Chylothorax after cardiothoracic surgery

8 patients with postoperative chylothorax were reported: 7 after resection of esophageal carcinoma, 1 after radical correction of tetralogy of Fallot. 1 case was treated conservatively and 7 by ligation of thoracic duct after rethoracotomy. All the cases recovered. The factors causing postoperative chylothorax, the principles of treatment, and the role of prophylactic ligation of thoracic duct were discussed. The authors point out that, the mechanisms of postoperative chylothorax after open heart surgery by sternotomy may be: (1) injury of perithymotic and anterior mediastinal lymph ducts; (2) injury of thoracic duct through posterior wall of pericardium; and (3) effect of hypertension of systemic veins on flow of thoracic duct.     

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.     

Chylothorax complicating esophagectomy for cancer: a plea for early thoracic duct ligation

OBJECTIVE: Postoperative chylothorax remains an uncommon but potentially life-threatening complication of esophagectomy for cancer, and the ideal management is still controversial. The aim of the study was to compare the outcomes of patients treated nonoperatively with those of patients promptly undergoing reoperation. METHODS: From 1980 to 1998, 1787 esophagectomies for esophageal or cardia cancer were performed, and 19 (1.1%) patients had postoperative chylothorax. We analyzed type of operation, surgical approach, delay of diagnosis of chylothorax, daily chest tube output, type of management, major complications, death, hospital stay, and final outcome. RESULTS: Of the 19 patients with chylothorax, 11 were initially managed nonoperatively (group A): 4 (36%) patients had spontaneous resolution of chylothorax, and the other 7 required reoperation for the persistence of a high-volume output. There were three infectious complications and one postoperative death in this group. No reliable predictive criteria of successful versus unsuccessful nonoperative management could be found. The 8 most recent patients underwent early reoperation (group B). All patients recovered, and no major complications possibly related to chylothorax or hospital deaths were observed. They were discharged after a median of 22 days (range, 12-85 days) compared with a median of 36 days (range, 21-64 days) for patients of group A. CONCLUSIONS: Early thoracic duct ligation is the treatment of choice for chylothorax occurring after esophagectomy. Reoperation should be performed immediately after the diagnosis is made to avoid the complications related to nutritional and immunologic depletion caused by prolonged nonoperative treatment.     

Linfografía y embolización del conducto torácico como tratamiento del quilotórax tras esofagectomía por cáncer de esófago

IntroductionChylothorax is a rare complication in esophagectomies that is associated with increased postoperative mortality. Several factors have been described that may favor its appearance. Its treatment is controversial, and lymphography with percutaneous embolization of the thoracic duct is used by several groups.Material and methodOur retrospective study included patients who underwent esophagectomy for cancer of the esophagus or the esophagogastric junction (Siewert I/II) between January 2010 and April 2019 and developed chylothorax as a complication. Epidemiological data, type of surgery, morbidity and treatment were analyzed.Results274 cancer-related esophagectomies were performed in the study period. Thirteen patients (4.7%) were diagnosed with chylothorax in the postoperative period; 3 were resolved with conservative treatment. In the remaining 10 patients, lymphography was performed with aspiration of the cisterna chyli and thoracic duct embolization, which resolved the chylothorax in 9. One patient (10%) presented a biliary fístula after the procedure.ConclusionsLymphography with aspiration of the cisterna chyli and thoracic duct embolization is a technique with low morbidity that provides good results for the resolution of chylothorax after esophagectomy.     

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.     

The first series of completely robotic esophagectomies with three-field lymphadenectomy: initial experience

Background This study investigated the use of robotics to perform extended esophageal resection in a series of patients. Methods A total of 14 patients with a median age of 64 years underwent esophagectomy using the da Vinci robot. At presentation, there were 12 cases of cancer, staged at T2N1 (n = 2), T3N0 (n = 2), T3N1 (n = 6), T4N1 (n = 1), and M1a (n = 1); 2 cases of high-grade dysplasia; 8 cases of adenocarcinoma; and 4 cases of squamous cell cancer; as well as 2 middle third, 9 lower third, and one gastroesophageal junction tumor. Nine patients had undergone preoperative chemoradiotherapy, and six had undergone prior abdominal surgery. The patients were categorized into three chronological groups according to the procedure performed. Group 1 consisted of the first three patients in the series, whose surgery was thoracic only (robotically assisted esophagectomy). Group 2, the next three patients, had robotically assisted thoracic esophagectomy plus thoracic duct ligation using a laparoscopic gastric conduit. Group 3, the last eight patients, underwent completely robotic esophagectomy. Results For Group 3, the total operating room time was 11.1 ± 0.8 h (range, 11.3–13.2 h), with a console time of 5.0 ± 0.5 h (range, 4.8–5.8 h). The estimated blood loss was 400 ± 300 ml (range, 200–950 ml). One patient in group 1 had a thoracic duct leak. In groups 2 and 3, thoracic duct ligation resulted in no further leaks. Other postoperative complications included severe pneumonia (1 case), atrial fibrillation (5 cases), cervical anastomotic leak (2 cases), wound infection (1 case), and bilateral vocal cord paresis requiring tracheostomy (1 case). In seven of the cases, no intensive care unit time was required. There was one death from pneumonia 72 days after the procedure. The rate of disease-free survival was 87%. Conclusion The robotic approach facilitates an extended three-field esophagolymphadenectomy even after induction therapy and abdominal surgery. Larger scale trials are needed to define the role of this technique.     

