膈上胸导管结扎术在食管癌切除术中的应用

目的探讨胸导管结扎术对食管癌术后乳糜胸的预防和治疗作用。方法回顾性分析我院2003年1月至2009年6月的两组共836例食管癌切除术后的乳糜胸发生情况和治疗效果。其中结扎组431例,术中常规在膈上水平整块结扎胸导管,非结扎组405例,术中未常规结扎胸导管,术后并发乳糜胸者,再次采用手术治疗。结果结扎组无术后乳糜胸发生。非结扎组术后发生乳糜胸15例（3．7％）,治愈13例（86．7％）,死亡2例（13．3％）,1例死于呼吸功能衰竭,1例死于多器官功能衰竭。结论食管癌切除术中常规结扎胸导管可有效预防术后乳糜胸的发生。膈上胸导管结扎法稳妥有效。食管癌术后并发乳糜胸应积极手术治疗。     

Prophylactic Thoracic Duct Mass Ligation Prevents Chylothorax After Transthoracic Esophagectomy for Cancer

Background  Chylothorax after transthoracic esophagectomy for cancer is an uncommon but potentially life-threatening postoperative complication. It has been reported that preventive thoracic duct ligation can reduce the incidence of postoperative chylothorax after esophagectomy for cancer. In this prospective series, we evaluated the results of preventive intraoperative thoracic duct mass ligation in patients who underwent transthoracic esophagectomy for cancer. Methods  From 2001 to 2006, 323 patients underwent transthoracic esophagectomy for cancer and duct ligation during the operation was routinely performed. Results  No intraoperative or postoperative complications directly related to the procedure were recorded. No postoperative chylothorax was observed. Conclusions  In this series, the technique of intraoperative thoracic duct mass ligation proved to be safe and effectively prevented postoperative chylothorax in patients who underwent transthoracic esophagectomy for cancer.     

Management of thoracic duct injuries after oesophagectomy.

BACKGROUND: Thoracic duct laceration is a rare but potentially life-threatening complication of oesophagectomy. The management of such an injury is uncertain in respect of the relative merits of conservative and surgical treatment. METHODS: The literature was reviewed by searching Medline databases from 1966 to the present time. The majority of the evidence presented is level 3, as no randomized or controlled data are available. RESULTS: Prolonged conservative treatment of thoracic duct injury is associated with a mortality rate of 50-82 per cent. The results of early surgical ligation of the duct are more encouraging, with a mortality rate of 10-16 per cent. Elective ligation of the duct reduces the incidence of postoperative chylothorax. CONCLUSION: The thoracic duct should be ligated during oesophagectomy. A high index of suspicion for duct injury must be maintained in all patients after operation. A policy of very early thoracic duct ligation at 48 h from diagnosis is proposed for duct injury if aggressive conservative management fails.     

Video-assisted right supradiaphragmatic thoracic duct ligation for non-traumatic recurrent chylothorax.

BACKGROUND: Chylothorax is an uncommon disorder with respiratory, nutritional and immunological manifestations. Surgical management is indicated in case of recurrence or failure after conservative treatment. We report our experience with video-assisted right-sided supradiaphragmatic thoracic duct ligation for non-traumatic, non-postoperative persistent or recurrent chylothorax. PATIENTS AND METHODS: The medical records of six patients operated at our institution between 1999 and 2004 were retrospectively reviewed. A right-sided chylothorax was found in four patients, a left-sided in one, and a bilateral in one. Three patients developed chylothorax after chemotherapy and chest irradiation for malignant diseases (lymphoma in two patients and breast cancer in one), one in the context of lymphangioleiomyomatosis, one due to a non-diagnosed lymphoma, and one after heart transplantation. RESULTS: The mean operative time was 102 min, with an average length of hospital stay of 14 days. Persistent cessation of chylous effusion within 7 days after surgery was observed in 5/6 patients without recurrence during a mean follow-up time of 41 months. One patient with undiagnosed mediastinal lymphoma required re-operation and thoracic duct ligation on day 8 by right-sided thoracotomy due to persistent chylothorax. No 30-day mortality was recorded. Two patients presented postoperative complications including respiratory insufficiency requiring mechanical ventilation in one, and chylous ascites development requiring peritoneo-venous LeVeen shunting in one patient. CONCLUSIONS: Recurrent or persistent non-traumatic chylothorax may be successfully treated by video-assisted right supradiaphragmatic thoracic duct ligation.     

