Management Of Chylothorax Research Articles

Skim Milk Preparation for the Management of Chylothorax Developing after Congenital Diaphragmatic Hernia Repair.

Skim Milk Preparation for the Management of Chylothorax Developing after Congenital Diaphragmatic Hernia Repair.

RECURRENT NECK SWELLING LEADS TO MULTIPLE SPONTANEOUS CHYLOTHORACES

SESSION TITLE: Disorders of the Pleura 1 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 pm - 02:15 pm INTRODUCTION: Spontaneous Chylothorax is a rare clinical entity and often with an obscure presentation. Chylothorax is defined as the presence of chyle in the pleural space. The etiology of this condition is often traumatic however, non-traumatic etiologies including malignancies such as lymphoma and other autoimmune conditions can occur. CASE PRESENTATION: 69 year old female with no significant past medical history presents to the ED with painless swelling on the left side of her neck. While driving back to Scottsdale Arizona from Montana she noticed an acute swelling on the left side of her neck. The patient experienced some generalized chest tightness and shortness of breath with the neck swelling. She denied recent history of fever, chills, weight loss, malaise, rash, or arthralgias. On exam, her vitals, joint, lymphatic and abdominal exams were all normal except for non-tender swelling on the left neck. A neck CT demonstrated either edema, hematoma, or other infiltrating process involving the root of the left neck, the left chest wall and axilla, the mediastinum, and the upper retroperitoneum without abscess, obvious mass, abnormal enhancement, or vascular abnormality. There were small pleural effusions. A thoracentesis was performed and cloudy white fluid was extracted from the left pleural space. Pleural fluid analysis was significant only for the findings of chylomicrons. Further imaging with a nuclear lymphatic scan showed an intact thoracic duct without evidence of lymphatic leak. The patient had a normal CBC, CMP, ESR, CRP, SPEP, lymphocyte panel, fungal screening and cancer markers. Patient’s ANA returned positive with a speckled pattern and at titer of 1:160, however, additional markers for lupus were done and all returned negative. At that time the patient’s symptoms resolved and she was discharged. Patient presented two months later with a second episode. The supraclavicular swelling was now painful and associated with pleuritic chest pain and tightness. Further workup for lymphoma and auto-immune causes included a bone marrow biopsy that did not show any evidence of lymphoma, a negative flow cytometry study, a repeat nuclear lymphoscintigraphy of the head was negative for lymphatic leak. She experienced 14 more episodes of neck swelling over the course of 6-8 months and went to Mayo for a second opinion and a PET scan showed no evidence of malignancy or obstruction. DISCUSSION: Based on testing done to date, no evidence of a lymphoproliferative disorder, autoimmune disease or malignancy has been detected. Chylothorax accounts for approximately 3% of pleural effusions in adults. Primary etiology is malignancy with 75% of cases being lymphoma. Other rare conditions include lymphangiomyomatosis, sarcoidosis, tuberculosis, venous thrombosis, congenital lymphatic malformations and trauma. CONCLUSIONS: With no clear etiology the diagnosis falls into the category of spontaneous chylothorax. Reference #1: Etiology of Chylothorax in 203 PatientsClinton H. Doerr, Mark S. Allen, Francis C. Nichols III, Jay H. RyuMayo Clinic Proceedings, Vol. 80, Issue 7, p867–870, July 2005 Reference #2: Varona Porres D, Persiva O, Pallisa E, Sansano I. Diagnostic imaging in spontaneous rupture of a thoracic duct cyst in the mediastinum. Radiologia. 2016;58(6):491-495 Reference #3: Lyon S, Mott N, Koukounaras J, Shoobridge J, Hudson PV. Role of interventional radiology in the management of chylothorax: A review of the current management of high output chylothorax. Cardiovasc Intervent Radiol. 2013;36(3):599-607 DISCLOSURES: No relevant relationships by Alexis MacDonald, source=Web Response No relevant relationships by Kimberly Parker, source=Web Response

