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Ann Thorac Surg 1995;60:272-274
© 1995 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

Isolated Thoracic Duct Injury After Penetrating Chest Trauma

Department of Cardiothoracic Surgery, University of Cape Town, Cape Town, South Africa

Accepted for publication April 1, 1995.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. Isolated thoracic duct injuries as a result of penetrating chest trauma without any major vascular or tracheoesophageal injury seldom are seen.

Methods. A retrospective 13-year review identified 8 patients with this injury.

Results. Seven had supraclavicular or suprascapular knife stabs, and the eighth had a low-velocity gunshot injury entering the mid-lateral right chest wall. All 7 stab victims presented with left-sided chylothoraces, and the site of injury of the thoracic duct was within Poirier's triangle, the borders of which are the arch of aorta, the left subclavian artery, and the vertebral column as seen from a lateral approach. Five patients initially were treated conservatively for 13.4 ± 4.4 days without success. Surgical intervention thus was necessary and was successful in all 8 patients. The thoracic duct injury was controlled successfully through a left posterolateral thoracotomy in 6 patients. A supraclavicular repair was attempted in 1 patient but failed to control the leak and required reexploration via the supraclavicular approach. The right chylothorax from the gunshot injury was explored via a right posterolateral thoracotomy; the leak into the pleura was identified and obliterated.

Conclusions. As conservative management was uniformly unsuccessful, we advocate early operative management through a thoracotomy on the side of the chylothorax for this relatively rare injury.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
A chylothorax from injury to the thoracic duct can occur after penetrating, blunt, or iatrogenic trauma. Iatrogenic chylothorax is a well-described complication of operations in the chest [1–4] and is noted in as many as 0.2% of thoracic operations [5]. Blunt trauma resulting in thoracic duct rupture occurs rarely and is thought to be due to hyperextension along the thoracic spine [2, 6–9]. Injury to the thoracic duct from penetrating chest trauma is usually overshadowed by associated major intrathoracic injuries [2, 7], whereas isolated penetrating thoracic duct injury is seldom seen. We present our experience with isolated penetrating injury of the thoracic duct and discuss its pathophysiology and surgical management.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
We retrospectively reviewed the records of all patients admitted to Groote Schuur Hospital, Cape Town, for thoracic complications of penetrating chest or neck trauma between 1981 and 1993. Only patients with isolated thoracic duct injuries with neither major vascular nor tracheoesophageal injuries were included in this study. Patients with minor vascular and pulmonary injuries only requiring insertion of thoracostomy tubes were included in the study. Individual patient characteristics, external site of injury, clinical presentation, course, and surgical management all were reviewed.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
More than 13,000 patients were treated in our trauma ward for penetrating chest or neck trauma over the 13-year study period. We identified 8 patients who had sustained an isolated thoracic duct injury. The penetrating wound was caused by knife stabs in 7 patients and a low-velocity gunshot injury in 1 patient.

Patient Characteristics
All 8 patients were male; they had a mean age at presentation of 22.7 ± 1.5 years. Five patients had been stabbed in the supraclavicular fossa: 2 in the right fossa and 3 in the left. One patient was stabbed in the suprasternal notch and 1 posteriorly above the left scapula. The gunshot injury was in the mid-lateral right chest wall.

All seven stab victims presented with left-sided chylothoraces, despite the external stab wound being on the right in 2 patients. The site of injury of the thoracic duct was within the confines of Poirier's triangle [10] (Fig 1) in all these patients. In contrast, the gunshot victim presented with a right-sided chylothorax, and the thoracic duct was injured at the level of the azygos vein and superior vena cava confluence.

View larger version (31K): [in this window] [in a new window]   Fig 1. . The thoracic duct is readily identified within the confines of Poirier's triangle, via a left posterolateral thoracotomy. The borders of Poirier's triangle (shaded area) are (1) arch of aorta, (2) left subclavian artery, and (3) vertebral column. The thoracic duct traverses the triangle on the esophagus that forms the floor of the triangle.

Management and Clinical Course
Five patients initially were treated medically by tube thoracostomy drainage and a medium-chain triglyceride diet. Total parenteral nutrition was commenced in 2 of these patients because of persistent chyle drainage. The mean duration of medical treatment was 12 days (range, 7 to 29 days). The volume of daily chyle drainage decreased from 1,565 ± 509 mL on admission to 860 ± 184 mL after 12 days of medical treatment. The thoracic duct injury did not close spontaneously in any of these medically treated patients. Furthermore, major complications occurred in 1 patient who persistently refused operation and therefore was treated medically for 29 days; epileptic seizures, probably due to electrolyte disturbances, as well as a deep vein thrombosis complicated his 21 days of total parenteral nutrition.