Intraoperative fluorescence lymphography using indocyanine green in a patient with chylothorax after esophagectomy: report of a case

We report a case of chylothorax treated successfully by a new diagnostic tool: indocyanine green (ICG) fluorescence lymphography. The patient, a 65-year-old man with adenocarcinoma of the esophagogastric junction, underwent radical esophagectomy, which was followed by the development of chylothorax. On postoperative day 10, we performed transabdominal ligation of the thoracic duct. During the re-operation, we injected ICG into the mesentery of the small bowel. We then performed mass ligation of the tissue right and dorsal of the aorta, including the thoracic duct, after which a near-infrared camera system revealed a fluorescent stripe on the caudal part of the ligation. The remnant thoracic duct appeared to be dilated as a result of lymphatic stasis. The patient was discharged 35 days after his initial surgery. We report this case to demonstrate the usefulness of intraoperative ICG lymphography as a tool to identify and confirm ligation of the thoracic duct transabdominally.     

结扎胸导管预防不同部位胸段食管癌切除术后乳糜胸的疗效分析

目的分析术中结扎胸导管对不同部位胸段食管癌患者手术后预防发生乳糜胸的作用。方法对2003年3月至2007年6月手术切除的胸段食管癌243例患者的临床资料进行回顾性分析。根据不同病变部位将患者分为上段、中上段、中段、中下段和下段5组，了解不同部位胸段食管癌患者术中结扎和不结扎胸导管与术后乳糜胸发生有无相关性。结果术后共计8例患者出现乳糜胸，总发生率3．3％。上段病变结扎组乳糜胸发生3例，未结扎组5例；中上段病变结扎组和未结扎组均未发生乳糜胸；中段病变未结扎组1／28（3．6％）；中下段病变结扎组乳糜胸发生率1／39（2．6％），未结扎组1／35（2．9％）；下段病变结扎组乳糜胸发生率1／37（2．7％），未结扎组2／44（4．5％）。Logistic回归分析显示。不同部位胸段食管癌切除术中是否结扎胸导管结扎对术后乳糜胸的发生均无影响（P〉0．05）。结论预防性结扎胸导管不能降低不同部位胸段食管癌术后继发乳糜胸的发生率。     

Results of prophylactic thoracic duct ligation in advanced esophageal carcinoma

Objective  Esophageal carcinoma is one of the most common lethal malignancies in northwest Iran. The purpose of this study is to determine the efficiency of prophylactic thoracic duct ligation and compare the incidence, risk factors and outcomes of chylothorax in patients undergoing esophageal cancer surgery. Methods and Material  From 1995 through 2005 a total 420 patients undergoing esophageal resection with or without mediastinal lymph node dissection. In first five years (Group I: 210 patients) that after any esophagectomies we have not used prophylactic thoracic duct ligation (1995–2000). In last five years for prevention of chylothorax after any esophagectomies (Group II: 210 patients), thirty patients with advanced stage of esophageal carcinoma underwent to prophylactic thoracic duct ligation (2000–2005). Data analysis included Chi-square or Fisher exact test and Independent Samples t test. A p-value of <0.05 was considered significant. All analyzes were performed using the SPSS.15/_win software. Results  There were 100 men and 110 women with a mean age of 53.18±12.35 years in Group I, 108 men and 102 women with a mean age of 56.1±9.83 years in Group II. The initial procedures were transhiatal esophagectomies and transthoracic esophagectomies. Six patients of group I, developed to chylothorax with average daily postoperative drainage greater than 1000 ml/day for 6 days, and underwent to reoperation at a mean of 7.12±1.85 days after diagnosis (4–8 days). Chest tube drainage was stopped during 48 hours after reoperation. In Group II chylothorax did not occur. Conclusions  Chylothorax increases mortality and duration of hospitalization after esophageal cancer surgery. Most cases of chylothorax after esophageal resection are cured with early surgical intervention. It could be concluded that prophylactic thoracic duct ligation reduce the occurrence of chylothorax in advanced cases of esophageal carcinoma.     

Thoracoscopic direct clipping of the thoracic duct for chylopericardium and chylothorax

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.     