PS02.056: TIMELY LIGATION OF THORACIC DUCT IN POST ESOPHAGECTOMY CHYLE LEAK: KEY TO SUCCESSFUL MANAGEMENT

Abstract Background Chyle leak after esophagectomy for carcinoma esophagus is a rare but life threatening condition with reported an incidence of 1–6%. Mortality rate of up to 50% have been reported. Management of chyle leak is controversial. We reviewed our experience with iatrogenic chylothorax after esophagectomy for carcinoma esophagus. Methods From 2003 to 2017, 560 patients underwent esophagectomy for cancer at our department of oncosurgery. Eight patients developed post operative chyle leak. Transthoracic or transabdominal ligation of duct was done in six patients with in first week. 100 ml of cream was given 30 min before induction to visualize the leak intraoperatively. We used 4–0 prolene pledgeted suture to ligate the duct. Results Six patients who underwent early ligation could be salvaged and the two who were managed conservatively succumbed. Oringer et al. pointed towards conservative treatment having little place in the management of chylothorax in nutritionally depleted patients. Hence, prompt ligation of thoracic duct decreases morbidity and mortality of chylothorax. Thus the role of early surgery needs to stressed. There is a wide difference of mortality rate of conservative management of 82% with respect to the mortality rate of surgery of 10–16%. Though no conclusion data are available regarding the indication and time point of surgical ligation of the thoracic duct, it is important not to procrastinate while the condition deteriorates to a level at which surgery would be detrimental.Administration of cream to the patient (through feeding jejunostomy) around half an hour before surgery makes identification of site of leak simpler.The importance of pledgeted sutures cannot be denied as the thoracic duct is paper thin and chyle contains no fibrin. Thus non pledgeted sutures will tear it further. Infact, stitching should not be done through the duct but into the surrounding tissue around the duct and should allow the pledgets to close the duct. Conclusion Disclosure All authors have declared no conflicts of interest.

PS02.221: THE SUCCESSFUL CONSERVATIVE MANAGEMENT OF CHYLOTHORAX WITH ETILEFRINE AND SOMATOSTACHIN ANALOG AFTER ESOPHAGECTOMY: A CASE REPORT AND REVIEW OF THE LITERATURE

Abstract Background Chylothorax is a severe complication after esophagectomy and is sometimes difficult to treat. Patients are treated with surgical and conservative therapies, including nutritional management. Methods Case: The patient was an 80-year-old man who had complained of dysphagia. Upper gastrointestinal endoscopy demonstrated a Borrmann type 2 tumor in the lower esophagus. Biopsy revealed squamous cell carcinoma. He was referred to our hospital after radiotherapy (40 Gy). The clinical stage, according to the UICC 7th edition, was cT3N1M0 cStage IIIA. Transthoracic esophagectomy with 2-field lymph node dissection was performed. The thoracic duct was observed. The postoperative chylothorax volume was < 1000 ml/day and required continuous drainage management. Results The single use of somatostatin analog failed to reduce the patient's chylothorax. Treatment with etilefrine and somatostachin analog led to the resolution of the patient's chylothorax. Conclusion The management of chylothorax with etilefrine and somatostachin analog may be a treatment option for patients with a low chylothorax volume or elderly patients. Disclosure All authors have declared no conflicts of interest.

A protocol to decrease postoperative chylous effusion duration in children.

Our primary goal was to decrease time to resolution of postoperative chylothorax as demonstrated by total days of chest tube utilisation through development and implementation of a management protocol. A chylothorax management protocol was implemented as a quality improvement project at a tertiary-care paediatric hospital in July, 2015. Retrospective analysis was completed on patients aged 0-17 years diagnosed with chylothorax within 30 days of cardiac surgery in a pre-protocol cohort (February, 2014 to June, 2015, n=20) and a post-protocol cohort (July, 2015 to March, 2016, n=22).Measurements and resultsPatient characteristics were similar before and after protocol implementation. Duration of mechanical ventilation and cardiac ICU and hospital lengths of stay were unchanged between cohorts. Following protocol implementation, total duration of chest tube utilisation decreased from 12 to 7 days (p=0.047) with a decrease in maximum days of chest tube utilisation from 44 to 13 days. Duration of medium-chain triglyceride feeds decreased from 42 days to 31 days (p=0.01). In total, three patients in the post-protocol cohort underwent additional surgical procedures to treat chylothorax with subsequent resolution of chylothorax within 24 hours. There were no chest tube re-insertions or re-admissions related to chylothorax in either the pre- or post-protocol cohorts. Protocol compliance was 81%. Adoption of a chylothorax management protocol is feasible, and in our small cohort of patients implementation led to a significant decrease in the duration of chest tube utilisation, while eliminating practice variability among providers.

