Persistent Chylothorax Research Articles

Treatment of concomitant persistent chylothorax and superior vena cava syndrome through innominate vein-right atrial bypass.

Persistent chylothorax is a major challenge in paediatric patients. We present a case of a 6.5-kg, one-year-old boy with SVCS and persistent chylothorax, who underwent successful surgery without cardiopulmonary bypass. His medical history included multiple co-morbidities such as myeloproliferative disease, short bowel syndrome, and central vein catheterizations. The patient also had IV thrombosis, progressing to SVC, and was on anticoagulants. Despite dietary changes and somatostatin, his high-output chylous pleural effusion persisted. He was treated with innominate vein-to-right atrial bypass using a 6 mm Dacron graft. Postoperatively, there was a significant reduction in effusion and accelerated recovery. Somatostatin failure was likely due to mechanical obstruction of the thoracic duct.

Delayed Chylothorax Following Blunt Chest Trauma Treated with Repeated Lymphangiography: A Case Presentation

Chylothorax is mostly iatrogenic, with blunt chest trauma being a rare cause. Treatment depends on the volume of drainage. Specifically, conservative treatment, such as total parenteral nutrition and pleural drainage, is performed in cases of low daily output (< 500 mL/day). Patients with persistent chylothorax despite medical treatment or with high daily output (> 1-1.5 L/day) are candidates for surgical or radiological intervention. We present a case of delayed-onset chylothorax after blunt trauma caused by thoracic spine fractures, in which persistent chylothorax was successfully managed with repeated lymphangiography with lipiodol when other treatment modalities failed. The case is peculiar in that the chylothorax occurred 40 days after the initial traumatic event and was treated with lipiodol injection, despite maintaining moderate to high daily output.

Non-conservative Management of Chylothorax.

Chylothorax is caused by lymphatic leakage, which can develop after thoracic surgery and is associated with cancer. Although prospective randomized trials have not been performed, radiological interventions have been performed in several cases with persistent chylothorax, adjunct to 2 weeks of conservative management. The success rate of such interventions is diverse due to anatomical variations, although the results are promising. However, in cases of treatment failure after cycles of interventions, a team approach may be necessary to determine whether surgical management is warranted.

Detection of Chyle Leakage Site With Lymphoscintigraphy SPECT/CT in a Patient With Chylothorax Secondary to T-Cell Lymphoblastic Leukemia.

We present a pediatric case with T-cell lymphoblastic leukemia and persistent chylothorax who was referred to lymphoscintigraphy to identify the site of leakage. Planar lymphoscintigraphy with SPECT/CT revealed hot spots at the left jugulovenous angle and the confluens of the vena brachiocephalica to vena cava, which were compatible with the sites of leakage. Hybrid imaging with SPECT/CT technique have great impact on accurate detection of the defects in the lymphatic system in patients with chylothorax.

Platelet-rich plasma fibrin glue for treatment of chylothorax following cavopulmonary connections.

The postoperative persistence of chylothorax is a fatal complication of paediatric cardiac surgery. There is an urgent need for an effective treatment of chylothorax. This study reports the application of allogenic platelet-rich plasma fibrin glue (PRP-FG) as a conservative therapy before reoperation. Over a 9-year period, from 2010 to 2019, 27 patients with persistent chylothorax following a cavopulmonary connection, with a mean latency period of 11 days (range 10-15 days), were treated with PRP-FG. These patients were selected because they had not responded positively to initial conservative management plans. The patients were followed up for 9 years. Twenty-five patients (92%) responded positively to treatment with PRP-FG; 2 patients did not respond to the treatment and died after reoperation. All of the successfully treated patients in follow-up continued to live a healthy life without further complications. Recalcitrant chylothorax that persists after paediatric cardiac surgery responded positively to treatment with PRP-FG. This technique precluded the need for another operation and significantly decreased the morbidity and mortality rates.

Innominate Vein Turn-down Procedure for Failing Fontan Circulation.

