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PubMed1998

Chylothorax following oesophagogastrectomy for malignant disease.

OBJECTIVE: To define the incidence, causes, management and impact of Chylothorax after oesophagogastrectomy for malignant disease in Nottingham Thoracic Surgery unit. PATIENTS AND METHODS: Retrospective analysis of 523 patients with cancer of the oesophagus or the gastro-oesophageal junction who underwent oesophageal resection between January 1987 and November 1997 in a single unit using similar techniques and uniform routine perioperative management. RESULTS: Chylothorax occurred in 21 patients (4.0%). There were 12 males and 9 females with a mean age of 64.7 years (SD 7.5). Age, sex, tumour site, length, histological type, depth of wall penetration, nodal status and type of operative approach were not significant predisposing factors on univariate and multivariate analysis. Seventeen patients were treated conservatively (four deaths, 23.5%) and four surgically (one death, 25.0%), effective control of the chylous leak being achieved in all four cases. Eleven patients with a chylous drainage of up to 2.2 l/day, diminishing within 1 week of conservative treatment had an uneventful recovery. However, a chylous drainage of more than 2.5 l/day in the remaining ten patients was associated with increased morbidity, hospital stay, operative mortality and the need for surgical intervention. In comparison with the remaining patients (n = 502), those who developed chylothorax (n = 21) had more respiratory complications (42.8%, P = 0.008), longer mean hospital stay (23.8 days, P = 0.004), higher operative mortality (23.1%, P = 0.004) and, unexpectedly, reduced 5 year survival rate (P < 0.0001). CONCLUSIONS: There appeared to be no clear predisposing factor in the development of a chylous leak other than the routine extensive dissection. Although definitive conclusions can not be drawn, where there is early reduction of the initial amount (in this series up to 2.2 l/day) of drainage, there may be a place for successful non-surgical management; in cases of high output chylothorax, persisting after a few days of conservative treatment, however, early re-operation and ligation of the thoracic duct, seems to be advisable.

Aged↗
PubMed2002

Management of unremitting chylothorax by percutaneous embolization and blockage of retroperitoneal lymphatic vessels in 42 patients.

PURPOSE: To demonstrate the applicability, technique, and efficacy of percutaneous transabdominal catheter embolization or needle disruption of retroperitoneal lymphatic vessels in the treatment of high-output or unremitting chylothorax. MATERIALS AND METHODS: Forty-two patients (21 men, 21 women; mean age, 56 y; range, 19-80 y) who had chylothorax with various etiologies were referred from the thoracic surgery department for treatment as soon as chylothorax was documented. The thoracic duct was punctured and catheterized via a peritoneal cannula to facilitate embolization with use of microcoils, particles, or glue; if there were no lymph trunks that could be catheterized, attempts were made to disrupt lymph collaterals with use of needles. RESULTS: The thoracic duct was catheterized in 29 patients and embolized in 26 patients. In patients with lymph trunks that could be catheterized, treatment resulted in cure within 7 days in 16 patients and partial response with cure within 3 weeks in six patients. In the patients with lymph trunks that could not be catheterized (n = 16), disruption with use of needles resulted in cure in five patients and partial response in two patients. Cure and partial response rates after thoracic duct embolization and needle disruption were 73.8%, with no morbidity. Surgical thoracic duct ligation was performed in seven patients. The nonprocedural mortality rate was 19%. Follow-up was 3 months or longer. CONCLUSIONS: Effective percutaneous treatment of high-output or medically uncontrollable chylothorax was performed promptly and safely in more than 70% of referred cases. This procedure should be attempted, especially if patients are very ill, before riskier surgical thoracic duct ligation is considered.

Adult↗
PubMed2004

Spontaneous neonatal chylothorax treated with octreotide in Turkey: a case report.

Chylothorax, which is usually idiopathic, is the most common form of pleural effusion encountered in neonates. Herein we report a 2-week-old infant who had spontaneous chylothorax and was treated with octreotide. Neonatal chylothorax responded well to octreotide treatment, which appeared to shorten the duration of hospitalization. We conclude that octreotide should be considered in the treatment of neonatal chylothorax.

Abnormalities, Multiple↗
PubMed2000

Chylothorax occurring 23 years post-irradiation: literature review and management strategies.