Surgical chylothorax in neonates: management and outcomes.

Postoperative chylothorax occurs due to trauma to lymphatic vessels and can occur after any thoracic procedure. This study reviewed recent literature to evaluate the management and outcomes of surgical chylothorax in neonates. PubMed database was searched for articles in English, Portuguese and Spanish from 2000 to 2016. Data were collected for surgery, chylothorax management, complications, mortality and length of hospital stay (LOS). Twenty studies offered 107 neonates: congenital diaphragmatic hernia (CDH)(n = 76,71%), cardiac malformations(n = 25,23.4%), esophageal atresia(n = 5,4.7%) and CDH+extralobar sequestration(n = 1,0.9%). Medium-chain triglycerides (MCT) was the initial treatment in 52 neonates (48.6%), prednisolone+MCT in one (0.9%), total parenteral nutrition in 51 patients (47.7%), and three patients (2.8%) did not require any treatment. Octreotide and somatostatin were used as second or third line treatment in 25 neonates (23.4%), and 15 neonates (14%) underwent 17 surgeries, including thoracic duct ligation (TDL)(n = 9); pleurodesis(n = 3) (2 patients required TDL); TDL+pleurodesis(n = 2), and TDL+placement of hemostat(n = 1). Complications due to the chylothorax were reported in 27 neonates (25.2%): hypoalbuminemia+hyponatremia(n = 18), hypoalbuminemia(n = 4), hypoalbuminemia with cutaneous flushing as colateral effect of somatostatin(n = 1), loose stool after somatostatin use(n = 1), pneumonia(n = 1), congestive heart failure+hypernatremia(n = 1), and hyponatremia(n = 1). There were 21 deaths (19.6%) and median LOS was 53.4days (30-93.1days). Conservative management is appropriate as initial treatment for neonatal postsurgical chylothorax. Octreotide and somatostatin are safe in neonates and surgical approach should be considered in prolonged leaks.

Chylothorax mimicking as anastomotic leak in a case of esophageal atresia

Chylothorax, as a complication of surgery for esophageal atresia (EA), is rare. It can be misdiagnosed as reflux of milk into the chest cavity. Here, we present a case of EA complicated by chylothorax. A preterm neonate with anorectal malformation and EA (Gross type C) underwent high sigmoid colostomy and posterolateral thoracotomy. Intraoperatively, the baby was found to have a wide gap between the upper and lower end of the esophagus not amenable to primary repair. The lower esophageal end was closed using 4-0 vicryl interrupted sutures. The cervical esophagostomy, feeding gastrostomy, and chest tube insertion were done. The chest tube started draining milky fluid 2 days after starting gastrostomy feeds. It was suspected to be lower esophageal stump blow-out with reflux of gastrostomy feeds onto the chest cavity. Dye study and biochemical analysis of pleural fluid helped to make the correct diagnosis of chylothorax. Successful conservative management of chylothorax was done. In conclusion, chylothorax can mimic as anastomotic leak or reflux of gastric contents into the chest cavity and should be kept in differential diagnosis after surgery for EA. Pleural fluid analysis showing lymphocytic predominant fluid with high fluid/serum triglyceride ratio can clinch the diagnosis.

