Ann Thorac Surg 2008;85:334-336. doi:10.1016/j.athoracsur.2007.04.109
© 2008 The Society of Thoracic Surgeons
Case Reports
Treatment of Chylothorax by Robotic Thoracic Duct Ligation
Kari J. Thompson, MD,
Kemp H. Kernstine, MD, PhD*,
Frederic W. Grannis, Jr, MD,
Pablo Mojica, MD,
Andres Falabella, MD
City of Hope, Duarte, California
Accepted for publication April 26, 2007.
* Address correspondence to Dr Kernstine, City of Hope, 1500 East Duarte Rd, Duarte, CA 91010 (Email: kkernstine{at}coh.org).
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Abstract
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This is the first report describing the use of robotic technology for the treatment of chylothorax. We present a 22-year-old with mixed embryonal cell and seminoma germ cell cancer refractory to medical and surgical treatment. The patient had rising markers and a growing left lower lung lobe metastasis. After left lower lobectomy, left-sided chylothorax developed. Conservative management failed, and a robotic right-sided thoracic duct ligation was performed. Other treatment options are reviewed.
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Introduction
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Chylothorax secondary to thoracic duct trauma occurs in post-thoracotomy patients with a frequency of 0.25% to 0.5% [1]. Risk factors include extensive mediastinal dissection, mediastinal radiation therapy, or mediastinal neoplasia. There are 40% to 60% of patients who exhibit anatomical variability of the thoracic duct, making it challenging to avoid during surgical dissection. Potential methods to address iatrogenic chylothorax include observation, mechanical drainage, low fat diet with or without medium chain triglycerides supplementation, pleurodesis, oversewing of the thoracic duct injury, lymphatic ligation, and prophylactic thoracic duct ligation [2–4]. Due to malnutrition secondary to protein and fatty acid loss, immunosuppression from lymphocytes loss, and respiratory compromise from atelectasis, treatment of chylothorax is indicated.
Minimally invasive treatment of traumatic or iatrogenic chylothorax has been described [5–7]. Ligation of the thoracic duct at the entrance to the posterior mediastinum is highly successful; however, port placement and visibility in the inferior posterior sulcus can be cumbersome. Given our prior experience with robotic esophagectomy, we speculated that a robotic approach would decrease operative time and morbidity. Three- dimensional visibility and numerous degrees of freedom allow precise ligation.
We present a case of post-thoracotomy chylothorax refractory to conservative management. Robotic thoracic duct ligation was performed with immediate arrest of chylous drainage. This is the first report describing the use of robotic technology for treatment of chylothorax.
The patient is a 22-year-old, nonsmoking, college student with a history of right testicular mixed embryonal cell and semi-nomatous germ cell tumor with metastatic disease to the retroperitoneum, liver, mediastinum, and both lungs. After right orchiectomy and 11 cycles of chemotherapeutic regimens consisting of platinum, vincristine, methotrexate, bleomycin, actinomycin, cyclophosphamide, and etoposide (POMB-ACE), a new lesion developed and the normalized markers (ie, beta HCG and alpha-fetoprotein) began to rise. The patient was then treated with gemcitabine, oxaliplatin, and Taxol (paclitaxel; Bristol-Myers Squibb, Princeton, NJ) (GOT) for eight cycles. After treatment, a single liver nodule persisted. It was resected by a laparotomy. Histologically the nodule was comprised of necrotic tumor. Lesions subsequently appeared in both lungs and markers rose again. He was then treated with vinblastine, ifosfamide, and cisplatin (VEIP) for four cycles and markers normalized. Two months later, markers rose to alpha-fetoprotein of 25.1 nG/mL (nL 
10.8), lactate dehydrogenase 547 U/L (297–537 nL) and a beta human chorionic gonadotropin 129.7 (nL < 40). A single 2.5-cm left lower lobe pulmonary nodule was found on computed tomography. Although the prognosis was understood to be poor, surgical salvage was attempted. Under single lung ventilation, an exploratory thoracoscopy was performed. The pulmonary nodule was not visualized. A left-sided thoracotomy was performed. Enlarged, matted lymph nodes were resected along with the left lower lobe (R2 resection). Immediate pathologic examination of the mass demonstrated persistent embryonal cell cancer with extensive nodal involvement in nine of ten perihilar nodes and three of four aortopulmonary window nodes. Drains were placed and the chest was closed.