Chylothorax is an uncommon condition rarely seen outside the clinical scenario of trauma or malignancy, and management may be difficult. We report the case of a 52-year-old man with a right chylothorax occurring 23 years after mantle irradiation for Hodgkin's disease. In addition, a Medline literature search was performed. Chylothorax occurring post-irradiation is rare and the aetiology is uncertain. Recurrent malignancy must be excluded. There are a number of management options and our patient was successfully treated with a combination of thoracocentesis, medium chain triglyceride diet and thoracoscopy with talc pleurodesis. There was no evidence of recurrent chylothorax at 2 years follow up. Prompt assessment and treatment is required. Surgical measures need to be considered early if medical treatment is unsuccessful.

Chylothorax↗
PubMed2001

Chylothorax in cats: is there a role for surgery?

Chylothorax is a complex disease with many identified underlying causes including cardiac disease, mediastinal masses, heartworm disease and trauma. Management of this disease should be directed at identifying the cause, if possible, and treating the underlying disorder. In cats with idiopathic chylothorax, medical management is recommended initially because the condition may resolve spontaneously. Owners should be made aware of the potential development of fibrosing pleuritis in affected cats. When medical management is impractical or unsuccessful, surgical intervention should be considered. Surgical options include mesenteric lymphangiography and thoracic duct ligation, pericardiectomy, omentalisation, passive pleuroperitoneal shunting, active pleuroperitoneal or pleurovenous shunting, and pleurodesis. Of these, only thoracic duct ligation and pericardiectomy are preferred by the author because, if successful, the result is complete resolution of the chylothorax, thereby reducing the risk of developing fibrosing pleuritis. Omentalisation may be beneficial in some animals as adjuvant therapy, but this procedure may still allow fibrosing pleuritis to occur. Until the aetiology of the effusion in cats with idiopathic chylothorax is understood, the treatment success rate will be less than ideal. Future research needs to be directed at determining the pathophysiologic mechanisms underlying this disease in cats.

Animals↗
PubMed1978

[Pathogenesis, clinical application and therapy of chylothorax (author's transl)].

With the growth of traffic density and the spread of thoracic surgery, the clinical picture of the chylothorax can be observed with increasing frequency. Above all, the spontaneous or symptomatic chylothorax presents diagnostic problems, since, in about 70% of the cases, it only represents the concomitant symptom of a malignant tumor. Only after exact diagnostics and the exclusion of a malignant primary disease can one be content with the cursory diagnosis of an idiopathic chylothorax. However, this requires strict postoperative control and observation of the patients. Two patients are presented in whom the genesis of the chylothorax still remained unclear 3 1/2 years after the successful ligature of the thoracic duct.

Accidents, Traffic↗
PubMed2000

Congenital chylothorax.

The objective of this paper is a retrospective study of all infants treated for congenital chylothorax at the Royal Children's Hospital (RCH), Melbourne, Australia and King Fahad National Guard Hospital (KFNGH), Riyadh, Kingdom of Saudi Arabia. The charts of all infants with congenital chylothorax admitted to RCH over a period of 13 years, June 1982-August 1994, and admissions to KFNGH over a 7-year period, June 1992-August 1998 inclusive, were reviewed including management outcome and complications. There were 19 infants, 13 from RCH and 6 from KFNGH; 11 females and 8 males. Three infants were managed antenatally. Fifteen infants presented immediately after birth. Seven were born with hydrops fetalis, 6 infants had syndromes and 10 infants were born prematurely. Regular infant feeding formula and/or breast milk were used successfully in 12 infants, while in 7 infants medium chain triglycerides (MCT) rich formula was used. Sixteen infants were mechanically ventilated with 75% of them ventilated for < or = 28 days. Fifteen infants received total parenteral nutrition (TPN), and in 80% for < or = 32 days. Hydropic infants had longer duration of mechanical ventilation and hospital stay with mean (range) of 33.9 (3-120) and 115 (23-225) days, respectively, compared with 18 (1-62) and 34.3 (14-88) days for nonhydropic infants. Five infants underwent surgery with failure in four. Sepsis and bronchopulmonary dysplasia were the main complications. The survival rate was 100% regardless of the mode of therapy. The prognosis of Isolated congenital chylothorax in term, and preterm infants is good even in the presence of hydrops. Breast milk and/or regular infant feeding formula should be used initially before proceeding to MCT-rich formula, which may be necessary in some cases. Surgery should be considered if conservative management of congenital chylothorax fails after 4-5 weeks.

Chylothorax↗
PubMed2003

Successful management of severe chylothorax with argon plasma fulguration and fibrin glue in a premature infant.

