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PubMed2003

Congenital idiopathic chylothorax in neonates: chemical pleurodesis with povidone-iodine (Betadine).

Chylothorax is defined as an accumulation of chyle in the pleural space. This condition usually occurs after an operation, the congenital idiopathic form being rare (1/15 000 births). Recovery is observed within four to six weeks of diagnosis in most cases. Treatment is either conservative or surgical. Four cases are reported of congenital chylothorax (three idiopathic, one accompanied by diffuse lymphangectasia) managed by chemical pleurodesis (intrapleural injection of povidone-iodine). Tolerance was satisfactory: unaltered thyroid function in the three cases explored; one case of transient generalised oedema. Treatment was deemed successful in three of the four cases. One child died from renal failure (unrelated to the chemical pleurodesis). Pleurodesis by povidone-iodine appears to be well tolerated and may represent a good alternative to mechanical abrasion or surgery for congenital idiopathic chylothorax. Its use for refractory chylothorax may also decrease the morbidity related to prolonged hospital stay.

Chylothorax↗
PubMedDate not supplied

Complex disease of the pleural space: radiographic and CT evaluation.

Pleural space disease is often complex, difficult to diagnose, and problematic to manage. At computed tomography (CT), empyema appears as an oblong fluid collection with smooth inner margins that compresses and displaces the surrounding lung and airways away from the pleural collection. CT findings in hemothorax include heterogeneous attenuation of pleural fluid, hyperattenuating areas of debris within pleural fluid, and a "fluid-hematocrit" level. Nodular pleural thickening at chest radiography or CT indicates a malignant pleural effusion; the cross-sectional capability of CT allows scrutiny of all pleural surfaces to detect enhancing tumor implants in addition to pleural effusions. Pleural plaque, rounded atelectasis, and pleural pseudotumor can mimic neoplastic disease on chest radiographs but can often be diagnosed with CT. Bronchopleural fistula may also be difficult to diagnose with radiography alone, necessitating further analysis with CT. Pleurocentesis fluid containing chyle, cerebrospinal fluid, amylase, or hyperalimentation fluid indicates pleural space disease with an unusual or iatrogenic cause. Recent advances in image-guided procedures have significantly improved treatment options for many complex pleural space processes.

Adult↗
PubMed1990

Lymphangioma of the retroperitoneum: CT and sonographic characteristic.

The authors retrospectively evaluated radiologic, clinical, and pathologic findings in 19 cases of lymphangioma of the retroperitoneum. The tumors were judged confined to one compartment of the retroperitoneum in 68% of the cases, whereas in 32% of cases the tumor involved more than one compartment. Abdominal radiography depicted the mass in all cases. Excretory urography demonstrated organ displacement without tumor invasion in all cases. Sonography showed multiloculated fluid in 61% of cases and a unicameral mass in 39% of cases. All but one of the multiloculated lymphangiomas had thick septa. Sonography also depicted the fluid as uncomplicated in 56% of cases. The remainder had debris that sometimes layered in the dependent portion of the cyst. Computed tomography (CT) showed a unicameral mass in 57% and a septated mass in 43% of cases. CT also showed thin, smooth walls in 79% and thick, irregular walls in 21% of cases. At CT the fluid contents were found to be homogeneous and of fluid attenuation in 64% and were complex in 36% of cases. The attenuation of fluid in one case was the same as that of retroperitoneal fat. In two cases the mass contained mural calcification. The most characteristic radiologic finding of lymphangioma of the retroperitoneum is an elongated tumor containing uncomplicated fluid with or without septa. Chyle and mural calcification are very uncommon in this location.

Adolescent↗
PubMed1987

Differential intestinal absorption of two fatty acid isomers: elaidic and oleic acids.

The absorption of 14C-labeled oleic acid and 14C-labeled elaidic acid was studied in bile- and pancreatic juice-diverted adult rats. In some cases these acids were compared with 14C-labeled palmitic acid absorption. Sodium taurocholate-emulsified test infusates containing an equimolar mixture of monopalmitin and two fatty acids (oleic and elaidic or palmitic), one of which was 14C labeled, were infused through a duodenal canula. The chyle was collected from the mesenteric lymphatic vessel by plastic tubing. Among the three fatty acids studied, oleic acid exhibited the highest lymphatic recovery rate (43-50%). Elaidic and palmitic acids appeared more slowly and in lesser amounts (10-17%). Simultaneously, the highest amount of chylomicrons was observed when the lipid emulsion contained oleic acid alone; the lowest was observed when elaidic acid was the only unsaturated fatty acid. Experimental data have also shown that compared with elaidic acid, oleic acid is preferentially incorporated into the lymph triglycerides. We can conclude from the data presented that the enterocytic enzymes involved in the absorption of lipids show a high degree of specificity related to the fatty acid isomery, since the absorption of elaidic acid differs markedly from its isomer oleic acid.