After the Fontan, systemic venous hypertension induces pathophysiologic changes in the lymphatic system that can result in complications of pleural effusion, ascites, plastic bronchitis, and protein losing enteropathy. Advances in medical therapy and novel interventional approaches have not substantially improved the poor prognosis of these complications. A more physiological approach has been developed by decompression of the thoracic duct to the lower pressure common atrium with a concomitant increase of preload. Diverting the innominate vein to the common atrium increases the transport capacity of the thoracic duct, which in most patients enters the circulation at the left subclavian-jugular vein junction. Contrary to the fenestrated Fontan circulation, in which the thoracic duct is drained into the high pressure Fontan circulation, turn down of the innominate vein to the common atrium effectively decompresses the thoracic duct to the lower pressure system with "diastolic suctioning" of lymph. Innominate vein turn-down may be considered for medical-refractory post-Fontan lymphatic complications of persistent chylothorax, plastic bronchitis, and protein losing enteropathy. Prophylactic innominate vein turn-down may also be considered at time of the Fontan operation for patients that are higher risk for lymphatic complications.

Retroaortic closure of thoracic duct in the management of persistent chylothorax: a case report

BackgroundChylothorax is a life-threatening pathological condition associated with significant morbidity and mortality. If chyle leakage does not close spontaneously with medical therapy, surgical treatment is inevitable. Herein, we reported a case of spontaneous persistent chylothorax from mediastinal seminoma that was successfully closed between the descending thoracic aorta, and the vertebral column through a left mini-thoracotomy.Case presentationA 24-year old man with mediastinal seminoma was referred to our attention for management of high output persistent chylothorax (> 800 ml/24 h for 30 days) that did not close with conservative treatment. As the leak was isolated within left upper chest cavity, we planned to close the thoracic duct via Poirier’s triangle by uniportal thoracoscopy. However, the long conservative treatment favoured the formation of multiple, tenacious, and bleeding adhesions that made unfeasible thoracoscopy. A conversion to mini-thoracotomy was performed; by the incision of the posterior parietal pleura, the thoracic duct was isolated and ligated behind the thoracic aorta, in an anatomical space delimited by the 4th and the 5th posterior intercostal arteries and the vertebral column.ConclusionsComplete resolution of chylothorax was obtained the day after. Patient was discharged on post-operative day 5, and no recurrence was observed during the follow-up.

PS02.168: THORACIC DUCT EMBOLIZATION IN HIGH-OUTPUT CHYLOTHORAX AFTER ESOPHAGECTOMY FOR ESOPHAGEAL CANCER

Abstract Background Chylothorax after thoracic surgery is initially managed conservatively, but when persistent high-output chylothorax (> 1000 mL/day) is managed conservatively, the mortality rate exceeds 50%. The objective of this study was to examine the clinical results of thoracic duct embolization (TDE) in cases of chylothorax after esophagectomy for esophageal cancer. Methods The data of 9 patients (7 men, 2 women) whounderwent TDE for persistent high-output chylothorax after esophagectomy for esophageal cancer were gathered retrospectively. Lymphangiography was used to identify the supply route of lymphatic fluid from the lumbar lymphatics to the leakage site and lipiodol extravasation and its site. Transcatheter thoracic ductography was used to identify communication between the thoracic duct and the leakage site and extravasation of the iodinated contrast agent. TDE was performed by percutaneous transabdominal approach to cut off the supply route. The technical success and clinical success (drainage volume ≥ 10mL/kg/day within 7 days after TDE) of TDE were evaluated. Results The technical and clinical success rates of TDE were 89.9%, with no serious complications observed. In 44% of patients, the thoracic duct had ruptured. In the other 56%, the ruptured was in a collateral route bypassing the thoracic duct; the leaking lymphatic fluid was supplied without passing through the thoracic duct in 50% of these patients, but clinical success was achieved even in such patients. Conclusion TDE was found to be a safe method of treatment, with no serious complications. Disclosure All authors have declared no conflicts of interest.

Lymphovenous Anastomosis for the Treatment of Chylothorax in Infants: A Novel Microsurgical Approach to a Devastating Problem

Therapeutic, V.

Posterior retroperitoneoscopic thoracic duct ligation: a novel surgical approach.