Malignant Chylothorax Successfully Treated With Serial Talc Pleurodesis

SESSION TITLE: Pleural Effusions SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Chylothorax is the result of thoracic duct compromise with subsequent leakage of chyle into the pleural space. Ovarian carcinoma is a rare cause of chylothorax. CASE PRESENTATION: 77 year-old female with recent DVT and relapsed metastatic ovarian carcinoma presented with dyspnea. Point-of-care ultrasound (POCUS) revealed a large right pleural effusion and thoracentesis of 2.4L was performed, revealing chylothorax with 1508mg/dL triglycerides. 13 days later, she returned to the ED with dyspnea, tachycardia, and hypoxia with recurrent right pleural effusion. An indwelling pleural catheter was placed (day 2). Pleural fluid studies were consistent with lymphocyte predominant exudative chylothorax which was positive for ovarian adenocarcinoma. Subsequent CT was unrevealing for source of thoracic duct compromise but abdominal lymphadenopathy was present. Serial POCUS revealed reaccumulation of chyle despite a total of 3.55L drained over 5 days (table). She received nutritional supplementation including MFCA. On day 9, talc pleurodesis was performed due to dyspnea. After an additional 150mL of chyle was drained, a subsequent POCUS revealed further reaccumulation. She underwent a second talc pleurodesis (day 10). During the rest of her hospitalization no chyle was drained and hypoxia resolved. She was discharged with a plan to receive liposomal doxorubicin for recurrent ovarian carcinoma. DISCUSSION: Conservative management of chylothorax consists of replacing nutrients lost in the chyle including MCFA. Our patient did not respond to conservative management. Due to poor functional status, this patient was unable to undergo chemotherapy. Therefore, she underwent talc pleurodesis, which has proven efficacy in chylothorax. However, it has never been performed in a chylothorax related to ovarian malignancy until this case. Our patient continued to produce chyle despite initial pleurodesis. Indwelling pleural catheters have lower morbidity than other interventions such as thoracic duct ligation. Therefore, we opted for repeat pleurodesis. The second pleurodesis effectively sealed the potential space for chyle reaccumulation (Fig). The decision was made to retain the indwelling pleural catheter in the event of future reaccumulation. CONCLUSIONS: This case represents an alternative treatment of a rare condition. We conclude that this is the first reported case of an ovarian carcinoma-related chylothorax that was resolved with sequential pleurodesis without palliative chemotherapy. Reference #1: Mayo Clin Proc. 2005;80(7):867-70. DISCLOSURE: The following authors have nothing to disclose: Eric Bondarsky, Neil Patel, Lina Miyakawa, Alfredo Astua No Product/Research Disclosure Information