Animals↗
PubMed1988

Absorption and metabolism of orally fed arachidonic and linoleic acid in the rat.

[3H]arachidonic [( 3H]20:4) and [14C]linoleic acid [14C]18:2) were fed to rats in Intralipid or cream. Later (30-240 min) the stomach, small intestine, plasma, and liver were analyzed for radioactivity in different lipid classes. [3H]20:4 and [14C]18:2 were emptied from the stomach and absorbed by the intestine at similar rates. The [3H]20:4:[14C]18:2 ratio of the lipids in the small intestinal wall increased, however, with time. This was due to a higher retention of [3H]20:4 than [14C]18:2 in intestinal phospholipids. In contrast, more of the [14C]18:2 was in triacylglycerol of the small intestine and plasma. The highest 3H:14C ratios were found in phosphatidylethanolamine and phosphatidylinositol. The 3H:14C ratio of intestinal phosphatidylcholine varied with the type of fat vehicle used, being highest in the Intralipid experiments. After feeding Intralipid (30-60 min), significantly more of the plasma [3H]20:4 than plasma [14C]18:2 was in diacylglycerol, the 3H:14C ratio of which was much higher than that of plasma free fatty acids. [3H]20:4 and [14C]18:2 of chyle triacylglycerol are thus metabolized differently.

Administration, Oral↗
PubMed2006

Compartimentalization for chylothorax originating from the abdomen after extended esophagectomy. Report of two cases and review of the literature.

BACKGROUND: Chyle leakage from the chest after extended esophagectomy originating from the abdomen is a rare complication with various clinical presentations and treatments. METHODS: Two cases of chylothorax originating from the abdomen are discussed and the literature concerning diagnosis, management and outcome is reviewed. RESULTS AND CONCLUSION: Initially conservative measures should be installed; however, prolonged conservative treatment should be avoided. Reoperation gives an opportunity to identify the leak. If the leakage originates from the abdomen, compartimentalization is the essential step to solve the problem.

Abdomen↗
PubMed1991

Linoleic acid chyloportal partition and metabolism during its intestinal absorption.

1-14C linoleic acid intestinal absorption and simultaneous biochemical events were followed up on rats under vascular perfusion and on main mesenteric lymphatic duct fistulated rats. 1-14C linoleic acid was introduced in the duodenum alone in doses from 1.2 to 90 mumol or in the presence of oleic acid and monopalmitin (30/30/30 mumol/mumol/mumol). Mesenteric portal venous blood and chyle, respectively, were collected continuously for 1 and 6 h after the infusions. Blood-labeled lipid recovery varied from 4.7 to 2.2% of the 14C linoleic acid infused as the 14C linoleic acid dose infused increased, and dropped to 1.8% with the mixed lipid infusate. Lymph-labeled lipid recovery increased from 25.7 to 31.8% of the 14C linoleic acid infused as the dose infused increased, and rose to 48.1% with the mixed lipid infusate. The oxidation of 1-14C linoleic acid remained low: 0.8-3% of the infused radioactivity. A desaturation and elongation of 14C linoleic acid into 14C arachidonic acid was detected and discussed. We can conclude that the linoleic lymph absorption pathway remained preferential in our experimental conditions, simultaneous to a low rate of oxidation and an eventual ability for the enterocyte to convert this essential fatty acid arachidonic acid.

Animals↗
PubMed1995

Successful treatment of postretroperitoneal lymph node dissection in massive chylous ascites.

A rare complication of retroperitoneal surgery is damage to lymphatic vessels, leak of chyle and the development of chylous ascites. This complication can be life threatening and has a relatively high mortality rate. We describe a 38-year-old patient with a massive chylous ascites after extensive retroperitoneal lymph node dissection of metastatic nonseminomatous germ cell testicular tumor. The patient was treated surgically and with fat-free diet, medium chain triglycerides and diuretics resulting in complete resolution of the ascites.

Adult↗
PubMed1981

Effect of gastric inhibitory polypeptide on plasma levels of chylomicron triglycerides in dogs.