On postoperative day 5, chest tube drainage doubled and became chylous with a triglyceride level of 170 mg/dL, total protein of 2.4 G/dL, and glucose of 66 mg/dL. The patient was placed on a low-fat diet, and chest tube suction was decreased to –10 cm H2O. Chest tube drainage increased from 560 mL/day to 1100 mL per day. Pleural effusion was not seen on the follow-up chest x-ray film in spite of the reduced suction. A central venous line was placed, total parenteral nutrition was initiated, and oral feeding was discontinued. For the next 2 days, daily thoracic output increased to 1.6 L/day.
After consideration of all options, on postoperative day 7, a right-sided robotic approach with single lung ventilation was performed. With the patient in a nearly prone and slightly reversed Trendelenburg position, four port sites were made (two for the robotic arms, one for the robotic videoscope, and one for a fan retractor and passage of suture) (Fig 1). With 15 mm Hg of CO2 insufflation there was good visualization of the most inferior aspect of the posterior sulcus. Just cephalad to the diaphragm, the posterior mediastinal tissue between the descending aorta and azygous vein was triple ligated with No. 0 Ethibond (Ethicon Inc, Johnson and Johnson, Cincinnati, OH) in a figure eight fashion. Two No. 19 round Blake thoracostomy drains (Ethicon Inc) were placed. On postoperative day 1, output from the left chest tube decreased to 200 mL of clear fluid. Output from the right chest drains was minimal. Over the next 2 days the drains were removed and the patient was discharged home. Chest x-ray films 2 weeks later demonstrated no evidence of effusion.
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Fig 1. After double lumen intubation, the patient is positioned on the left side, somewhat down and semiprone. The robotic chassis is brought over the patient’s back, left side. Four ports are placed: three for the robotic arms (circled) and one accessory 12-mm port (short line). The rightward robotic (8 mm) port is placed at the fifth intercostal space adjacent to the anterior aspect of the scapular tip, posterior to the posterior axillary line. Along the same linear plane, approximately 12 to 14 cm away, the 12-cm port is placed for the robotic videoscope and the third robotic port (8 mm) is placed 12 to 14 cm away along the same place as the first two ports. The final port is placed 14 cm anterior to the plane of the first three ports. The fan retractor and suture are passed through it.
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Comment
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Chylothorax represents a significant health risk increasing morbidity and mortality as well as healthcare costs. To guide treatment, algorithms encompassing medical and surgical treatment options have been established. In this immune-compromised patient, persistent chylothorax would have further lengthened hospitalization, increased the likelihood of postoperative complications (including wound infection, bronchial stump disruption, and pneumonia), and delayed additional chemotherapy. Ligation of the thoracic duct was considered preferable to pleurodesis, as the latter has inconsistent efficacy especially in patients with large volumes of effusion. Due to the degree of prior mediastinal dissection, there was concern that it would have been difficult to identify the lymphatic injury, potentially creating injury to adjacent, uninvolved structures. Right-sided thoracoscopy was also considered, but the small size of the inferior posterior sulcus, especially in the heavier patient, would have made accurate deep suture placement technically difficult.
Our choice was to ligate the thoracic duct where it enters the mediastinum from the retroperitoneum, between the ascending aorta and the azygous vein [8]. We commonly perform this technique robotically during our robotic esophagectomy and resection of posterior mediastinal masses [9]. Docking times are typically approximately 10 minutes. In this case, total operative time was 40 minutes. Robotic surgery allowed enhanced visibility in a small space, facilitated suture placement, and minimized patient morbidity. Robotic thoracic duct ligation is an attractive treatment modality for treatment of persistent chylothorax.
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References
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- Buchan KG, Hosseinpour AR, Ritchie AJ. Thoracoscopic thoracic duct ligation for traumatic chylothorax Ann Thorac Surg 2001;72:1366-1367.[Abstract/Free Full Text]
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- Wuring PN, Hollaus PH, Ohtsuka T, Flege JB, Wolf RK. Thoracoscopic direct clipping of the thoracic duct for chylopericardium and chylothorax Ann Thorac Surg 2000;70:1662-1665.[Abstract/Free Full Text]
- Kausel HW, Reeve TS, Stein AA, et al. Anatomic and pathologic studies of the thoracic duct J Thorac Surg 1957;34:631.[Medline]
- Kernstine KH, DeArmond DT, Karimi M, et al. The robotic, 2-stage, 3-field esophagolymphadenectomy J Thorac Cardiovasc Surg 2004;127:1847-1849.[Free Full Text]
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Abstract
Introduction