LOW THORACIC DUCT LIGATION FOR POSTOPERATIVE CHYLOUS EFFUSIONS IN INFANTS AND CHILDREN

Three patients aged from three months to six years underwent thoracic duct ligation at the level of the diaphragm for chylothorax which occurred following cardiac operations. Another three-month-old patient underwent thoracic duct ligation for massive postoperative chylopericardium. Indications for operation were a large recurrent chyle accumulation or prolonged chyle drainage. Operative ductograms to deliniate the cisterna chyli and to exclude the presence of multiple lymph channels were performed in three patients. Excellent postoperative results were obtained in all patients for periods of up to two years. Low thoracic duct ligation is a reliable means of control of postoperative chylothorax and lengthy persistence with conservative treatment is no longer necessary.     

Supradiaphragmatic thoracic duct clipping for chylothorax through left-sided video-assisted thoracoscopic surgery.

Chylothorax is a life-threatening clinical entity. Traditional surgical management for cases refractory to conservative treatment is thoracic duct ligation through a right open thoracotomy or closure of the site of duct laceration through an open thoracotomy. We report herein two patients with left chylothorax successfully treated by supradiaphragmatic thoracic duct (STD) ligation through left-sided video-assisted thoracoscopic surgery (VATS). This approach offers optimal exposure for the thoracic duct ligation and is useful for treatment of left chylothorax after left-sided thoracic surgery and idiopathic left chylothorax.     

Low thoracic duct ligation for postoperative chylous effusions in infants and children.

Three patients aged from three months to six years underwent thoracic duct ligation at the level of the diaphragm for chylothorax which occurred following cardiac operations. Another three-month-old patient underwent thoracic duct ligation for massive postoperative chylopericardium. Indications for operation were a large recurrent chyle accumulation or prolonged chyle drainage. Operative ductograms to deliniate the cisterna chyli and to exclude the presence of multiple lymph channels were performed in three patients. Excellent postoperative results were obtained in all patients for periods of up to two years. Low thoracic dust ligation is a reliable means of control of postoperative chylothorax and lengthy persistence with conservative treatment is no longer necessary.     

Chylothorax after thoracoscopic esophagectomy.

Among 30 patients who underwent thoracoscopic esophagectomy with lymphadenectomy for thoracic esophageal cancer, from July 1995 to May 1997, chylothorax developed in 2 patients (7%). In Case 1, the ligation of the thoracic duct under conventional right thoracotomy was performed on the 9th day after esophagectomy. After ligation, the pleural effusion was decreased, and the patient was discharged from hospital on the 25th day after the second operation. In Case 2, massive pleural effusion developed on the 10th day after esophagectomy (at 3 days after thoracic drainage tube was removed). The thoracic duct was ligated at the level just cranial to the diaphragm thoracoscopically on the 14th day after esophagectomy. The patient was discharged from hospital on the 30th day after the second operation. Injury to the thoracic duct due to a magnification effect of the view of scopic surgery remains a pitfall in thoracoscopic esophagectomy. But thoracoscopic ligation of thoracic duct was effective and safe for these two cases of chylothorax after esophagectomy.     

Thoracoscopic thoracic duct sealing with LigaSure in two children with refractory postoperative chylothorax

PURPOSE: Chylothorax is an uncommon complication of cardiac surgery. We report two cases of the thoracoscopic management of persistent postoperative chylothorax by thoracic duct thermofusion and section with the LigaSure device. MATERIALS AND METHODS: A 6-year-old boy and a 3-year-old girl developed persistent chylothorax following an aortic coarctation repair and a Fontan procedure, respectively. The former presented with a left chylothorax due to direct surgical injury, and the latter, a right chylothorax due to indirect lymphatic rupture secondary to increased venous pressure. In both patients, voluminous chylous drainage persisted for more than 3 weeks despite maximal medical treatment. Ultimately, a right thoracoscopic coagulation and section of the thoracic duct with the 5-mm LigaSure device was performed. The LigaSure is a computer-controlled bipolar diathermy system designed to seal blood vessels up to 7 mm in diameter, with no specific recommendations regarding the lymphatics. RESULTS: The lymph leakage ceased within 2 days in the first patient and immediately in the second one, with no recurrence after oral intake resumption on day 5. Both patients are free of recurrence at 1 year. CONCLUSION: Thoracoscopic coagulation and section of the thoracic duct above the diaphragm with the LigaSure device appears to be a simple, effective, and safe therapeutic option for treatment of refractory postoperative chylothorax in children.     