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。     

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.     

A left thoracic approach in a prone position for thoracoscopic thoracic duct ligation in a patient with post-esophagectomy chylothorax: A case report

IntroductionWe debate whether or not to approach from right thorax for the left chylothorax after esophagectomy.Presentation of caseA 50 s-year-old female underwent right-sided thoracoscopic esophagectomy with three-field lymphadenectomy for esophageal carcinoma (type 0-IIa, 3.4 × 2.2 cm, T1bN0M0, Stage IA), followed by reconstruction with esophagogastric anastomosis through the posterior mediastinum. The thoracic duct was excised and ligated. The left thoracic drainage increased to 2115 mL/day on the fifth postoperative day. Thoracic duct injury was diagnosed, and surgery was performed on sixth postoperative day. With the patient in a prone position, the thoracic duct was ligated successfully under thoracoscopy in the left thorax. The leakage point was found in the crushed duct by 8.8-mm titanium clips. Then, we performed mass ligation of the thoracic duct with 11-mm titanium clips below the leakage point after careful dissection. The surgery took 58 min, with an estimated total blood loss of 0 g.DiscussionAlthough thoracic duct is anatomically located on the right side of the descending aorta, we employed a left-sided thoracoscopic approach due to the chylous leakage in the left thorax. With the patient in the prone position, surgeons can easily convert from a left thoracic approach to a right thoracic approach immediately without postural change if the thoracic duct cannot be found in the left thoracic cavity.ConclusionThis technique is useful and should be considered for patients with left chylothorax.     

食管癌切除术并发胸导管损伤的早期诊断及治疗

我院1990年至1993年共施行食管癌切除术160例，术中胸导管损伤5例，发生率为2．1％，5例中3例于术中发现并及时处理，未发生乳糜胸，另2例于术后并发乳糜胸才诊断，经早期剖胸手术治愈,本文介绍了食管癌切除术并发胸导管损伤的早期诊治体会。     

Chylothorax: an assessment of current surgical management

The development of chylothorax is a serious and often life-threatening clinical entity. Optimal management of this problem has not been well defined to date. We reviewed our experience with chylothorax in patients of all ages during the past 10 years. Ages ranged from 2 days to 69 years. The etiologies were traumatic in 17 and congenital or idiopathic in three. Six patients (five infants) were treated nonoperatively with either repeated thoracenteses or chest tube drainage. Fourteen patients (11 infants) underwent operative treatment: transthoracic thoracic duct ligation (five patients), pleuroperitoneal shunting (seven), pleuroperitoneal shunting combined with reoperation on a patient with congenital heart disease (one), and reoperation alone on a patient with congenital heart disease (one). Duration of preoperative therapy ranged from 9 days to 2 months (average 3.3 weeks). Five of six (83.3%) patients treated nonoperatively died. Of the surgically treated group, only two of 14 (14.3%) died, and 11 of the 12 survivors had resolution of the chylothorax and immediate clinical improvement. Our experience suggests that both pediatric and adult patients respond poorly to nonoperative treatment of chylothorax and that this treatment has a high mortality rate. Post-traumatic and congenital chylothorax should be treated operatively after a limited trial (1 to 2 weeks) of nonoperative therapy. Pleuroperitoneal shunting may offer a reasonable and effective alternative to thoracotomy and thoracic duct ligation.     

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.     

Does ligation of the thoracic duct during oesophagectomy reduce the incidence of post-operative chylothorax?