All 8 patients eventually were treated surgically. In the group of 5 patients initially treated medically, the time from admission to operation was 13.4 ± 4.4 days as opposed to the group of 3 patients who underwent elective early surgical exploration 4 ± 1.53 days after admission.

Surgical Approach
All 7 patients with knife stab injuries had left-sided chylothoraces. Six of these patients underwent a left posterolateral thoracotomy. The site of injury was identified within the confines of Poirier's triangle in 5 of these patients, and the thoracic duct was ligated above and below the injury. In the sixth patient the specific site of the leak could not be identified and a mass suture ablation of the surrounding area was performed using Teflon pledgets. The thoracic duct injury was identified and the duct ligated in the remaining stab patient via a supraclavicular approach. However, chyle drainage recommenced on the first postoperative day in this patient, and after 7 days he required reexploration via a supraclavicular approach and a further ligation of the thoracic duct. It was not necessary to ligate the thoracic duct at the recommended supradiaphragmatic site in any of these patients.

The patient with the gunshot injury was the only patient with a right chylothorax. The leak into the pleura was identified without isolation of the thoracic duct and obliterated using a pleural flap through a right thoracotomy.

All 8 patients recovered rapidly after surgical intervention. Normal oral feeding was started on the second postoperative day. The intercostal drains were removed within 3 days, and the patients were discharged 8.67 ± 0.88 days after operation.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
We have presented 8 cases of isolated thoracic duct injury after penetrating trauma to the chest, which constituted 0.06% of all penetrating neck and chest injuries seen at Groote Schuur Hospital over a 13-year period. It is extremely rare for the thoracic duct to be injured in isolation as this injury usually is masked by associated major vascular or visceral injuries.

It has been stated that the anatomy of the thoracic duct is constant only in its variability [11], with the described course of the thoracic duct being constant in only 65% of the population. The anatomic relations of the thoracic duct are, however, relatively constant at two sites: (1) The first is where it enters the right thoracic cavity, lying on the vertebral column behind the esophagus and to the right of the aorta between the aorta and azygos vein. [11, 12]. Nevertheless, despite this constant location there may be two or more ducts in 33% of patients [11]. (2) The second relatively constant area is within the left chest cavity in Poirier's triangle, which is bounded by the arch of aorta, the left subclavian artery, and the vertebral column. The esophagus lies in the base of this triangle with the thoracic duct lateral to the esophagus (see Fig 1). The site of thoracic duct injury in 7 of our patients was within this anatomic area.

In contrast to the observed failure of medical therapy in our patients with isolated penetrating thoracic duct injuries, the rate of spontaneous closure of iatrogenic thoracic duct injuries treated conservatively has been shown to be high [1]. However, chylous leaks only closed after prolonged hospital stay of up to 3 months and massive chyle drainage occasionally totaling 80 L, before the use of total parenteral nutrition [12, 13]. Moreover, no chylothoraces from stab wounds and only 50% of bullet-injured thoracic ducts were treated successfully conservatively in the series by Goorwich [14].

Medical treatment aimed at decreasing chyle flow in the duct while awaiting spontaneous ductal closure was uniformly unsuccessful in all our patients. There are significant risks of dehydration, electrolyte losses, loss of fat and fat-soluble vitamins, protein loss, and impaired immunity by loss of circulating lymphocytes produced by a persistent chylothorax [4, 15]. This can partly but not fully be corrected by dietary management [5]. There is no consensus in the literature as to the timing of operation in patients with persistent traumatic chylothoraces. Ross [15] and Patterson and associates [3] recommend 7 days of initial conservative therapy, whereas others recommend at least 14 days or longer [1, 7, 11] provided nutritional and metabolic status is not compromised. However, sufficient T cell loss to place the patient at risk of septicemia occurs within 8 days of chyle drainage, despite optimal supportive care [8]. Death due to sepsis has been documented in other series [3, 4], and major complications occur in as many as 47% of patients during the period of nonoperative management of traumatic chylothoraces [12, 16].

