Control of Traumatic Chylothorax with EUS-Guided Thoracic Duct Injection Sclerotherapy

Abstract

Chylothorax due to thoracic duct (TD) trauma is traditionally treated with duct ligation at thoracotomy. We describe a novel endoscopic approach to this difficult management dilemma using endoscopic ultrasound (EUS) and fine needle injection (FNI) of the TD. A 41 year-old male was involved in a high-speed motor vehicle accident resulting in ejection from the vehicle and severe chest injuries. During his hospitalization refractory hiccups and nausea prompted a chest CT scan. A 4.9 × 3.1 cm focal fluid collection was identified between the esophagus and aorta in the subcarinal region. Bilateral pleural effusions were seen but no pulmonary mass or adenopathy was present. Rupture of the thoracic duct was considered and an EUS confirmed a 6 cm fluid collection under the aortic arch. A dilated 2.2 mm thoracic duct could be tracked into the collection and 35 ml of milky, straw colored fluid was aspirated; pathology confirmed a chyloma. In preparation for thoracic duct occlusion the following day and to optimize TD visualization, the patient was fed 2 canisters of high fat Ensure. The next day the fluid had fully re-accumulated and the thoracic duct was again identified. Color flow Doppler interrogation of surrounding structures confirmed its relation to the azygous vein. Twenty ml was again aspirated, fully collapsing the collection. Because of its safety profile and sclerosant properties, 1.5 ml of sodium morrhuate (NaM) was directly into the TD under EUS control. There were no complications. The nausea and hiccups resolved and the patient was discharged uneventfully. No surgical intervention or chest tube placement was required. To our knowledge, this represents a novel and minimally invasive approach to manage traumatic chylothorax. We have replicated this approach in swine models and will present gross and histopathologic proof of principle.