To determine whether gastric inhibitory polypeptide (GIP) promotes the clearance of chylomicron triglycerides (TG) from the circulation in dogs, chyle collected from donor dogs via a thoracic duct fistula was infused at a rate of 2 ml/min i.v. into normal recipient dogs during an infusion of either porcine GIP (1 microgram/kg per h) or saline as a control. In the GIP-infused dogs the rise in plasma TG was significantly below that of the control animals [mean peak of 36 +/- 4 mg/dl vs. 82 +/- 18 mg/dl (P less than 0.05)]. It is concluded that GIP exerts an effect upon the removal of chylomicron TG from the blood. The results suggest that GIP may play a physiologic role in the disposition of ingested fat.

Animals↗
PubMedDate not supplied

Chylothorax--a complication of subclavian vein catheterization.

Insertion complications of subclavian vein catheter placement are well documented. Thoracic duct injury is a potential problem which has rarely been reported. A patient with duct injury and resultant chylothorax is presented. The management of this problem is discussed with emphasis placed on chyle leakage from both the nutritional and mechanical aspect. The anatomy and function of the thoracic duct as well as the pathophysiology and treatment of chylothorax are detailed.

Aged↗
PubMed1985

Bilateral chylothorax from radical neck dissection.

Bilateral chylothorax is a rare complication occurring after head and neck surgery, with only six cases reported. The diagnosis is not difficult if a high index of suspicion is held. Early recognition and treatment prevent the devastating metabolic effects of excessive chyle loss and reduce the respiratory restriction that can progress to fatal anoxia. Dietary management with medium-chain triglycerides is essential to successful outcome. Repeated invasive therapy should be minimized.

Adult↗
PubMed2003

Chylothorax following coronary bypass grafting: treatment by talc pleurodesis.

Chylothorax after myocardial revascularization is a rare but serious complication. There is as yet no definitive treatment. We report a case in which chylothorax was diagnosed on the 3rd postoperative day. Conservative management with dietary restriction to medium-chain triglyceride led to reduction of chyle leakage from 300 to 400 mL/day to 50 to 60 mL/day 3 days later. However, the leak persisted until talc pleurodesis was performed.

Chylothorax↗
PubMedDate not supplied

Techniques for preserving vertebral artery perfusion during thoracic aortic stent grafting requiring aortic arch landing.

Thoracic endografting offers many advantages over open repair. However, delivery of the device can be difficult and may necessitate adjunctive procedures. We describe our techniques for preserving perfusion to the left subclavian artery despite endograft coverage to obtain a proximal seal zone. We reviewed our experience with the Talent thoracic stent graft (Medtronic, Santa Rosa, CA). From 1999 to 2003, 49 patients received this device (29 men, 20 women). Seventeen patients required adjunctive procedures to facilitate proximal graft placement. We performed left subclavian-to-left common carotid artery transposition (6), left common carotid-to-left subclavian artery bypass with ligation proximal to the vertebral artery (7), and left common carotid-to-left subclavian artery bypass with proximal coil embolization (4). Patients who had anatomy unfavorable to transposition or bypass with proximal ligation (large aneurysms or proximal vertebral artery origin) were treated with coil embolization of the proximal left subclavian artery in order to prevent subsequent type II endoleaks. Technical success rate of the carotid subclavian bypass was 100%. Patient follow-up ranged from 3 to 48 months with a mean of 12 months. Six patients had follow-up <6 months owing to recent graft placement. Primary patency was 100%. No neurologic events occurred during the procedure or upon follow-up. One patient had a transient chyle leak that spontaneously resolved in 24 hours. Another patient had a phrenic nerve paresis that resolved after 3 weeks. We believe that it is important to maintain patency of the vertebral artery specifically when a patent right vertebral system and an intact basilar artery is not demonstrated. Furthermore, we describe a novel technique of coil embolization of the proximal left subclavian artery in conjunction with left common carotid-to-left subclavian artery bypass. This circumvents the need for potentially hazardous mediastinal dissection and ligation of the proximal left subclavian artery in cases of large proximal aneurysms or unfavorable vertebral artery anatomy.

Anastomosis, Surgical↗
PubMedDate not supplied

Octreotide.