Post-traumatic neonatal chylothorax is a rare entity. Management includes medical and surgical treatment. We describe here a newborn who developed a severe chylothorax after repair of an oesophageal atresia. The chylothorax was treated successfully by a combination of argon beam coagulation of the mediastinum and fibrin glue application. However, the patient developed complete thrombosis of the left femoral vein with clot extension to the inferior vena cava which resolved after infusion of recombinant tissue plasminogen activator (rt-PA). The use of argon plasma coagulation and mediastinal fibrin glue application for treating postoperative chylothorax appears to be attractive and is easy to perform even in small premature infants and may replace a more extensive surgical procedure. However, the coagulation profile should be monitored and special care should be taken to prevent vascular thrombosis after surgery.

Argon↗
PubMed2004

[Neonatal chylothorax with trisomy 21].

Neonatal chylothorax is an uncommon cause of respiratory distress in the newborn. It may result from anomalous lymph drainage with or without association with aneuploidy syndromes (trisomy, Turner's syndrome, Noonan's syndrome), from injury to the thoracic duct, and from obstruction of the superior vena cava. We report a term newborn and a premature infant with neonatal chylothorax, both associated with trisomy 21. In the case of the term infant, bilateral pleural effusions were diagnosed immediately before birth. The baby suffered from respiratory distress. The physical findings were characteristic of trisomy 21. In the premature infant (gestational age 24 weeks, 735 g) the ductus arteriosus was ligated on day nine after birth. Four days after surgery a central venous line was inserted via the left vena mediana cubiti into the left vena subclavia. Nine days after surgery a left-sided chylothorax occurred. The infant had subtle signs of a trisomy 21 (slightly enlarged tongue, brachycephalic head. questionable simian crease). In both children, cytogenetic studies were done and confirmed the diagnosis of trisomy 21. Infants with neonatal chylothorax should be carefully evaluated for dysmorphic signs of a trisomy or monosomy. Premature infants may present with only subtle clinical signs requiring cytogenetic studies to confirm an aneuploidy syndrome.

Chromosome Mapping↗
PubMed2002

Treatment strategy for chylothorax after pulmonary resection and lymph node dissection for lung cancer.

OBJECTIVE: We reviewed our experience with iatrogenic chylothorax after pulmonary resections for lung cancer to evaluate our treatment strategy and to identify factors that predict the need for reoperation. METHODS: From July 1992 through February 2000, a total of 1110 patients underwent pulmonary resection (at least lobectomy) and systematic mediastinal lymph node dissection for lung cancer at our division. Twenty-seven patients (2.4%) had postoperative chylothorax develop. We initially treated 26 of these patients conservatively with complete oral intake cessation and total parenteral nutrition, and these patients constituted the subjects in this study. RESULTS: There were 21 men and 5 women with a median age of 62 years (range 44 to 80 years). The initial procedures were pneumonectomy in 2 cases, bilobectomy in 1 case, and lobectomy in 23 cases. Twenty-one patients (81%) had the condition cured with conservative treatment. These patients resumed a normal diet at a median of 8 days after chylothorax diagnosis (range 4-35 days). The remaining 5 patients (19%) underwent reoperation at a median of 14 days after diagnosis (range 5-35 days). Chest tube drainage of less than 500 mL during the first 24 hours after complete oral intake cessation and total parenteral nutrition predicted a cure with conservative treatment. CONCLUSION: Although most cases of chylothorax after pulmonary resection with systematic mediastinal lymph node dissection can be cured with a conservative strategy, early surgical intervention may be indicated if chest tube drainage is more than 500 mL during the first 24 hours after complete oral intake cessation and total parenteral nutrition.

Adult↗
PubMed1998

On the possible role of positive end-expiratory pressure ventilation in the treatment of chylothorax caused by blunt chest trauma.

Recent reports on the treatment of chylothorax postulate a benefit to ventilator therapy, especially using positive end-expiratory pressure (PEEP). This report describes the use of mechanical ventilation with PEEP in the management of a 24-year-old male motorcyclist who sustained a ligamentous Chance fracture of the thoracic spine at the T6-7 level with bilateral traumatic chylothorax. Treatment of the chylothorax consisted of high PEEP ventilation, bilateral chest tube thoracostomies, and total parenteral nutrition. The chylothoraces resolved within 4 days of treatment and mechanical ventilation was stopped. Ventilator therapy of traumatic chylothorax and the physiologic grounds for its use are discussed. A review of the literature and experimental evidence seem to suggest that ventilator treatment of traumatic chylothoraces is effective.

