Ann Thorac Surg 2002;74:263-265
© 2002 The Society of Thoracic Surgeons
Case report
Thoracoscopic ultrasonic coagulation of thoracic duct in management of postoperative chylothorax
Sadanori Takeo, MD*a,b,
Koji Yamazaki, MDa,
Mikako Takagi, MDa,
Atsuhiro Nakashima, MDb
a Department of Thoracic Surgery, National Kyushu Medical Center, Fukuoka, Japan
b Department of Clinical Research, National Kyushu Medical Center, Fukuoka, Japan
Accepted for publication December 28, 2001.
* Address reprint requests to Dr Takeo, Department of Thoracic Surgery, National Kyushu Medical Center, Jigyohama 1-8-1 Chuo-ku, Fukuoka 810-8563, Japan
e-mail: sada{at}qmed.hosp.go.jp
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Abstract
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Chylothorax is a rare but potentially serious complication of cardiac operations. We report here a 72-year-old man who underwent replacement of a descending aneurysm with a synthetic graft for dissecting aneurysm (IIIa). A persistent postoperative chylothorax developed, which necessitated continuous drainage, despite conservative treatment more than 12 days. Thoracoscopic high-frequency ultrasonic coagulation of the thoracic duct without clipping finally stopped chyle production. This method may be useful from the standpoint of minimal access, rapid recovery, less pain, and a shorter operation.
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Introduction
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When the nonoperative treatment of chylothorax fails, thoracic duct ligation is usually performed through a thoracotomy. Improvements in video endoscopic surgical equipment and a growing enthusiasm for minimally invasive surgical approaches have fostered video-assisted thoracic surgery (VATS). There have been several reports of the exact identification and clipping of the thoracic duct by thoracoscopy. We report here thoracoscopic thoracic duct coagulation using Autosonix System Ultrashears (United States Surgical Corporation, Norwalk, CT), 5-mm ultrasonic cutting shears (Autosonix), without clipping. We used this equipment to coagulate and cut thymic veins as previously reported [1].
A 72-year-old man (weight, 72 kg) underwent replacement of a descending aneurysm with a synthetic graft for dissecting aneurysm (IIIa). Left lateral intercostal thoracotomy was performed under incision of the fourth and sixth intercostals. The early postoperative course was uneventful with normal hemodynamic measurements. However, oral feeding was started on day 4 postoperatively, and approximately 3 L of milky effusion was found on day 5. Chest radiography revealed right pleural effusion, and a right chest drain was placed surgically. The diagnosis was confirmed to be chylothorax. Although fasting was stopped immediately and total parenteral nutrition was started, methicillin-resistant Staphylococcus aureus enteritis emerged and the nutritional state gradually deteriorated. The patient finally underwent a thoracoscopic procedure on the 12th postoperative day. The patient received 200 mL of milk orally 2 hours before operation. This facilitated visualization of the chyle leak and identification of the thoracic duct. After induction of general anesthesia, a double-lumen endobronchial tube was used for selective ventilation, and the patient was positioned in the left lateral position. One 10.5-mm port and three 5.5-mm ports were used. A 5-mm Hopkins-telescope for adults was introduced through a 5.5-mm thoracic port in the sixth intercostal space on the midaxillary line from the right side. Two more 5.5-mm thoracic ports were then placed to introduce endoscopic instruments: one in the fourth and one in the eighth intercostal space on the midaxillary line. A 10-mm Endopath Short Straight Grasper (Ethicon Endo-surgery, Inc., Cincinnati, OH) was inserted from the sixth intercostal space on the anterior axillary line, and used to pull the right lower lobe anteriorly (Fig 1).
Vigorous flowing of chylous fluid could then be observed from the cut edge under direct vision during thoracoscopy. The complete cut edge of the thoracic duct was observed: it was the right distal side of where the descending aneurysm was replaced with a synthetic graft for dissecting aneurysm (Fig 2).
It was difficult to exfoliate and clip this thoracic duct at the edge because of severe adhesion to surrounding tissues.
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Fig 1. Arrangement of thoracoscopic ports and surgical instruments used to approach the thoracic duct through the right chest.
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Fig 2. Vigorous flowing of chylous fluid can be observed from the cut edge under direct vision during thoracoscopy. The cut was on the right distal side of where the descending aneurysm was replaced with a synthetic graft for dissecting aneurysm. It was difficult to exfoliate and clip this thoracic duct at the edge because of severe adhesion to surrounding tissues.
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Therefore, the thoracic duct was coagulated using Autosonix with a grasping probe without clipping (Fig 3).