Treatment of postoperative chylothorax can be challenging. Conservative treatment and/or surgical management by means of open or minimally invasive thoracic duct ligation for persistent chylothorax are accepted therapeutic options. We present a new retroperitoneoscopic approach for thoracic duct ligation. Between January 2006 and May 2017, posterior retroperitoneoscopic thoracic duct ligation was performed in four patients. The thoracic duct was identified transdiaphragmatically and ligated cranially to the cisterna chyli using absorbable clips. Retroperitoneoscopic ligation resulted in a complete and lasting chylothorax resolution in three patients and marked improvement in a fourth one. Mean operative time was 86min (range 40-135). There were no perioperative or postoperative complications. Retroperitoneoscopic thoracic duct ligation is feasible and safe. It allows for a precise anatomical exploration of the thoracic duct caudally to the chyle leak, avoiding the previous operative field and resulting in minimal morbidity. In patients with persistent chylothorax, our approach provides an additional therapeutic option.

Lymphangiography and thoracic duct embolization following unsuccessful thoracic duct ligation: Imaging findings and outcomes

ObjectiveTo summarize the imaging findings and outcomes of thoracic duct (TD) embolization (TDE) performed in patients with chylous leaks persisting after TD ligation (TDL). Materials and MethodsIn this review of 50 patients (30 males and 20 females; median age, 54 years) referred for TDE following unsuccessful surgical TDL, records were reviewed for lymphangiographic findings, technical success of TDE, and outcome of TDE. Comparisons between groups were performed using the Fisher exact test. ResultsThe causes of chylothorax were traumatic in 39 patients (78%) and nontraumatic in 11 (22%). Lymphangiography identified missed TDL in 30 patients (60%) and complete TDL in 15 patients (30%); however, in 12 of these 15 patients, collaterals around the ligation site supplying the leak could be identified. Incomplete ligation was observed in 4 patients (8%). In 1 patient (2%), a second TD was identified circumventing a complete ligation of the main TD. TDE was performed in 49 patients, and TD disruption was performed in 1 patient. Resolution of the chylous leak occurred in 45 patients (90%). There were 3 minor complications that resulted in no clinical sequela. ConclusionsTDE produced cessation of chylous leak in the majority of the patients with persistent chylothorax after surgical TDL. Missed ligation is the most common finding on lymphangiography in patients with failed TDL. These findings support the use of image-guided closure of TD leaks.

Sixteen years of experience with persistent chylothorax in children

Persistent chylothorax in children is rare. Conservative management represents the gold standard but, in case of failure (persistent effusion or relapse), surgery must be considered. This paper aimed at presenting our series of patients who underwent surgical treatment of persistent idiopathic chylothorax and at discussing the role of thoracic duct ligation in its management.We included all patients who underwent surgery for persistent chylothorax in the period between January 1994 and January 2010.Nine patients were included (median age 25 months). Five patients had primitive or idiopathic chylothorax. Five patients had right-sided chylothorax, 3 left-sided, and 1 bilateral. Pleurodesis was applied to 8 patients (bilateral in one) and thoracic duct ligation to 4 patients for a total of 12 procedures in 9 patients. Complete cessation occurred within a median of 5 days (range 2 to 10) after thoracic duct ligation and 10 days (range 4 to 25) after pleurodesis. In 3 patients (all with right sided effusion and a median daily output higher than 20 ml/kg) pleurodesis failed and thoracic duct ligation was subsequently required to definitively treat chylothorax. Conversely, 5 patients were effectively treated with pleurodesis and 1 with thoracic duct ligation alone. Regardless of previous procedures, none of the patients who underwent thoracic duct ligation experienced relapses.Although based on a small number of patients, our experience confirmed that thoracic duct ligation represents an effective therapeutic option for persistent unresponsive chylothorax. In cases of right sided effusion with high output rate (>20 mL/kg) thoracic duct ligation might be considered as first choice treatment.

Percutaneous treatment of persistent chylothorax: technical challenges in a complex case.

We thank Dr. Kaiser for his interest in our paper (1). We are grateful for the insightful comments about the complexity of management of chylous leak (CL) as well as the potentiality of non-operative approaches, which was initially described by his group in 1999 (2).

