Ann Thorac Surg 2001;72:1366-1367
© 2001 The Society of Thoracic Surgeons
Case report
Thoracoscopic thoracic duct ligation for traumatic chylothorax
Keith G. Buchan, FRCS (C/Th)a,
Amir-Reza Hosseinpour, MDa,
Andrew J. Ritchie, PhDa
a Department of Cardiothoracic Surgery, Papworth Hospital, Papworth Everard, Cambridge, United Kingdom
Accepted for publication November 13, 2000.
Address reprint requests to Dr Ritchie, Department of Cardiothoracic Surgery, Papworth Hospital, Papworth Everard, Cambridge CB3 8RE, UK
e-mail: andrew.ritchie{at}papworth-tr.anglox.nhs.uk
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Abstract
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Traumatic chylothorax requires surgical intervention when conservative medical management fails to reduce chyle leakage. This usually entails thoracotomy or laparotomy. We report a case in which successful ligation of a torn thoracic duct was achieved using a video-assisted thoracoscopic technique.
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Introduction
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Chylothorax in adults is usually due to blunt trauma or, more rarely, penetrating injury. It may also follow interventional or operative procedures, such as central venous cannulation or intrathoracic surgery, and is associated with a large number of medical conditions [1]. Conservative treatment comprises a low-fat diet and intravenous nutrition, and may take weeks to work. Where the initial fistula output is high or there is no reduction in its output, then surgical measures may be more appropriate. We report a case in which high output traumatic chylothorax was successfully treated by video-assisted thoracic duct ligation.
An 18-year-old man sustained blunt trauma in a road traffic accident in which the other passenger was fatally injured. After a period of hospital observation, he was discharged but re-presented 4 days later with shortness of breath. The clinical impression of a right-sided pleural effusion was confirmed radiologically, and a diagnosis of traumatic chylothorax was made after 5.2 liters of chyle was drained at tube thoracostomy. Conservative medical management, including low-fat diet with medium chain triglycerides, was instituted. After 5 days, however, chyle output remained high (up to 1,300 mls per 24 hours) and he was referred for surgical closure of the thoracic duct. One hour before anesthetic, the patient was given 50 mls of cream to help with identification of the leak. The right lung was deflated after placement of a left-sided double lumen endotracheal airway. In the right lateral position, three port access sites were made. Residual chyle was removed and the lung retracted superiorly, after division of the inferior pulmonary ligament. The diaphragm was pushed inferiorly using an endoscopic retractor (Autosuture "Endoretract") to reveal the thoracic duct between the azygous vein posteriorly and the aorta anteriorly. Inferiorly, the duct had a typical beaded appearance and was observed to leak chyle. Superiorly, the duct was less easy to define. Endoclips (Autosuture 9.5 mm "Premium Surgiclips") were applied to the thoracic duct above and below the site of leakage (see Figs 1 and 2). The chest cavity was lavaged and a single drain placed under direct vision. Subsequent chest drainage steadily declined and changed in character from hemoserous to serous fluid. Twenty-four hourly drain outputs on the 1st, 4th, and 7th postoperative days were 500 mls, 275 mls, and 150 mls. The daily drainage on days 8 and 9 was 50 mls, and during this time normal diet was resumed with no evidence of chyle leak. The patient was discharged on his 11th postoperative day after removal of the chest drain. He remains well 6 months after surgery.
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Fig 1. The operative set-up for thoracoscopic thoracic duct ligation on the right side. The dotted line represents the former site of attachment of the inferior pulmonary ligament.
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Fig 2. The final operative appearances showing the clipped thoracic duct (TD). The phrenic nerve (PN), pericardium (P), and diaphragm (D) are visible for orientation.
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Comment
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Chylothorax is associated with considerable morbidity and mortality if untreated. Where conservative medical management has failed, ligation of the thoracic duct in the open chest or the cysterna chyli in the open abdomen is required. Adjunctive surgical procedures in the chest such as pleurectomy, talc pleurodesis, or decortication may also be required, particularly where there is associated malignancy. If these surgical goals can be achieved thoracoscopically, this technique offers advantages in terms of morbidity and mortality, and may allow closure in patients judged unfit for thoracotomy on account of poor general condition.
Thoracoscopic talc pleurodesis is of some efficacy in the management of chylothorax secondary to lymphoma [2]. Hyperextension of the thoracic spine resulted in duct tearing in our patient. Identifying the thoracic duct can be difficult even at open thoracotomy, but was assisted by the oral administration of cream. The beaded appearance of the distal (caudal) duct was easy to identify, whereas the macerated proximal duct was more difficult to locate. We were not able to define a site of proximal chyle leakage, but a clear view of the torn distal duct was obtained and, hence, we elected to ligate it endoscopically. We are aware of 1 other case where chylothorax was successfully treated thoracoscopically by clipping the thoracic duct, supplemented by application of fibrin glue [3]. This case was included in a series of 12 patients with chylothorax, all of whom underwent thoracoscopy (principally for talc pleurodesis). We hope that this report will encourage other surgeons to consider using the thoracoscopic approach when considering surgical methods of thoracic duct ligation.
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References
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Inchel Y., Sassoon C. Hemothorax and chylothorax. Curr Opin Pulm Med 1997;3:310-314.[Medline]
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Mares D.C., Mathur P.N. Medical thoracoscopic talc pleurodesis for chylothorax due to lymphoma. Chest 1998;114:731-735.[Abstract/Free Full Text]
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Graham D.D., McGahren E.D., Tribble C.G., et al. Use of video-assisted thoracic surgery in the treatment of chylothorax. Ann Thorac Surg 1994;57:1507-1512.[Abstract]
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Abstract
Introduction
