplinary approach for the management of chylothorax that includes both medical and surgical options.