159. Klinik und Therapie des traumatischen Chylothorax

Zusammenfassung Der traumatische Chylothorax bleibt eine seltene Komplikation, wenn auch durch die steigende Zahl thoraxchirurgischer Eingriffe und die häufiger werdenden Verkehrsunfälle in letzter Zeit öfter beschrieben. Wir berichten über 5 Fälle von traumatischem Chylothorax: 2 nach stumpfem Thoraxtrauma, 2 postoperativ, 1 mal nach Legen eines Subclaviakatheters. In einem Fall sistierte die Chylusfistel spontan, 2mal mußte der D. thoracicus ligiert werden, 2mal kam es nach lymphographischer Darstellung des Lecks (Lipiodol) zu einem Sistieren der Sekretion.     

Octreotide as therapeutic option for congenital idiopathic chylothorax: a case series

Background: Octreotide, a somatostatin analogue, is used for the management of patients with refractory chylothorax although its safety and efficacy in neonates have not been evaluated in controlled clinical trials. We present one of the largest case series about the use of octreotide in congenital idiopathic chylothorax. Methods: Six cases of congenital chylothorax (CC) were prospectively collected, who were managed with same unit protocol for octreotide. Mean (SD) gestation was 34.5 (±2.2) weeks, and birthweight was 3410 (±840.4) g. All infants required chest drains from day 1 of life, and the mean (SD) duration of insertion was 36.1 (±8.5) days. Octreotide was commenced at a median age of 13.5 days (range 8–22), given for a median duration of 20 days (range 12–27). The starting dose was 0.5–1 μg/kg/h with an increment of 1–2 μg/kg/day to a maximum of 10 μg/kg/day. Resolution of chylothorax was achieved in five patients, being resistant to treatment in the sixth patient. None had adverse effects from octreotide. Full enteral feeds were reached at a mean age of 44 days. Conclusion: Early commencement of octreotide is recommended although further reports to evaluate the safety and efficacy would add to the profile of this medication in the treatment of CC.     

Somatostatin or octreotide as treatment options for chylothorax in young children: a systematic review

Objective Chylothorax is a rare but life-threatening condition in children. To date, there is no commonly accepted treatment protocol. Somatostatin and octreotide have recently been used for treating chylothorax in children. We set out to summarise the evidence on the efficacy and safety of somatostatin and octreotide in treating young children with chylothorax.Design Systematic review: literature search (Cochrane Library, EMBASE and PubMed databases) and literature hand search of peer reviewed articles on the use of somatostatin and octreotide in childhood chylothorax.Patients Thirty-five children treated for primary or secondary chylothorax (10/somatostatin, 25/octreotide) were found.Results Ten of the 35 children had been given somatostatin, as i.v. infusion at a median dose of 204 μg/kg/day, for a median duration of 9.5 days. The remaining 25 children had received octreotide, either as an i.v. infusion at a median dose of 68 μg/kg/day over a median 7 days, or s.c. at a median dose of 40 μg/kg/day and a median duration of 17 days. Side effects such as cutaneous flush, nausea, loose stools, transient hypothyroidism, elevated liver function tests and strangulation-ileus (in a child with asplenia syndrome) were reported for somatostatin; transient abdominal distension, temporary hyperglycaemia and necrotising enterocolitis (in a child with aortic coarctation) for octreotide.Conclusions A positive treatment effect was evident for both somatostatin and octreotide in the majority of reports. Minor side effects have been reported, however caution should be exercised in patients with an increased risk of vascular compromise as to avoid serious side effects. Systematic clinical research is needed to establish treatment efficacy and to develop a safe treatment protocol.No funding was provided for the review, there were no conflicting interests.     

食管癌术后乳糜胸的诊断和分析

目的总结食管癌手术后并友乳糜胸的诊断和治疗经验。方法回顾性分析33例食管癌手术后并发乳糜胸的诊治情况。结果治愈32例,其中保守治疗22例,有21例得到治愈,另外1例因肺部感染后导致呼吸衰竭放弃治疗后出院;有11例行电视镜腔镜手术治疗,均痊愈。结论在临床上对于食管癌术后发生乳糜胸的情况应本着预防为主的原则进行治疗,这样可以使大部分患者避免进行第二次手术,减少痛苦;若病情未能改善,果断实施手术是积极有效的治疗方式。     

食管癌贲门癌切除术后乳糜胸的诊断与治疗(附22例分析)

目的:探讨食管癌贲门癌术后并发乳糜胸的诊断与治疗。方法:22例中10例行手术治疗,12例行保守治疗。结果:10例手术治疗者8例痊愈,2例死亡;12例保守治疗者9例痊愈,3例死亡。结论:食管癌贲门癌切除术后并发乳糜胸,应该酌情选择手术治疗和积极的保守治疗。     

Value of CT lymphangiography in the detection of lymphatic leakage: a report of nine cases

Purpose

To demonstrate the value of CT lymphangiography to detect lymphatic leakage, especially at the thoracic level, prior to therapeutic intervention.

