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Ann Thorac Surg 2000;70:1662-1665
© 2000 The Society of Thoracic Surgeons

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Original articles: general thoracic

Thoracoscopic direct clipping of the thoracic duct for chylopericardium and chylothorax

^a Department of Surgery, The Christ Hospital, University of Cincinnati, Cincinnati, Ohio, USA

Address reprint requests to Dr Wolf, Division of Cardiothoracic Surgery, The Ohio State University Medical Center, N816 Doan Hall, 410 W 10th Ave, Columbus, OH 43210
e-mail: wolf-4{at}medctr.osu.edu

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. Chylothorax is a challenging clinical problem. Untreated, it carries a high mortality and morbidity. Traditional surgical management for cases refractory to conservative treatment is thoracic duct ligation through a right open thoracotomy.

Methods. We describe 4 patients treated successfully by video-assisted thoracic surgery, using ports and no thoracotomy, and precise ligation and division of the thoracic duct just above the diaphragm. A pericardial window was made in the patient with chylopericardium, as in the patient with end-stage renal disease. Pleurodesis was used in the patient with esophageal carcinoma and the patient with jugular and subclavian vein thrombosis.

Results. There were 2 women aged 18 and 42 years and 2 men, aged 61 and 65 years. No procedure-related mortality or morbidity occurred. In patients 1, 2, 3, and 4, the postoperative duration of drainage was 5, 7, 7, and 5 days, respectively (mean duration, 6 days) and the hospital stay, 5, 9, 10, and 5 days, respectively (mean stay, 7 days). There was no recurrence of chylothorax or chylopericardium during follow-up (range, 2 to 24 months; mean follow-up, 9 months). One patient died of esophageal carcinoma 4 months after operation.

Conclusions. Video-assisted thoracic surgery without a thoracotomy is an effective way of treating chylothorax and carries minimal morbidity.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
Chylothorax is the accumulation of lymphatic fluid in one or both of the pleural spaces or in the pericardium. The treatment of pleural or pericardial effusion requires prompt and aggressive measures. Without treatment, the risk of mortality is as high as 45% [1, 2], and thus, early aggressive therapy is indicated. Conservative therapy consists of removal of the chyle from the pleural spaces or the pericardium by intermittent aspiration or continuous tube drainage, fluid and electrolyte replacement, and nutritional support. Parenteral hyperalimentation is the method of choice for nutritional support [3] because oral feeding stimulates the production of chyle. Surgical treatment should be considered if 7 days of conservative treatment is not effective [4, 5]. Transthoracic ligation of the thoracic duct with or without talc pleurodesis has been recommended [6, 7]. Less pain may be associated with video-assisted thoracic surgery (VATS) [8]. We report the results of clipping and division of the thoracic duct without thoracotomy by VATS in 4 patients and review the literature.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
We summarize the five case reports and then discuss our surgical techniques.

Patient 1
An 18-year-old woman was in a car accident and sustained trauma to the anterior chest wall, which was not thought to be important. Three months later, a chest roentgenogram showed a greatly enlarged cardiac silhouette. Pericardiocentesis yielded 1,500 mL of chyle. Within a few days, the pericardial effusion had recurred. Pericardiocentesis was repeated several times during the next 4 years. Each time, fluid was removed, and the effusion recurred within a few days. In the following 4 years, the procedure was repeated several times. Again, 1,500 mL of fluid was removed each time, resulting in prompt reformation of chylopericardium. Lymphangiography showed no anatomic abnormalities of the thoracic duct and no leakage. The patient finally underwent thoracoscopic clipping of the thoracic duct and creation of a pericardial window from the right side. There has been no further chylous leakage for 2 years.

Patient 2
A 61-year-old man had esophagogastrectomy for esophageal carcinoma. The postoperative course was uneventful except for prolonged chest tube drainage. Ten days after discharge from the hospital, he was readmitted because of dyspnea, and a chest roentgenogram showed right-sided hydrothorax. An intercostal pleural tube was inserted, and 2,500 mL of chyle promptly drained. The patient received parenteral hyperalimentation and no oral feedings for the next 10 days, and the rate of chest tube drainage did not decrease. Thoracoscopic clipping of the thoracic duct was performed from the right side, and there was prompt cessation of drainage and no recurrence for 4 months. He died of carcinoma at that time.

Patient 3
A 42-year-old woman with end-stage renal disease as a result of diabetic nephropathy underwent kidney and pancreas transplantation in 1993. The kidney graft was lost during treatment of an aspergillar infection with Amphotericin B. Dialysis was resumed. Six months later, the chest roentgenogram showed a large cardiac silhouette, and an echocardiogram demonstrated a large pericardial effusion. Tapping the pericardium yielded 800 mL of milky fluid. The patient underwent thoracoscopic clipping of the thoracic duct and creation of a pericardial window from the right side. There has been no recurrence of pericardial effusion for 7 months.

