HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Yasuo Morishita Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Sakata, S. Articles by Morishita, Y. Search for Related Content PubMed PubMed Citation Articles by Sakata, S. Articles by Morishita, Y.

Ann Thorac Surg 2000;69:1581-1582
© 2000 The Society of Thoracic Surgeons

---

Case reports

Thoracoscopic treatment of primary chylopericardium

^a Second Department of Surgery, Gunma University School of Medicine, Gunma, Japan

Address reprint requests to Dr Sakata, #701, 2–14–14 Otemachi, Maebashi, Gunma 3710026, Japan

	Abstract

Top Abstract Introduction Comment References

 
The development of video-assisted thoracoscopy has changed the practice of thoracic surgery. This report describes a 20-year-old man who successfully underwent thoracoscopic thoracic duct ligation and partial pericardiectomy for primary chylopericardium. We recommend a right-sided thoracoscopic approach to the thoracic duct in the lower thoracic cavity.

	Introduction

Top Abstract Introduction Comment References

 
Video-assisted thoracoscopic surgery has been used to treat many diseases of the chest, and its role in the diagnosis and treatment of thoracic disease is constantly being expanded and refined. This report documents the safe and successful application of video-assisted thoracoscopic surgery to treat primary chylopericardium.

A 20-year-old man was admitted for the evaluation of cardiomegaly, which was noted on a routine chest radiograph. The patient was entirely asymptomatic, without a history of chest surgery or trauma. On physical examination, his pulse was 72 and his blood pressure 124/68 mm Hg without paradox. Heart sounds were audible but faint. Echocardiography demonstrated a large pericardial effusion. Percutaneous pericardiocentesis yielded 600 mL of milky fluid. Examination of the aspirate revealed a triglyceride level of 1246 mg/mL and microscopically visible fat droplets. The fluid reaccumulated within 14 days, resulting in the same degree of cardiomegaly on chest radiography. Bipedal lymphangiography was nondiagnostic. Mediastinal abnormalities were not detected on computed tomography.

After establishment of the diagnosis of primary chylopericardium, the patient underwent thoracoscopic surgery. Under general anesthesia, he was placed in the left lateral decubitus position. Four trocar sleeves were inserted between the fifth and eighth intercostal spaces on the right hemithorax. After division of the inferior pulmonary ligament, the deflated right lung was retracted. After incision of the parietal pleura over the spine, careful dissection between the esophagus and the spine disclosed the thoracic duct, which was ligated with multiple clips. All observed small lymph vessels were also ligated. Partial pericardiectomy was performed and 700 mL of chylous fluid was released. The patient has followed a good postoperative course with normal cardiac silhouette for more than 1 year.

	Comment

Top Abstract Introduction Comment References

 
Chylopericardium results from thoracic duct obstruction with failure of adequate collateral drainage and reflux of chylous lymph through the lymphatics draining the heart and pericardium [1]. It may be congenital or caused by surgical trauma, irradiation, or primary or metastatic mediastinal tumors [1, 2]. It is a rare disorder that must be considered in the evaluation of an enlarged cardiac silhouette.

All the patients with this disease should be treated because there is a fairly high risk of cardiac tamponade or pericarditis as large volumes of chyle accumulate or become infected. The treatment usually begins with dietary manipulation with medium-chain triglycerides. If this fails, pericardiocentesis, tube pericardiostomy, or a subxiphoid pericardial window should be considered. Ligation or resection of the thoracic duct with establishment of a pericardial window is undertaken when these treatments are ineffective. Pericardial–peritoneal shunting may provide a simple and effective alternative [2].

Surgical intervention should be considered first because conservative therapy often leads to reaccumulation of chylous fluid [2, 3]. The success of thoracic duct ligation above the diaphragm and partial pericardiectomy has been documented [1, 4]. Furrer and colleagues [5] described the first successful thoracoscopic approach to primary chylopericardium. The authors mentioned a mass ligation of all tissues situated between the azygos vein, vertebral body, and descending aorta. The mass ligation can also be performed easily by using the thoracoscopic approach. Thoracoscopic duct ligation and partial pericardiectomy can replace open thoracotomy, which should be reserved for repeat surgery.

The thoracic duct, especially in the lower thoracic cavity, is accessible at surgery from either the right or left side. Before the introduction of video-assisted thoracoscopy, Akamatsu and colleagues [4] reviewed the literature and concluded that a left thoracotomy was preferable. However, the left-sided approach has some disadvantages when using thoracoscopy [5, 6]. In the lower thoracic cavity the thoracic duct is located to the right of the descending aorta. This prevents easy access to the duct when entering from the left hemithorax. In addition, the heart hinders the manipulation of the instruments. We therefore recommend a right-sided thoracoscopic approach to the thoracic duct in the lower thoracic cavity.

	References

Top Abstract Introduction Comment References

 

1. Dunn R.P. Primary chylopericardium. Am Heart J 1975;89:369-377.[Abstract/Free Full Text]
2. Chan B.B.K., Murphy M.C., Rodgers B.M. Management of chylopericardium. J Pediatr Surg 1990;25:1185-1189.[Medline]
3. Charnilas Y., Levo Y., Weiss A., Glaser J., Levy M.J. Isolated idiopathic chylopericardium. J Thorac Cardiovasc Surg 1977;73:719-721.[Abstract]
4. Akamatsu H., Amano J., Sakamoto T., Suzuki A. Primary chylopericardium. Ann Thorac Surg 1994;58:262-266.[Abstract/Free Full Text]
5. Furrer M., Hopf M., Ris H.B. Isolated primary chylopericardium. J Thorac Cardiovasc Surg 1996;112:1120-1121.[Free Full Text]
6. Kent R.B., III, Pinson T.W. Thoracoscopic ligation of the thoracic duct. Surg Endosc 1993;7:52-53.[Medline]

This article has been cited by other articles:

				C. Dib, A. J. Tajik, S. Park, M. E.L. Kheir, B. Khandieria, and F. Mookadam Chylopericardium in adults: A literature review over the past decade (1996-2006) J. Thorac. Cardiovasc. Surg., September 1, 2008; 136(3): 650 - 656. [Abstract] [Full Text] [PDF]

				N. Lee and M. Coco Chylous pericardial tamponade in a haemodialysis patient with catheter-associated thrombosis of internal jugular and subclavian veins Nephrol. Dial. Transplant., September 1, 2006; 21(9): 2650 - 2653. [Full Text] [PDF]

				G. Sleilaty, I. Rassi, A. Alawi, and V. A. Jebara Primary isolated chronic chylopericardium Interact CardioVasc Thorac Surg, December 1, 2002; 1(2): 86 - 87. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Yasuo Morishita Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Sakata, S. Articles by Morishita, Y. Search for Related Content PubMed PubMed Citation Articles by Sakata, S. Articles by Morishita, Y.