Accidents, Traffic↗
PubMed1994

Sarcoidosis complicated by chylothorax.

Chylothorax is a rare complication of sarcoidosis; only one well-documented case has been described previously. Before chylothorax is diagnosed in a patient with sarcoidosis, infection and malignancy need to be aggressively excluded as possible diagnoses. We report the case of a 34-year-old black woman with sarcoidosis confirmed by lung, pleural, and mediastinal lymph node biopsies whose clinical course was complicated by chylothorax. Oral corticosteroid treatment resulted in prompt resolution of the chylothorax.

Adult↗
PubMed1999

Always remember chylothorax.

Chylothorax is a rare cause of pleural effusion in association with cardiovascular surgery. A 68-year-old man had a coronary artery bypass graft; 10 days after surgery, he had progressive shortness of breath and a massive left pleural effusion. After chylothorax was diagnosed, it was successfully treated with a thoracostomy tube and total parenteral nutrition. The patient had an uneventful recovery. Nutrition is the most important issue in the treatment of chylothorax. Once chylothorax is identified, nutritional support is the priority, since it will have an important role in the recovery of the patient. Besides our case, we hereby present a short review of the literature regarding the diagnosis and management of this rare entity.

Aged↗
PubMed2006

Octreotide and chylothorax.

PURPOSE OF REVIEW: This article reviews the current literature concerning the role of somatostatin and its synthetic analogue, octreotide, in the treatment of chylothorax. RECENT FINDINGS: Management of chylothorax includes evacuation of the pleural cavity through a chest tube to alleviate dyspnoea, and dietary fat restriction aimed at reducing lymph flow. When these measures fail to control lymph flow, surgical interventions are employed to achieve definite closure of the thoracic duct leak. Several case reports and series have shown that octreotide is safe and probably effective in both children and adults with chylothorax of different origins. The property of somatostatin and octreotide to induce leak closure is attributed to a decelerating effect on lymph flow, although their exact mechanism of action is not well defined. In successful cases, a substantial reduction of lymph drainage through the chest tube is evident within the first few days of commencing the drug, and treatment lasts for 1-2 weeks. Treatment failure has been also reported, however. SUMMARY: Accumulating evidence suggests that octreotide is a putative novel therapeutic intervention for chylothorax. It is imperative that randomized controlled studies are conducted in order to fully elucidate the efficacy and safety of this treatment.

Adult↗
PubMed2004

Thrombolysis for central venous occlusion causing bilateral chylothorax in a patient with down syndrome.

A 20-year-old woman with Down syndrome (trisomy 21) and acute lymphoblastic leukemia presented with severe respiratory compromise secondary to bilateral chylothorax as a result of central venous thrombosis and extensive upper-limb deep venous thrombosis. The chylothorax was successfully managed by catheter-directed thrombolysis and angioplasty of the venous occlusions. The development of venous thrombosis was likely to have been multifactorial. It is recognized that there is an increased incidence of congenital lymphatic anomalies in Down syndrome, which may have been a contributing factor in the development of chylothorax in this patient. This report illustrates the angiographic findings, demonstrates the successful vascular recanalization, and discusses the etiology and management of central venous thrombosis and chylothorax. The case is also presented to contribute to the expanding evidence in support of catheter-directed venous thrombolysis in selected clinical circumstances.

Adult↗
PubMed2004

Chylothorax as a result of chronic lymphocytic leukemia: case report and review of the literature.

Chylothorax occurs when a disruption in the thoracic duct allows chyle to escape into the pleural space. The most commonly reported cause is malignancy, especially lymphoma. However, chylothorax caused by chronic lymphocytic leukemia is rarely reported in the literature. We describe a patient who developed chylothorax secondary to chronic lymphocytic leukemia. In addition, the pathogenesis, diagnosis, and treatment of chylothorax are reviewed.

Aged↗
PubMedDate not supplied

Spontaneous neonatal chylothorax treated with octreotide.

Chylothorax is the most common cause of pleural effusion causing respiratory distress in the neonate. Cases unresponsive to conservative management usually require surgery. We report a case of spontaneous neonatal chylothorax where surgery was avoided with the compassionate trail of octreotide. The chylothorax resolved promptly with no observed side effects. After reviewing the literature reporting the use of octreotide in the neonatal period, we found that neonates with isolated spontaneous chylothorax might be viewed as a group different from those with major cardiac malformations. They are at a lower risk for adverse effect of octreotide and lower threshold for commencement of octreotide may benefit them most.

Chylothorax↗
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↗