A best evidence topic in surgery was written according to a structured protocol. The question addressed was whether prophylactic thoracic duct ligation during oesophagectomy results in a lower incidence of post-operative chylothorax. 29 relevant papers were found using the reported search, of which 5 papers represented the best evidence to answer the clinical question. The authors, date and country of publication, patient group, study type, relevant outcomes and results of these papers are tabulated. Of these studies, only one was a prospective randomised controlled study with sizeable patient numbers. This was also the most recent study and demonstrated a significant decrease in post-operative chylothorax incidence following intra-operative thoracic duct ligation. Of the four remaining retrospective studies, one showed an increase in chylothorax rate following ligation whilst three showed a reduction in the incidence of chylothorax (although in only one of these three studies was this decrease statistically significantly). We conclude that for patients undergoing oesophagectomy, although there are conflicting results from retrospective studies, prospective randomised controlled trial evidence points to prophylactic ligation of the thoracic duct as an effective measure to reduce the incidence of post-operative chylothorax.     

Prone thoracoscopic thoracic duct ligation for postsurgical chylothorax

Background  Chylothorax after complex abdominal and thoracic procedures remains a challenging complication with a mortality rate reaching 50% if untreated [1]. Iatrogenic trauma accounts for almost 20% of all chyle leaks, and esophagectomy is the most common iatrogenic cause [2]. Consequences of ongoing chyle leak include dehydration, malnutrition, and immunocompromise. Methods  When nonoperative management techniques fail, prompt ligation of the thoracic duct at the diaphragmatic hiatus should be attempted. The authors present prone thoracoscopic thoracic duct ligation performed for two patients after laparoscopic transthoracic esophagectomy and revision paraesophageal hernia repair. Results  The prone position for thoracoscopic thoracic duct ligation offers several benefits to the surgeon. Gravity retracts the lung anteriorly, exposing the diaphragmatic hiatus. Single-lumen endotracheal intubation combined with low-pressure carbon dioxide insufflation efficiently collapses the lung to create ample working space. For the two reported patients, only three trocars were necessary to complete suture ligation of the thoracic duct via the right chest. Both patients had complete resolution of their chylothorax and recovered uneventfully. Based on this experience, the authors currently advocate early thoracoscopic treatment for cost and morbidity savings. Conclusions  The authors believe prone thoracoscopic thoracic duct ligation offers significant advantages to the patient in preventing the dangerous consequences of chyle leak in a timely, minimally invasive fashion. Importantly, the prone technique with carbon dioxide insufflation makes the technical challenges of thoracic duct ligation more facile for the surgeon. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

食管癌二次手术19例原因分析

目的：探讨食管癌行二次手术的原因及防治措施。方法回顾性分析2000年1月至2012年12月间北京大学肿瘤医院单一手术组施行的946例食管癌手术患者的临床资料,其中19例因术后严重并发症需行二次手术,总结该19例患者的临床特点及治疗经过。结果19例二次手术的患者中因术后胸腔内出血行开胸止血术4例,因膈疝行膈疝还纳、膈肌修补术4例,因乳糜胸行胸导管结扎术4例,因腹部切口裂开行切口缝合术4例,因创伤性胰腺炎行胸腹腔探查、腹腔置管引流术1例,因肠梗阻行回盲部切除、回肠造瘘术1例,因双侧喉返神经麻痹行气管切开术1例。19例二次手术患者全部治愈,无围手术期死亡和再次并发症发生。结论食管癌术后再次手术常见原因主要为术后出血、膈疝、乳糜胸和腹部切口裂开。     

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.     

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.     

Chylothorax. Clinical experience in nine cases

Clinical experience in nine cases of chylothorax is presented. In five cases the cause was iatrogenic, in two cases idiopathic and in two cases the chylothorax was secondary to an advanced malignant disease. Iatrogenic chylothorax occurred after mediastinoscopy, thoracic sympathectomy, pneumonectomy, resection of an aneurysm of the thoracic aorta and closure of a patent ductus arteriosus. Only one of these patients needed an operative closure of the thoracic duct. In one of the two cases of a neoplastic origin the chylothorax was caused by a malignant mesothelioma and thoracic duct ligation was needed while in the other case it was due to an inoperable pancreatic carcinoma and was treated by thoracocentesis. In one of the idiopathic cases supradiaphragmatic ligation of the thoracic duct was necessary. It is concluded that in most iatrogenic or traumatic cases chylothorax can be cured by conservative therapy (diet, thoracocentesis); in other cases the operative therapy should be adjusted to the primary disease, and the ligation of the thoracic duct should be performed at a level where it is able to prevent the chylous leak without unnecessarily interfering with the collateral lymphatic circulation. Abundant and prolonged chylous leakage should be always treated operatively to prevent disastrous nutritional and immunological deficiencies.     

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.