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.     

Chylothorax after neck dissection for thyroid carcinomas: report of three cases

Chylothorax is a rare complication of neck dissection. We report three cases of chylothorax after neck dissections for thyroid carcinoma and attribute this relatively high incidence to the assumption that most patients are asymptomatic. Thus, conventional chest X-ray or ultrasonography in the early postoperative period may be warranted to exclude asymptomatic chylothorax, especially if the thoracic duct is injured and ligated during the operation. We suggest that for chylothorax induced by ligation of the thoracic duct, which may be transient and resolve quickly, short-term thoracic drainage is enough.     

Treatment of postoperative chylothorax through laparoscopic thoracic duct ligation.

We report the laparoscopic transhiatal thoracic duct ligation to solve postoperative chylothorax after right total pleurectomy for malignant diffuse mesothelioma.     

Surgical management of chylothorax: a report of 65 cases

Sixty-five cases of chylothorax treated at the Shanghai Chest Hospital over the past 30 years are reviewed. The causes of chylothorax in this series were mainly traumatic and postoperative (47/65). Two cases were associated with chylopericardium and another 2 with chylous sputum. The authors believe that untreated chylothorax is a serious, often life-threatening entity and that the following principles are applicable in its management: (1) If daily chyle loss exceeds 1000 ml in adults with no tendency of subsidence, surgery is indicated especially in the effusion may lead to disastrous nutritional and immunologic consequences; (2) Ligation of the thoracic duct is effective by a mass ligature encircling all tissues between the azygos vein and the aorta. The most favorable site for ligation is immediately above the diaphragm. Over dissection of the thoracic duct should be avoided; (3) The proper surgical approach is on the side of the effusion in unilateral chylothorax, but right side approach is preferred in case of bilateral chylothorax or when the origin of chylous fistula is unknown; (4) Pleurodesis is indicated for those cases if the duct is not obviously present or chyle comes from the pleural lymphatics. Concentrated glucose solution with or without Talc suspension is recommendable.     

Aggressive treatment of chylothorax complicating transhiatal esophagectomy without thoracotomy

Chylothorax is an unusual complication after transhiatal esophagectomy (THE) and in the past 10 years has occurred in 11 of 320 patients (3%) undergoing this operation for diseases of the intrathoracic esophagus. Four patients had benign esophageal disease: scleroderma reflux esophagitis (1), caustic stricture (1), and achalasia (2), and each had undergone at least one previous esophageal operation. Seven patients had intrathoracic esophageal carcinoma--two upper-third, two middle-third, and three distal-third lesions. Excessive chest tube drainage more than 72 hours after THE was the standard presentation, and the diagnosis of chylothorax was confirmed by the administration of cream through the jejunostomy feeding tube placed routinely at operation. The character of the chest tube drainage changed from serous to opalescent. Aggressive treatment of this complication was the rule, and every patient underwent a thoracotomy between 2 to 14 days (average, 6 days) after the diagnosis was established. Cream was administered through the jejunostomy tube before operation, and in each case the thoracic duct injury was readily identified and controlled with suture ligatures. There were no deaths in this group, and there was one recurrence of the fistula that required reoperation; all patients were discharged from the hospital within 3 to 29 days (average, 10 days) after thoracic duct ligation. It is concluded that early recognition of a chylothorax after transhiatal esophagectomy with prompt transthoracic ligation of the injured duct results in a shorter overall hospitalization and lower morbidity and mortality from this complication. The traditional conservative management of chylothorax with intravenous hyperalimentation and no or low-residue enteral feedings has little place in this nutritionally depleted patient population.     

Chylothorax following division of patient ductus arteriosus in an adult

A case of postoperative chylothorax following division of a patent ductus arteriosus in an adult is presented. The patient recovered following reoperation for ligation of the thoracic duct after an 11-day trial of conservative management. Arguments for conservative and operative management are discussed and the anatomy of the thoracic duct is shown.     

Bilateral chylothorax following thoracic duct ligation: Case report and review of the literature

Bilateral chylothorax following thoracic duct injury is a rare occurrence. Since 1907 there have been only six reports in the literature of this potentially serious complication. We report a case of bilateral chylothorax following ligation of the cervical thoracic duct during a left subclavian to carotid artery transposition.