Chylous fluid disappeared completely thereafter.
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Fig 3. Cut edge of thoracic duct was coagulated using Autosonix without clipping. Chylous fluid disappeared completely.
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A chest tube was applied and the thoracic ports were closed in the usual manner. The bilateral chest tube was removed by the fourth postoperative day.
Methicillin-resistant S aureus enteritis improved with the disappearance of chylothorax. Oral feeding was continued on the seventh day after the operation, and the patient’s physical state improved dramatically. After 2 years of follow-up, he has had no recurrence of chylothorax.
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Comment
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Most cases of chylothorax can be resolved with nonoperative management. If such management does not lead to a response after 2 to 3 weeks, most authors recommend operation. Surgical treatment is generally recommended in cases in which drainage exceeds 1500 mL per day in adult patients for more than 7 days. Traditionally, ligation of the thoracic duct has been performed by open thoracotomy, and the morbidity associated with a major thoracic procedure may have discouraged the timely implementation of this treatment modality and favored a prolonged period of nonoperative management.
Recent reports [2–4] have documented the safety and effectiveness of the thoracoscopic approach in the treatment of chylothorax. Chyle itself tends to prevent the formation of pleural adhesion, which makes it an attractive setting for VATS. The use of early thoracoscopic intervention may make it possible to avoid an unnecessarily prolonged period of nonoperative treatment, thus preventing the excessive morbidity and mortality associated with protracted chylothorax. An advantage of VATS is that it can be performed early before the patient has deteriorated, developed adult respiratory distress syndrome, and stiff lungs caused by the prolonged placement of a thoracic tube. In this case, chylous fluid was observed at the cut edge, which simplified identification of the thoracic duct.
It has been reported that fibrin glue can be applied to the leakage site under direct vision during thoracoscopy [5], but this method may not be adequate for chylothorax. Furrer and coworkers [6] used mass ligature of the tissues including the thoracic duct just above the diaphragm by VATS. However, this may not achieve permanent occlusion of the duct. The exact identification and clipping of the thoracic duct has also been reported [2, 3]. Clipping the thoracic duct using VATS has been shown to be a safe and effective procedure in patients with chylothorax. However, when the thoracic duct adheres to a chest wall and exfoliation is difficult, it can also be difficult to clip the thoracic duct directly. The hardest thing to do in chylothorax is to dissect the duct without making more holes in it. In this case, it was difficult to exfoliate and clip the thoracic duct at the edge because of severe adhesion to surrounding tissues.
Based on our previous clinical experience [1], we were encouraged to attempt coagulation of the thoracic duct using Autosonix without clipping. If a lot of chyle is floating around the cut edge of the thoracic duct, Autosonix with a grasping probe makes it easy to coagulate the thoracic duct. The main advantage of this technique is that virtually no dissection is required.
In summary, thoracoscopic high-frequency ultrasonic coagulation of the thoracic duct without ligation finally led to the cessation of chyle production. We believe that this method may be adequate operative therapy for a select group of patients with chylothorax. When conservative treatment of chylothorax is inadequate, early surgical intervention with VATS and coagulation of the thoracic duct may be indicated. This new surgical approach requires additional data, a larger series, and a longer follow-up to be fully evaluated and standardized.
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References
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- Takeo S., Sakada T., Yano T. Video-assisted extended thymectomy in patients with thymoma by lifting the sternum. Ann Thorac Surg 2001;71:1721-1723.[Abstract/Free Full Text]
- Peillon C., Hont C.D., Melki J., et al. Usefulness of video thoracoscopy in the management of spontaneous and postoperation chylothorax. Surg Endosc 1999;13:1106-1109.[Medline]
- Stringel G., Teixeira J.A. Thoracoscopic ligation of the thoracic duct. JSLS 2000;4:239-242.[Medline]
- Wurnig P.N., Hollalus P.H., Ohtsuka T., Flege J.B., Wolf R.K. Thoracoscopic direct clipping of the thoracic duct for chylopericardium and chylothorax. Ann Thorac Surg 2000;70:1662-1665.[Abstract/Free Full Text]
- Shirai T., Amano J., Takabe K. Thoracoscopic diagnosis and treatment of chylothorax after pneumonectomy. Ann Thorac Surg 1991;52:306-307.[Abstract]
- Furrer M., Hopf M., Ris H.B. Isolated primary chylopericardium: treatment by thoracoscopic thoracic duct ligation and pericardial fenestration. J Thorac Cardiovasc Surg 1996;112:1120-1121.[Free Full Text]
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Abstract
Introduction