The use of SC or IV octreotide, a long-acting synthetic analog of somatostatin, provides a promising pharmacologic approach to reducing drainage in selected patients with a congenital or postoperative chylothorax, who do not respond to conservative treatment strategies. Prompt institution of octreotide therapy after surgery in patients with significant drainage or the formation of chyle may reduce the expense and morbidity associated with a prolonged hospital stay. Given the individual variability in patient response to octreotide and the limited clinical data regarding its use in the pediatric population, octreotide therapy must be individualized with careful consideration being given to possible benefits versus inherent risks.

Chylothorax↗
PubMed2004

Chylothorax and chyloascites complicating cirrhosis of liver.

Chylothorax and chyloascites is the accumulation of chyle in pleural and peritoneal spaces and are rarely seen. This case report describes the occurrence and management in an old lady. However, she expired due to frank haematemesis and encephalopathy. Chylothorax/chyloascites are difficult to manage and associated with poor prognosis.

Aged↗
PubMed2005

Surgical strategy for thyroid bed recurrence in patients with well-differentiated thyroid carcinoma.

BACKGROUND: Well-differentiated thyroid carcinoma (WTC) has a low but definite rate of recurrence. The majority of these occur locoregionally and present a significant diagnostic and management challenge. It is the aim of this article to convey the complexities associated with revision surgery involving the thyroid bed and to present sound surgical strategies to deal with this problem in a manner that minimizes morbidity, adheres to oncologic principles, and achieves appropriate cure rates. METHOD: Between 1992 and 2002, 14 patients with revision surgery involving the thyroid bed were identified and managed according to an algorithm taking into account clinical, biochemical, and radiologic indices. All underwent revision surgery, and we applied our technique of wide field exposure by horizontally sectioning all of the ipsi- or bilateral strap muscles. We use blunt dissection to identify the recurrent laryngeal nerves and parathyroid glands. RESULTS: There were six males and eight females, with a median age of 38 years (range 23-62 years). The median time between procedures was 25 months (range 6-120 months). The diagnosis was established by clinical examination, thyroglobulin determination, and/or imaging. All were treated with surgery and postoperative iodine 131 (I131). The median follow-up was 6 months (range 2-48 months). Complications included two cases of temporary recurrent laryngeal nerve palsy, two patients with permanent and two patients with temporary hypocalcemia, two cases of temporary chyle leaks, and one recurrence. One patient underwent a negative exploration. CONCLUSION: The management of infield recurrence of WTC presents both a diagnostic and a therapeutic challenge owing to the disparity in presentation, the complexity of the anatomy, and indistinct tissue planes. The optimal treatment of these patients is surgical resection and postoperative I131. This can be accomplished safely and with little morbidity. The key to this type of surgery is a sound and systematic approach.

Adult↗
PubMed2000

Bilateral pleural effusion following cervical abscess drainage: a case report.

Postoperative bilateral chylothorax after cervical surgery has been rarely reported, whereas unilateral chylothorax has been occasionally reported after thoracic surgery. Here, we report a rare case of bilateral pleural effusion that developed after cervical abscess drainage. On the second day after the drainage, the patient felt dyspnea, and bilateral pleural effusion was found on a chest X-ray. The effusion was thought to be chyle and was successfully treated with conservative management. Additionally here, we have suggested that non-traumatic chylothorax was caused by increasing intraluminal pressure occurring inside the thoracic duct after its ligation. Careful follow up of any respiratory symptoms and of chest X-rays is recommended after cervical intervention.

Abscess↗
PubMed1980

Inhibition of hepatic chylomicron remnant uptake in the cholestatic rat.

[3H]retinal- or [3h]cholesterol- and [14C]fatty acid-labeled chylomicrons and chylomicron remnants were injected intravenously into normal rats and rats subjected to partial or total obstruction of the bile duct 8 or 48 h earlier. The clearance from plasma of the [3H]retinyl and the [3H]cholesteryl esters in 30-120 min was markedly decreased in rats with total obstruction, and the uptake of 3H by the liver was significantly less than in control rats. The elimination of the [14C]triacylglycerol of the native chyle lipoprotein was not significantly affected, and the delayed plasma clearance was seen also when the [3H]lipid ester radioactivity was injected as chylomicron remnants prepared in vitro. If only one of the two main bile duct branches was ligated, the uptake of radioactivity did not differ markedly in the obstructed and unobstructed part of the liver and only small effects on the plasma disappearance were seen. The defective clearance of the chylomicron remnants was thus not related to the obstructed bile flow per se but rather to the consequences of the total obstruction, such as the high plasma bile acid level or the accumulation of abnormal lipoproteins in plasma.

Animals↗