Bilateral Chylothorax Secondary to Cirrhosis and Chylous Ascites

SESSION TITLE: Disorders of the Pleura SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Chylothorax is commonly caused by injury or obstruction of the thoracic duct within the thorax. Rarely, chylothorax can occur as a manifestation of decompensated liver disease with chylous ascites. CASE PRESENTATION: A 61 year old male with decompensated alcoholic liver disease was hospitalized for progressive dyspnea and abdominal distension. Physical examination and radiographic imaging identified large, bilateral pleural effusions and ascites. He did not respond to diuresis and therapeutic paracentesis, so bilateral thoracentesis was performed. Gross appearance of the bilateral pleural fluid was milky and amber in color, contrary to the expected appearance seen with transudative hepatic hydrothorax. Pleural fluid analysis was consistent with bilateral exudative chylothorax (triglycerides of 183 mg/dl and 197 mg/dl from the right and left, respectively). Pleural fluid to serum triglyceride ratio was 4.925 and cholesterol ratio was 0.333, definitively characterizing the pleural fluid as chyle. Although basic initial ascites fluid studies were consistent with portal hypertension as the mechanism, retrospective analysis was consistent with chylous ascites (triglycerides 148 mg/dl). Based on a MELD-Na of 26 and lack of responsiveness with aggressive medical management including diuretics, dietary modification, and abstinence from alcohol, the patient was referred for liver transplantation. DISCUSSION: The mechanism for chylothorax secondary to cirrhosis is due to portal hypertension causing rupture of small lymphatics and leakage of whole intestinal lymph into ascitic fluid, which then passes through diaphragmatic recesses. This mechanism is akin to the more commonly encountered hepatic hydrothorax which is typically transudative in nature. Management of chylothorax resulting from decompensated liver disease is similar to that of hepatic hydrothorax, although there are some additional considerations including use of octreotide to decrease lymphatic flow and post-prandial triglycerides, bowel rest with TPN, and use of orlistat. Medium-chain triglyceride supplementation, used in post-surgical chylous ascites, leads to increased hepatic encephalopathy and death in cirrhotic patients. CONCLUSIONS: For patients with cirrhosis, ascites, and pleural effusions, thoracentesis with thorough pleural fluid analysis can lead to accurate diagnosis of chylothorax, leading to appropriate identification and treatment. When suspected in patients with cirrhosis and ascites, pleural fluid studies should include triglycerides, cholesterol, and chylomicrons, in addition to serum cholesterol and triglycerides to allow for accurate recognition of chylothorax and the underlying etiology. Reference #1: Doerr, CH. “Etiology of Chylothorax in 203 Patients.” Mayo Clin Proc 80.7 (2005): 867-70. Print. Reference #2: Romero, S, and C Martin. “Chylothorax in Cirrhosis of the Liver: Analysis of Its Frequency and Clinical Characteristics.” Chest 114.1 (July 1998): 154-59. Print. DISCLOSURE: The following authors have nothing to disclose: Mark Nau, David Ferraro No Product/Research Disclosure Information

Evidence-based management of chylothorax in infants

PurposeManagement guidelines for infants with chylothorax lack substantial evidence. We sought to identify variables that impact outcomes in these patients in order to develop an evidence-based management algorithm. MethodsWe retrospectively reviewed the medical records of all infants diagnosed with chylothorax from June 2005 to December 2014 at our institution. Data collected included demographics, chest tube output (CTO), medical and dietary interventions, surgical procedures, and absolute lymphocyte count (ALC). Outcomes analyzed included death, sepsis, necrotizing enterocolitis (NEC), requiring surgery, and success of therapy, defined as CTO decrease by >50% within 7days. ResultsOf 178 neonates with chylothorax, initial therapy was high medium chain triglyceride (MCT) feedings in 106 patients, nothing by mouth (NPO), total parenteral nutrition (TPN) in 21, and NPO/TPN plus octreotide in 45. Octreotide use in addition to NPO/TPN revealed no significant differences in any outcome including success (47% vs. 43%, p=0.77). Initial CTO and ALC correlated with needing surgery (p=0.002 and p=0.006, respectively), and with death (p=0.028 and p=0.043, respectively). ALC also correlated with sepsis (p<0.001). ConclusionsOctreotide has no advantage over NPO/TPN alone in infants with chylothorax. CTO and ALC predict requiring surgery. We propose a management guideline based on CTO and ALC without a role for octreotide. Type of studyRetrospective case–control study. Level of evidence3

Incidence and management of chylothorax after Ivor Lewis esophagectomy for cancer of the esophagus

ObjectiveChylothorax is a major complication after esophagectomy. As recent studies refer to heterogeneous patient cohorts and surgical procedures, this study was conducted to report the incidence and evaluate the optimal management of chylous fistula in patients treated with transthoracic esophagectomy and 2-field lymphadenectomy for esophageal cancer. MethodsFrom January 2005 to December 2013, a total of 906 patients underwent transthoracic esophageal resection for esophageal carcinoma at our institution. En bloc esophagectomy was performed with routine supradiaphragmatic ligation of the thoracic duct. The incidence of chylothorax, and associated morbidity and mortality, were analyzed, and subsequent therapeutic management was reviewed. ResultsChylothorax after Ivor Lewis esophagectomy was observed in 17 (1.9%) patients. Fifteen patients required surgical intervention with rethoracotomy and repeat duct ligation. Thoracic duct ligation was successful in all patients. Two patients died within 90 days after primary esophageal resection. The median time between initial tumor resection and rethoracotomy was 13 days. Average daily chest-tube output at time of reoperation was 1900 mL. In 2 patients, pleural effusion did not exceed 1000 mL per day. In these cases, conservative management with additional thoracic drainage and total parenteral nutrition led to complete resolution of chylous fistula. ConclusionsOccurrence of chylothorax after prophylactic thoracic duct ligation during transthoracic esophagectomy for esophageal cancer is rare. In patients with high-output chylous fistula, an early rethoracotomy with repeat ligation of the thoracic duct is safe and helps to shorten recovery time. In cases of low-volume drainage, a conservative approach is feasible.