Patient 4
A 65-year-old man had refractory right chylous effusion after the development of jugular and subclavian vein thrombosis secondary to multiple permanent transvenous pacemaker wire insertions. Multiple thoracenteses on the right side each yielded more than 1 L of chylous fluid. Despite a low-fat diet, the right pleural effusion recurred 1 to 2 weeks after each tap. A right video-assisted thoracoscopy was performed with evacuation of 3.5 L of chylous fluid and thoracoscopic ligation of the thoracic duct with clips and talc pleurodesis. There has been no recurrence of pleural effusion for 2 months.

Surgical technique
General anesthesia is established with a double-lumen endotracheal tube. The patient is turned on the left side. Heavy cream, 200 mL, is administered through a nasogastric tube. Three intercostal ports are placed in the lateral chest wall, one for the thoracoscope and two for instruments. The inferior pulmonary ligament is divided, and the mediastinal pleura is incised just above the diaphragm to expose the esophagus. With blunt dissection and cautery, the esophagus is mobilized away from the spine. After the distal thoracic esophagus is elevated, its position is maintained using an endoscopic kittner.

A space is created whose lateral border is the azygos vein and whose medial border is the aorta. The esophagus is held above this space. Within this triangle, the thoracic duct is located in the fatty layer between the azygos vein and the aorta. It is a pale 1.5- to 3-mm tubular structure with a thin overlying capillary adventitial network. After clear identification of the thoracic duct a hemoclip is placed proximally and then the duct partially divided distally from the clip so that chylous fluid can be observed at the cutting edge. A clip is then placed distally (Fig 1). A large pericardial window is made anterior to the phrenic nerve in patients with chylopericardium. In selected patients, talc pleurodesis can be added.

View larger version (53K): [in this window] [in a new window]   Fig 1. Operative sites. (A) The thoracic duct (t) with two clips. (B) The cut edge of the duct with a clip on each side.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
There was no procedure-related mortality or morbidity. In patients 1, 2, 3, and 4, the duration of drainage was 5, 7, 7, and 5 days, respectively (mean duration, 6 days) and the hospital stay, 5, 9, 10, and 5 days, respectively (mean stay, 7 days). During follow-up (range, 2 to 24 months; mean follow-up, 9 months), no recurrence of chylothorax or chylopericardium was observed. One patient died of esophageal carcinoma 4 months after operation. The remaining 3 patients had a full recovery and are alive with no evidence of effusion. They are examined by chest roentgenography once a year.

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
Chylothorax was first reported by Quinke [9] in 1875. The causes are variable and include both congenital and acquired conditions [4, 10]. Congenital chylothorax can result from birth trauma or from an embryological phenomenon [11]. However, the most frequent causes are blunt or penetrating trauma and neoplasm [2, 5, 12]. Less common causes are caval thrombosis, infection, severe paroxysms of cough, sudden hyperextension of the thoracic spine as a result of a blast or blunt trauma with rupture of the duct just above the diaphragm, and various invasive diagnostic procedures [1]. Chylothorax can be a complication of cardiac, esophageal, or pulmonary surgical procedures [13].

The poor results of nonoperative treatment with a mortality rate of nearly 50% reported by Sharkelford and Fisher [14] can be attributed in part to the lack of adequate fluid and nutritional management, which was not available at the time [15]. A continuing leak of chyle can lead to serious metabolic, nutritional, and immunologic abnormalities [15].

There is no consensus about the indications for surgical intervention. Suggested guidelines include average daily loss of chyle exceeding 500 mL over a 5-day period, failure of conservative treatment after 14 days, and nutritional complications. Surgical treatment has been suggested in patients after a traumatic event if the daily loss of chyle over a 5-day period exceeds 1,500 mL in adults and 100 mL per year of age in children [16, 17]. A decrease in the volume of milky drainage may not indicate closure of the fistula but rather may be a result of impairment of the drainage.

The anatomy of the thoracic duct has been the subject of several investigations [18, 19]. It is a single duct from the cisterna chyli to the level of the eighth thoracic vertebra. A 38.7% incidence of duplication or multiplication of the mediastinal part of the thoracic duct has been found [20]. Kausel and coauthors [18] reported a single thoracic duct in 38% of specimens studied; it joined the left subclavian vein in 2% and the right subclavian vein in 36% [18]. In 34% of the thoracic ducts examined, the lower intrathoracic part was divided into a few smaller ducts and the upper part, also into a few smaller ducts. In 14%, the duct was divided in two in the lower intrathoracic part and became a single entity in the upper part. Therefore, clipping or ligating the duct much above the diaphragm is more apt to fail than if either method is done near the diaphragm.

Lymphangiography for chylothorax is recommended in nontraumatic instances and can be useful for surgeons or oncologists in planning therapy [21]. Pleuroperitoneal shunting has been shown to be effective in the treatment of chylothorax when associated with superior vena cava obstruction in both adults and children [22].