Ligation of the thoracic duct was first performed by Lampson in 1948, and this decreased the mortality of traumatic chylothorax from 50% to 0% [14]. Numerous surgical options have been advocated for closure of the duct:

• Identification of the tear in the thoracic duct and:
  • Repair
    
  • Ligation
    
  • Patch closure with pleura
    
  
  
• Ligation of the thoracic duct at:
  • The diaphragm [3, 16, 17]
    
  • Poirier's triangle
    
  
  
• Instillation of fibrin glue into the pleural space [18]
  
• Pleuroperitoneal shunts [1, 16, 19]
  
• Pleuredesis by:
  • Pleurectomy [20]
    
  • Pleural abrasion
    
  • Pleural tetracycline instillation [1]
    
  • Talc insufflation [16]
    
  
  
• Video-assisted thoracoscopic techniques: clipping with or without talc insufflation [21]
  

We consider repair of the thoracic duct to be impractical and unnecessary. The thoracic duct can be relatively easily identified and ligated at the two aforementioned constant anatomic sites. Identification of the leak in the thoracic duct can be facilitated by the oral administration of 5 g of cream orally 4 hours before the operation. This in our experience reliably produces copious white chyle draining at the site of thoracic duct injury. The anatomic site of isolated thoracic duct injury was Poirier's triangle in the majority of our patients with isolated penetrating thoracic duct injuries. Through a left lateral thoracotomy, the pleura over Poirier's triangle was incised, the leak from the thoracic duct easily identified, and the thoracic duct dissected from the esophagus and ligated above and below the leak.

Other surgical options facilitating access to the thoracic cavity such as muscle-sparing incisions and thoracoscopic approaches [21] could be employed effectively in these cases. Even with thoracoscopic approaches we advocate ligation or clipping of the duct rather than talc insufflation or fibrin glue instillation in this group of young, otherwise fit people.

In our experience in this group of patients with isolated thoracic duct injuries, early surgical ligation of the thoracic duct resulted in shortened hospital stay and decreased costs both from shorter duration of stay and avoidance of total parenteral nutrition. This early aggressive approach should decrease the risks of fluid, nutritional, and immunologic depletion as well as infection resultant from prolonged chylous drainage.

In conclusion, patients with neck and high thoracic stab or bullet wounds presenting with isolated left-sided chylothorax should have the thoracic duct doubly ligated in Poirier's triangle through a left thoracotomy. In penetrating isolated right-sided traumatic chylothoraces, the duct should be ligated at the level of the diaphragm through a right thoracotomy.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Address reprint requests to Dr Worthington, Department of Cardiothoracic Surgery, University of Cape Town School of Medicine, Cape Town, 7925, South Africa.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

1. Meurer MF, Cohen DJ. Current treatment of chylothorax: a case series and literature review. J Tex Med 1990;86:82–5.
2. Grant PW, Brown SW. Traumatic chylothorax: a case report. Aust N Z J Surg 1991;61:798–800.[Medline]
3. Patterson GA, Todd TRJ, Delarue NC, Ilves R, Pearson FG, Cooper JD. Supradiaphragmatic ligation of the thoracic duct in intractable chylous fistula. Ann Thorac Surg 1981:32;44–9.[Abstract]
4. Ferguson MK, Little AG, Skinner DB. Current concepts in the management of postoperative chylothorax. Ann Thorac Surg 1985;40:542–5.[Abstract]
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10. Besson A, Saegesser F, eds. A colour atlas of chest trauma and associated injuries. Weert, Netherlands: Wolfe Medical Publications, 1982:304.
11. Bessone LN, Ferguson TB, Burford TH. Chylothorax. Ann Thorac Surg 1971;12:527–50.[Medline]
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13. Lampson RS. Traumatic chylothorax: a review of the literature and report of a case treated by mediastinal ligation of the thoracic duct. J Thorac Surg 1948;17:778–91.[Medline]
14. Goorwitch J. Traumatic chylothorax and thoracic duct ligation: case report and review of the literature. J Thorac Surg 1955;29:467–79.
15. Ross JK. A review of the surgery of the thoracic duct. Thorax 1961;16:12–21.
16. Milsom JW, Kron IL, Rheuban KS, Rodgers BM. Chylothorax: an assessment of current surgical management. J Thorac Cardiovasc Surg 1985;89:221–7.[Abstract]
17. Mohlala ML, Burrows RC, Mokoena TR. Early operative management of chylothorax by thoracic duct ligation. S Afr J Surg 1989;27:11–2.[Medline]
18. Akaogi E, Mitsui K, Sohara Y, Endo S, Ishikawa S, Hori M. Treatment of postoperative chylothorax with intrapleural fibrin glue. Ann Thorac Surg 1989;48:116–8.[Abstract]
19. Murphy MC, Newman BM, Rodgers BM. Pleuroperitoneal shunts in the management of persistent chylothorax. Ann Thorac Surg 1989;48:195–200.[Abstract]
20. Strausser JL, Flye MW. Management of nontraumatic chylothorax. Ann Thorac Surg 1981;31:520–6.[Abstract]
21. Graham DD, McGahren ED, Tribble CG, Daniel TM, Rodgers BM. Use of video-assisted thoracic surgery in the treatment of chylothorax. Ann Thorac Surg 1994;57:1507–12.[Abstract]

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