Patients and methods

Between 2004 and 2008, nine patients underwent lymphangiography, followed by CT for the evaluation of intractable lymphatic leakage in spite of optimal medical management. Patients included seven females and two males, with age ranging between 25 and 58 years. Lymphangiography was performed after unilateral or bilateral foot injection(s) of Lipiodol ultrafluid followed by standard radiographs of the chest and abdomen and CT of the chest, abdomen and pelvis. The images were reviewed by two experienced radiologists.

Results

Lipiodol leakage was observed in six patients, while three patients showed evidence of lymphangiectasia of the abdominal and/or thoracic lymphatics. Spontaneous resolution of leakage after lymphangiography occurred in three cases.

Conclusion

CT lymphangiography allows direct evaluation of lymphatics, from pelvis to chest, in order to detect the site of leakage at the origin of a chylous effusion and assist in its management.     

食管癌术后并发乳糜胸的护理

目的：探讨食管癌术后并发乳糜胸的护理措施。方法对6例食管癌术后并发乳糜胸患者临床资料进行回顾性分析。结果4例行保守治疗，2例行胸导管结扎术，均恢复良好。结论早期发现乳糜胸的征象，及时有效地处理和护理，有助于乳糜胸患者的康复。     

Pleural Effusion and Sarcoidosis: An Unusual Combination

Pleural involvement in sarcoidosis is uncommon and appears in several forms. To document the incidence and characteristics of pleural effusion in sarcoidosis patients, a review of the cases diagnosed in our center between January 2001 and December 2012 was carried out. One hundred and ninety-five patients with sarcoidosis were identified; three (two men and one woman) presented with unilateral pleural effusion (1.5%): one in the right side and two in the left. Two were in stage II and one was in stage IV. The pleural fluid of the two patients who underwent thoracocentesis was predominantly lymphocytic. One of these patients presented chylothorax and the other had high CA-125 levels. In general, these effusions are lymphocyte-rich, paucicellular, serous exudates (sometimes chylothorax) and contain proportionally higher levels of protein than LDH. Most cases are treated with corticosteroids, although it may resolve spontaneously.     

Cervical venous anastomoses of pulmonary lymphatic vessels

Summary The aim of this study was to describe in detail the anastomoses between the pulmonary lymphatic vessels and the veins of the neck so as to better understand their role in certain aspects of thoracic surgery. The lymphatic vessels of 687 pulmonary segments in 360 cadavers were injected. A detailed study of the proximal end of the right paratracheal, right tracheo-esophageal, left preaortocarotid and left recurrent lymph node chains was undertaken. The results showed the absence of any major right lymphatic vein. There were, however, many lymphatic arches draining into the jugulo-subclavian confluence ipsilaterally, and, in 10 to 15% of cases, contralaterally as well. The intertracheobronchial lymph nodes also drained into the venous confluence of the neck via direct lymphatic vessels, without lymph node relays. Finally, the left mediastinal lymph node chains were frequently found to drain into the arch of the thoracic duct (40% of cases), and reflux due to valvular incompetence at this level may account for chylous pericarditis and some cases of chylothorax after surgery.

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Connexions veineuses cervicales des lymphatiques d'origine pulmonaire

Résumé Le but de ce travail a été de préciser les anastomoses lymphaticoveineuses des lymphatiques pulmonaires au niveau cervical et d'essayer d'en mieux comprendre l'intérêt en pratique chirurgicale. L'étude a porté sur 360 cadavres et 687 segments pulmonaires ont été injectés. Les terminaisons des vaisseaux lymphatiques des chaînes lymphonodales prétrachéales droites, trachéo-sophagiennes, préaortocarotidiennes, récurrentielles gauches ont été particulièrement étudiées. Ce travail a démontré l'absence de grande veine lymphatique droite et l'existence de nombreuses crosses lymphatiques s'abouchant dans les confluents veineux cervicaux homolatéraux mais également controlatéraux dans 10 à 25 % des cas. Le groupe des lymphonoeuds intertrachéobronchiques se drainait lui aussi, malgré son éloignement, dans les confluents veineux cervicaux par des vaisseaux lymphatiques à trajet direct sans interposition de lymphonoeuds. Enfin, les chaînes médiastinales gauches s'abouchaient avec une grande fréquence dans la crosse du conduit thoracique (40 % des cas) et le reflux par incontinence valvulaire de chyle à ce niveau est l'explication anatomique vraisemblable des chylopéricardes et de certains chylothorax post-chirurgicaux.