Chylothorax Secondary to Spontaneous Rupture of the Cisterna Chyli Treated with Lymphangiography

We report a case of idiopathic chylothorax refractory to surgical management, where the leak was due to a spontaneously ruptured cisterna chyli. Surgical management was unsuccessful, including a left-sided pleuroscopy/pleurodesis and a right-sided thoracic duct ligation. After a prolonged period of hospitalization, lymphangiography ultimately demonstrated the site of the chyle leak as a spontaneously disrupted cisterna chyli. Due to the degree of disruption, it was not amenable to cannulation and embolization. However, lipiodol injection was sufficient in itself to lead to resolution of the chylothorax. Lymphangiography is a useful modality that can be potentially therapeutic in persistent chylothorax.

High Dose Octreotide for the Treatment of Chylothorax in Three Neonates

Chylothorax is an abnormal condition of lymphatic fluid collection in thea€€pleural space, and the somatostatin analog octreotide is thought to have a beneficial effect on chylothorax. However, the octreotide dosage and administration route for chylothorax have been inconsistent to date. We report three neonatal cases of persistent chylothorax successfully treated with high-dose octreotide infusion therapy (20 μg/kg/h). Case 1 was congenital chylothorax, Case 2 was secondary chylothorax after an operation for congenital diaphragmatic hernia, and Case 3 was chylothorax after a cardiac operation. In all cases, the chylothorax was not decreased by a low-dose octreotide infusion, but after a high-dose octreotide infusion, the chylothorax decreased and eventually vanished, with no side effects. Conclusion: We suggest that the dose of octreotide in neonatal chylothorax can be safely increased to a maximum of 20 µg/kg/h.

Mayo clinic experience of lung transplantation in pulmonary lymphangioleiomyomatosis

ObjectivesLymphangioleiomyomatosis (LAM) is a rare, cystic lung disease that generally results in progressive decline in lung function. Despite advancement of pharmacological therapy for LAM, lung transplantation remains an important option for women with end-stage LAM. MethodsPatients with LAM undergoing lung transplantation at the Mayo Clinic campuses in Rochester, Minnesota and Jacksonville, Florida since 1995 were retrospectively reviewed. ResultsOverall, 12 women underwent lung transplantation. Nine of 12 (75%) underwent double lung transplant. The mean age was 42 ± 8 years at the time of transplant. One patient (8%) had a chylothorax and 7 (58%) had recurrent pneumothoraces, 4 (33%) of which required pleurodesis. All had diffuse, cystic lung disease on chest CT consistent with LAM which was confirmed in the explant of all patients. The average length of ICU and hospital stays were 5 ± 4 and 19 ± 19 days, respectively.Mild to moderate anastomotic ischemia was evident in all patients but resolved with time. No patient was treated with sirolimus pre-transplant. Seven patients received sirolimus post-transplant; however, clinical benefit was documented in only 2 patients, 1 of which was treated for large retroperitoneal cysts with ureteral obstruction and another with persistent chylothorax and retroperitoneal lymphangioleimyomas. Five patients are deceased. The median survival by Kaplan–Meier analysis was 119 months with a median follow-up of 68 months (range 2–225 months). ConclusionsLung transplant remains a viable treatment for patients with end-stage LAM. The role of sirolimus peri-transplantation remains ill-defined.

Lymphoscintigraphy SPECT/CT: Instrumental Navigator in Repair of Thoracic Duct Injury