Minimally invasive surgical management of chylothorax complicating esophagectomy

Chylothorax is a rare complication of esophagectomy associated with increased morbidity and mortality. Prophylactic thoracic duct ligation is generally recommended during transthoracic esophagectomy, but despite this strategy chyle leak can occur. A possible explanation is that in up to 40% of individual the anatomical route of the thoracic duct is anomalous. A two-week wait and see policy with total parenteral nutrition and pleural drainage appears to be justified in patients with a chyle output of less than 1,000 mL per day. The introduction of video-assisted thoracic surgery has offered a safe and effective therapeutic alternative in these patients. We recommend primary en-bloc stapling of the thoracic duct through a right thoracoscopic approach in the semi-prone position.

Successful use of recombinant tissue plasminogen activator (r-TPA) for management of chylothorax associated with central venous thrombosis after neonatal cardiac surgery

Postoperative chylothorax is a frequently encountered pathology occurring in up to 5% of patients undergoing surgery for repair of congenital heart disease. Neck vein thrombosis can be associated with chylothorax and may contribute to its severity and duration. Furthermore, neck vessel thrombosis resulting in permanent vessel occlusion may hinder future management, diagnostic studies and cardio-surgical interventions. In this report we are describing a neonate who developed chylothorax on the 7th post-operative day following open-heart surgery. The chylothorax was linked to venous thrombosis in the cannulated right internal jugular vein with thrombus extending to the right atrium. After using low dose tissue plasminogen activator (r-TPA) infusion, the thrombi disappeared and the chylothorax resolved with no complications.

Incidence and management of chylothorax after esophagectomy.

BackgroundChylothorax is a rare but serious postoperative complication in esophageal cancer patients. The aim of this study was to identify risk factors associated with chylothorax and the indication for surgical intervention.MethodsA consecutive series of 1290 patients who underwent esophagectomy for esophageal cancer was included. Peri-operative data, including postoperative morbidity and mortality, were analyzed.ResultsThirty-four patients (2.6%) developed chylothorax and had significantly higher instances of pneumonia (26.5% vs. 11.1%, P = 0.012) and arrhythmia (17.6% vs. 2.9%, P = 0.001), and a longer hospital stay (22 vs. 18 days, P < 0.001). Reoperation was performed in 11 patients at a rate of 77.8%, 42.9%, 20%, and 0% for chylothorax diagnosed in two, three, four, and >= 5 days, respectively, after esophagectomy (P < 0.001). After three days of conservative therapy, the chest tube output was significantly greater in patients whose medical management had failed than in those successfully treated (P < 0.001). All patients who required reoperation had >= 13.5 ml/kg of drainage (sensitivity 100%); four of 23 patients with successful medical management had a chest tube output >= 13.5 ml/kg (specificity 83%). Logistic regression analysis showed that body mass index (BMI) < 25 was an independent risk factor for chylothorax (hazard ratio = 9.256, P = 0.029).ConclusionsPatients with a BMI < 25 are more likely to develop chylothorax after esophagectomy. Operative therapy should be seriously considered in patients who develop chylothorax early postoperatively. In addition, a high daily chylous output of >= 13.5 ml/kg after three days of conservative therapy might be a reliable indicator for reoperation.

