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Ann Thorac Surg 2000;70:2184
© 2000 The Society of Thoracic Surgeons

Correspondence

Postoperative chylothorax and mediastinal chyloma

Marc Riquet, MDa, Redha Souilamas, MDa, Francoise Le Pimpec-Barthes, MDa

a Service de Chirurgie Thoracique, Hôpital Laennec, 42 rue de Sèvres, 75007 Paris, France

e-mail: marc.riquet{at}lnc.ap-hop-paris.fr

To the Editor

Suzuki and collaborators [1] have provided us with a rare but very valuable case of postoperative mediastinal chyloma. The chyle was located within the space dorsal to the superior vena cava and ventral to the trachea, resulting form mediastinal lymph node dissection of the right upper mediastinum after a right upper lobectomy for lung cancer. We would like to further discuss the origin and management of the collection.

As we [2] previously demonstrated in an anatomic study, postresection chylothorax may be related to the injury of lymphatic vessels that come from the lung or mediastinal lymph nodes and enter directly into the thoracic duct in the mediastinum. The injured lymphatic vessels connecting the right upper mediastinal lymph nodes to the thoracic duct particularly follow the arch of the azygos vein from before backwards [3] (Fig 1). Such lymphatic vessels are always divided when dissecting mediastinal lymph nodes but chylous effusion is rare. Actually, these vessels possess valves that prevent reflux of chyle from the thoracic duct.



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  		Fig 1. Lymphatic vessel (arrows) of the arch of the azygos (1) connecting the right pretracheal lymph nodes (4 R) to the thoracic duct (2), posterior aspect of the trachea (3), and esophagus (4). In the lymph vessel are figured valves that ensure its continence.

 
Besides chylothorax after lung surgery, we [4] observed once a chylomediastinum after mediastinoscopy that was due to the same mechanism: injury to a right paratracheal lymphnode system that was supplied with chyle by an associated valve insufficient azygotic lymphatic vessel connected to the thoracic duct.

In the case reported by Suzuki and collaborators [1], the initial postoperative chylothorax was managed by chemical pleurodesis. The reflux of chyle through the insufficient azygotic lymphatic vessel persisted, allowing the chyle to further accumulate within the space between trachea and superior vena cava that was obliterated by the pleurodesis of the remaining lung lobe. This was probably the process leading to the related chyloma.

Ligation of the thoracic duct cephalad to the diaphragm after evacuation of the chyloma stopped the upward chyle flow through the thoracic duct, and indirectly suppressed any reflux from the duct above the ligation. However, knowledge of the location of pulmonary thoracic duct collaterals permits elective suture or clipping. They may be demonstrated by lymphangiography and identified when reoperating by thoracotomy or video-assisted thoracoscopy. In this very interesting case report, the mediastinal chyloma is not a complication of medical pleurodesis; the failure is caused by the persistence of the chylous leak within the right upper mediastinum.

References

  1. Suzuki K., Yoshida J., Nishimura M., Takahashi K., Nagai K. Postoperative mediastinal chyloma. Ann Thorac Surg 1999;68:1857-1858.[Abstract/Free Full Text]
  2. Riquet M., Hidden G., Debesse B. Les collatérales du canal thoracique d’origine ganglio-pulmonaire. Etude anatomique et chylothorax après chirurgie pulmonaire. Ann Chir: Chir Thorac Cardiovasc 1989;43:646-657.
  3. Riquet M., Dupont P., Hidden G., Debesse B. Mediastinal lymphatic pathways of the azygos and aortic arches: injection based on segments of the adult lung. Surg Radiol Anat 1991;13:149-152.[Medline]
  4. Riquet M., Darse-Derippe J., Saab M., Puyo P., Legmann P., Debesse B. Chylomediastin après médiastinoscopie. A propos d’une observation. Rev Mal Resp 1993;10:473-476.




This Article
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Right arrow Email this article to a friend
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Marc Riquet
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Right arrow Articles by Riquet, M.
Right arrow Articles by Le Pimpec-Barthes, F.

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