Thoracic duct ligation for chylothorax, first successfully performed by Lampson in 1948, has been the most effective operation and carries a low mortality. It has been repeatedly shown, both experimentally and clinically, that ligation of the thoracic duct leads to lymphatic collateral circulation, regardless of the level of ligation. Even extirpation of the thoracic duct and removal of the cisterna chyli has not been followed by harmful effects. Pressures as high as 50 mm Hg have been recorded in the obstructed thoracic duct. The total blood lipid level, normally 500 to 700 mg/100 mL, falls to around 280 mg/100 mL within 3 hours after thoracic duct ligation and then gradually returns to normal levels within 16 days [23]. The most frequently recommended operation for chylothorax is thoracotomy with ligation of the thoracic duct if the injury can be located or mass ligature above the diaphragm or below the aortic arch of the tissues that contain the thoracic duct [15]. Chemical or mechanical pleurodesis can be performed concomitantly [4, 5, 10]. The goals of surgical therapy are twofold: to drain the chyle from the pleural spaces or the pericardium to relieve the effects of compression of the lungs or heart and to stop the leak of chyle with its resulting fluid, electrolyte, nutritional, and immunologic losses. For the procedure to be successful, the thoracic duct should be ligated in the lower part of the thorax. In the case of chylopericardium, a pericardial window should be performed to ensure adequate drainage.

Video-assisted thoracic surgery with intrathoracic access solely by way of ports is becoming more widely used. It provides excellent visualization of intrathoracic structures, and there is less postoperative pain and pulmonary dysfunction [8]. Two cases of exact identification and clipping of the thoracic duct have been reported [17, 24]. Furrer and coworkers [25] used a mass ligature of the thoracic duct by VATS in another patient. Graham and associates [4] used VATS in only 2 patients in a series of 10. They did not describe identification of the duct and used talc pleurodesis. Shirai and colleagues [10] successfully treated 1 patient after pneumonectomy, conservative treatment having failed. The leakage site was identified during thoracoscopy, and fibrin glue was applied under direct vision. The authors suggested this technique as standard treatment for all patients with postoperative chylothorax.

We agree with other authors that fibrin gluing alone is not adequate treatment of chylothorax. The recurrence rate after treatment with fibrin glue is unknown [17, 24, 25]. When treatment has involved supradiaphragmatic clipping or mass ligature, no recurrence has been reported in the recent literature.

Using VATS, we have successfully treated 4 patients. A previous operation in the chest (esophagectomy) in 1 of them was not a contraindication. Extensive pleural adhesions can be a serious problem for VATS and may force conversion to an open procedure. Identification of the thoracic duct, which is crucial for successful clipping, was accomplished in all patients. We used talc pleurodesis in patient 4. Regardless of anatomic variations, we think it is important to identify the duct in the supradiaphragmatic space first. Identification of the thoracic duct makes it possible to precisely occlude the duct with a clip and then to incise it and to identify its contents as chyle for confirmation. Video thoracoscopy provides magnification, which is helpful in identifying the thoracic duct.

Mass ligature of the tissues including the thoracic duct just above the diaphragm is an alternative surgical procedure similar to ours. However, it may not accomplish permanent occlusion of the duct, as, here also, the lesion in the duct was not divided. If fibrosis of the tissues near the duct makes dissection difficult, a mass ligature may be the best alternative. There are no data in the literature favoring one of these surgical methods, ie, our method of choice or mass ligature, over the other.

Because the chylous fistula sometimes heals spontaneously, a period of conservative treatment consisting of a low-fat diet and parenteral alimentation for a week or so is recommended before surgical therapy [2, 4, 25]. A longer period of conservative treatment can lead to formation of pleural adhesions, inflammation, and fibrosis of mediastinal tissues that would make the operation more difficult. In patient 4, there was substantial parietal pleural inflammation. However, identification of the esophagus, the aorta, and the thoracic duct was possible with only the thoracoscopic approach. Locating itself is not mandatory. A nasogastric tube helps with the identification of the esophagus, making it more "touchable" even for minimally invasive chest instruments. The introduction of heavy cream into the stomach at the beginning of the operation facilitates the identification of the thoracic duct [25]. Its advantage is that chylous fluid can be observed at the cut edge, thereby simplifying the identification of the thoracic duct. In the case of pericardial effusion, a window should be made to allow drainage into the pleural cavity. This allows a safe way to exclude neurofibromatosis by histopathological study.

Clipping the thoracic duct using VATS proved to be a safe and effective procedure in our 4 patients with chylothorax. In each patient, the thoracic duct was identified and selectively clipped. When conservative treatment of chylothorax is not working, early surgical intervention with VATS and clipping of the thoracic duct is indicated.

	References

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