A 25-year-old female underwent resection of a large mediastinal tumour which was complicated by copious chylothorax, being worse on the left side. Minimally-invasive video-assisted thoracoscopic surgery (VATS) via a left-sided approach was performed and the severed ends of the thoracic duct were ligated. This only achieved temporary reduction of the amount of chylothorax, leading to a second attempt to repair the persistent leak. A hightriglyceride diet was prescribed for the patient 1-day prior to an open left thoracotomy to improve visualization of the leak. Intra-operatively, the previously repaired sites were intact, but there were several leaky points which were tackled by under-running the leaky channels. Again, the chylothorax improved only temporarily before it recurred and worsened 2 days post-repair. Magnetic resonance imaging (MRI) of the thorax to search for the leak site/s causing persistent chylothorax only demonstrated bilateral pleural effusions without providing a clue as to the the potential site of injury. We performed Tc-99 m nanocolloid lymphoscintigraphy, which demonstrated normal kinetics of lymphatic flow from the pedal injection sites to the cisterna chyli. The propagation of tracer slowed down and the lymphatic channel delineation was hardly discernible beyond the cisterna chyli on planar images (Fig. 1a-b). However, SPECT/CT images acquired at 9 h post-injection revealed and depicted the sites of leakage into bilateral pleural spaces at the juncture where the thoracic duct courses obliquely, from the right hemithorax across to the left hemithorax. Leakage into the right pleural and left mediastinal pleural spaces were localized at the level of the inferior endplate and superior endplate of T6 vertebra, respectively (Fig. 1c-e). This prompted the surgeon to take a different approach from the previous two attempts. It was deemed too risky and potentially futile to further attempt to go after the leakage sites bilaterally. Hence, the surgeon performed a right thoracotomy to ligate the thoracic duct proximal to the leakage sites at the aortic hiatus. This successfully stopped the leak permanently. Planar lymphoscintigraphy lacks accurate anatomical depiction which SPECT-CT could offer. Conversely, anatomical imaging failed to locate the site of the leak. SPECT/CT lymphoscintigraphy overcomes the limitation of either imaging alone, and has been reported to be valuable in documenting and depicting sites of injury [1–3]. In this case, the SPECT-CT depiction and confirmation of bilateral leakage sites was pivotal in guiding the surgeon to take a We confirm that the manuscript has not been published before or is not under consideration for publication anywhere else and has been approved by all co-authors.

Pleurodesis with povidone–iodine for refractory chylothorax in newborns: Personal experience and literature review

IntroductionRefractory chylothorax is a severe clinical issue, particularly in neonates. Conventional primary approach is based on diet with medium-chain fatty acids and/or total parenteral nutrition. In nonresponders, proposed second line treatments include chemical or surgical pleurodesis, thoracic duct ligation, pleuroperitoneal shunting and pleurectomy but none of these have been shown to be superior to other in terms of resolution rate and safety. Our aim is to report our experience on povidone–iodine use for chemical pleurodesis in newborn infants with chylothorax unresponsive to conservative treatment.Our aim is to report our experience on povidone–iodine use for chemical pleurodesis in newborn infants with chylothorax unresponsive to conservative treatment. MethodsSince 2013, povidone–iodine pleurodesis was attempted in all patients with persistent chylothorax who failed conservative treatment (no response to at least 10days of total parenteral nutrition and maximum dosage of intravenous octreotide). Pleurodesis consisted in the injection of 2ml/kg of a 4% povidone–iodine solution inside the pleural space, leaving the pleural tube clamped for the subsequent 4hours. ResultsFive patients were treated with chemical pleurodesis of persistent chylothorax. Four of 5 patients had their pleural effusion treated by one single povidone–iodine infusion. Median time for resolution was 4days. A patient with massive superior vena cava thrombosis did not benefit from pleurodesis. None of the patients experienced long term side effects of the treatment. ConclusionOur data suggest that povidone–iodine pleurodesis may be considered a safe and effective option to treat refractory chylothorax in newborns.

Percutaneous Embolization of a Chylous Leak from Thoracic Duct Injury in a Child

Postoperative chylous leak may result from thoracic duct injury during surgical procedures in the chest or neck and can be successfully treated with percutaneous embolization. We report the case of a child with persistent chylothorax and chyloperitoneum following multivisceral transplantation, which was performed due to unresectable inflammatory myofibroblastic tumor of the retroperitoneum. Intranodal lymphangiography was used to demonstrate the site of chylous leak from the lower segment of the thoracic duct and the leak resolved within days following percutaneous embolization of the thoracic duct.

Generalized lymphatic malformation with chylothorax: Long-term management of a highly morbid condition in a pediatric patient

Generalized lymphatic malformation (GLM) often causes chylothorax, which can be a highly morbid condition. Chylothorax in a pediatric patient with a lymphangiogenic disorder may be especially resistant to therapy, requiring more aggressive measures. We discuss the complex ongoing long-term management of a pediatric patient with GLM who presented with massive, persistent left chylothorax, which resolved by surgical ligation of the thoracic duct and medical management.