Abstract No. 526 - Role of the interventional radiologist in the diagnosis and management of chylothorax: a review of traditional and novel methods

Abstract No. 526 - Role of the interventional radiologist in the diagnosis and management of chylothorax: a review of traditional and novel methods

Octreotide for the Management of Chylothorax in newborns, case report

Chylothorax is the most common cause of pleural effusion in neonates. It is usually idiopathic. Neonatal chylothorax successfully respond to octreotide treatment and can reduce the duration of hospitalization. A number of therapeutic interventions have been used to reduce chyle production and promote resolution of a chylothorax. Initial management typically includes restriction or temporary cessation of enteral feedings. Enteral feedings high in medium-chain triglycerides (MCT) or parenteral nutrition may be used. These strategies alone are not successful in all patients. In the last several years, octreotide has become another option for management of patients with chylothorax. octreotide has a number of effects on the gastrointestinal system, including a decrease in splanchnic blood flow and inhibition of serotonin, gastrin, vasoactive intestinal peptide, secretin, motilin, and pancreatic polypeptide. We report an infant who had spontaneous chylothorax with patent ductus arteriosus that was managed primarily as congenital heart disease. Our case was treated successfully with octreotide without the need to insertion of chest tube.

Chylothorax: Percutaneous Embolization of the Thoracic Duct

Thoracic duct embolization is a percutaneous, image-guided intervention used in the management of chylothorax. Chylothorax, or chylous leak in the chest, is a rare condition that represents a spectrum of disorders that have in common leakage of intestinal lymph (chyle) into the thorax. Although conservative and surgical management are the standard of care, we present an overview of lymphangiography and percutaneous thoracic duct embolization.

EComment. Optimal management of chylothorax following oesophagectomy

eComment. Optimal management of chylothorax following oesophagectomy

The Incidence and Management of Postoperative Chylothorax After Pulmonary Resection and Thoracic Mediastinal Lymph Node Dissection

Our objective was to determine the incidence and optimal management of chylothorax after pulmonary resection with complete thoracic mediastinal lymph node dissection (MLND). This is a retrospective review of patients who underwent pulmonary resection with MLND. Between January 2000 and December 2012, 2,838 patients underwent pulmonary resection with MLND by one surgeon (RJC). Forty-one (1.4%) of these patients experienced a chylothorax. Univariate analysis showed that lobectomy (p<0.001), a robotic approach (p=0.03), right-sided operations (p<0.001), and pathologic N2 disease (p=0.007) were significantly associated with the development of chylothorax. Multivariate analysis showed that lobectomy (p=0.011), a robotic approach (p=0.032), and pathologic N2 disease (p=0.027) remained predictors. All patients were initially treated with cessation of oral intake and 200 μg subcutaneous somatostatin every 8 hours. If after 48 hours the chest tube output was less than 450 mL/day and the effluent was clear, patients was given a medium-chain triglyceride (MCT) diet and were observed for 48 hours in the hospital. If the chest tube output remained below 450 mL/day, the chest tube was removed, they were discharged home with directions to continue the MCT diet and to return in 2 weeks. Patients were instructed to consume a high-fat meal 24 hours before their clinic appointment. If the patient's chest roentgenogram was clear at that time, they were considered "treated." This approach was successful in 37 (90%) patients. The 4 patients in whom the initial treatment was unsuccessful underwent reoperation with pleurodesis and duct ligation. Chylothorax after pulmonary resection and MLND occurred in 1.4% of patients. Its incidence was higher in those with pathologic N2 disease and those who underwent robotic resection. Nonoperative therapy is almost always effective.

Is early surgical management of chylothorax following oesophagectomy beneficial?: Table 1:

A best evidence topic in surgery was written according to a structured protocol. The question addressed was whether the initial surgical management of chylothorax after oesophagectomy results in a better outcome. Altogether 357 papers were found as a result of the reported search, of which 4 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. Three studies were retrospective and from single centres with small patient numbers, while one study was a prospective, randomized controlled trial, from which a subgroup analysis was included in our results. We conclude that although all studies to date have had very small patient numbers and some contradictory results, there is some evidence that early surgical intervention of chylothorax following oesophagectomy reduces hospital stay when compared with conservative treatment.