Ann Thorac Surg 2009;87:1601-1603. doi:10.1016/j.athoracsur.2008.09.029
© 2009 The Society of Thoracic Surgeons
Case Reports
Peritoneoatrial Shunting for Intractable Chylous Ascites Complicating Thoracic Duct Ligation
Françoise Le Pimpec-Barthes, MD, PhDa,
Minh Pham, MDa,
Jérome Jouan, MDb,
Alain Bel, MDb,
Jean-Noël Fabiani, MD, PhDb,
Marc Riquet, MD, PhDa,*
a Department of Thoracic, Georges Pompidou European Hospital, Paris Descartes University, Paris, France
b Department of Cardiovascular Surgery, Georges Pompidou European Hospital, Paris Descartes University, Paris, France
Accepted for publication September 9, 2008.
* Address correspondence to Dr Riquet, Department of Thoracic Surgery, Georges Pompidou European Hospital, 20 Rue Leblanc, Cedex 15, Paris, 75908, France (Email: marc.riquet{at}egp.aphp.fr).
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Abstract
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Thoracic duct ligation for chylothorax is considered a safe and efficient procedure. However, we observed two cases that were complicated by intractable chylous ascites. Refractory chylous ascites are usually cured by surgical peritoneovenous shunting, but in both patients successful treatment required peritoneoatrial shunting. Actually, a peritoneovenous shunt was impossible because of extensive venous thrombosis in jugular and superior vena cava in one patient and failed because of constrictive pericarditis requiring pericardectomy in the other, both underlying diseases also accounting for the thoracic duct ligation complications.
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Introduction
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Supradiaphragmatic ligation of the thoracic duct through the right chest is currently favored by most authors to control chylothorax that is still present after a period of carefully supervised nonoperative conservative therapy [1]. Little is known about the consequences of this procedure, which is commonly considered safe and effective, but postoperative complications have been described, among them chylous ascites development requiring peritoneovenous LeVeen shunting [2]. This article illustrates the factors predisposing to this complication and their incidence on its management.
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Case Reports
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Patient 1
A 60-year old man was admitted to our department for an intractable massive chylous ascites of a 12-month duration. The patient had no previous medical history other than an acute superior vena cava (SVC) syndrome rapidly complicated by a chylopericardium and bilateral chylothorax. The SVC obstruction was related to complete thrombosis of an unknown origin despite a thorough search for any vascular disease.
Chylothorax persisted despite a low-fat enteral diet and systemic anticoagulation. Thoracic duct ligation was performed 1 month later under videothoracoscopy, associated with bilateral talc pleurodesis. A chylous ascites was diagnosed 3 months later, which rapidly proved to be massive (exceeding 15 L/w) despite medical therapy. The patient gradually sustained severe cachexia, but peritoneovenous LeVeen shunting could not be done because of persisting complete cervical veins and SVC thrombosis.
One year after the onset of this disease, the patient was referred to our hospital. The SVC and brachiocephalic veins not being available to bypass the chylous effusion, we implanted the LeVeen peritoneovenous shunt (Becton Dickinson, Grenoble, France) into the right atrium through a sternotomy. After removing 18 L of chylous ascites, the LeVeen shunt was subcutaneously tunnelled from under the xiphoid to the right flank of the abdomen and inserted into the peritoneal cavity, and then into the right auricle through a pursestring.
The patient had an uneventful postoperative course and was discharged 10 days after the procedure. His previous diet was maintained. No chylous effusion was observed during the following 6 months, and the lipid-free regimen was discontinued. The patient recovered a good nutritional status and is still faring well 1 year later.
Patient 2
A 39-year-old man whose previous history was a chylous pericarditis that was drained when he was 22 years old, presented 4 years later with symptomatic chylothoraces requiring repeated thoracentesis. Lymphography demonstrated a normal thoracic duct at its origin, with multiple dilated lymphatic channels in its midportion and upward. Thoracic duct ligation associated with bilateral pleurodesis was achieved under videothoracoscopy. Immediate result on chylothorax was good, but a chylous ascites was observed a few weeks later.
After failure of rigorous medical treatment, with repeated ascites paracenteses resulting in more than 15 L every 1 to 2 weeks, a peritoneovenous shunt was performed after a preoperative Doppler echocardiography confirmed the jugular veins and SVC permeability.
The patient's immediate postoperative course was uneventful, but peritoneal effusion recurred a few weeks later. New echocardiography and thoracoabdominal computed tomography scan were performed that disclosed a pericardial constriction causing increased venous pressure. We decided to implant a new shunt directly into the atrium while treating the constriction to relieve the venous pressure.
A careful sternotomy was performed because of dense adhesions between the sternum and the mediastinum. The pericardium was extremely thick, causing major cardiac constriction. Pericardectomy was difficult because of complete symphysis between the myocardium and pericardium. The initial SVC pressure was 24 cm H2O and dropped to 4 cm H2O after pericardectomy. A new LeVeen shunt was implanted between the peritoneal cavity and the right atrium (in the same way as in the first patient).
The patient's postoperative course was uneventful. No chylous effusion being observed during the following months, the lipid-free regimen was discontinued and the patient was still doing well 1 year later.
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Comment
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Nontraumatic chylothorax are mainly neoplastic [1, 2]. In rare instances, thrombosis of the jugular and subclavian veins or malformations of the lymphatic system, particularly in the thoracic duct itself, have been shown to cause this pleural effusion [1], as observed in both patients reported here. Supradiaphragmatic ligation of the thoracic duct through the right chest is currently favored by most authors to control chylothorax that is still present after a period of carefully supervised nonoperative conservative therapy [1], and appeared to be the last option for the patients. Actually, this procedure is considered safe and effective. Studies in animals have shown that collaterals between the lymphatic and systemic venous circulations develop after thoracic duct ligation [3, 4], thus explaining the effectiveness of the procedure and its good tolerance.
Nontraumatic chylous ascites is rare and may be observed in instances SVC thrombosis [5] and in elevated venous blood pressure related to left ventricular dysfunction [6] and constrictive pericarditis [7]. When the venous circulation is obstructed or when the blood pressure is too high, the lymphaticovenous circulation may become ineffective. Underlying diseases was also present in our observations. Furthermore, thoracic duct ligation in our patients might have aggravated the lymph stasis and the pressure within the intraabdominal lymphatics and favored their rupture. Such an elevated blood pressure probably also explains the chylothorax observed by Christodoulou and colleagues [2] after heart transplantation and the chylous ascites after its treatment by thoracic duct ligation.
The management of chylous ascites is challenging. A peritoneovenous shunt is an attractive treatment for controlling intractable ascites [5] and is also effective in treating chylous ascites [8] because it returns chylous ascites to blood circulation. A peritoneovenous shunt was contraindicated in the first patient because of SVC thrombosis. We "bypassed" the difficulty by directly deviating the chyle into the right atrium. The same procedure was performed in the second patient, but pericardectomy was probably the most important and might have been sufficient. This latter case illustrates the role played by elevated blood pressure not only in chylous ascites occurrence but also in the first peritoneovenous shunt failure.
To conclude, the important lesson learned from these 2 patients is that thoracic duct ligation must not be performed in patients whose cardiovascular status may represent a blockade to lymphaticovenous communications, unless the underlying disease is corrected. Second, peritoneoatrial shunting must be considered when a standard peritoneovenous shunt is contraindicated.
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References
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- Miller Jr JI. Anatomy of the thoracic duct and chylothoraxIn: Shields TW, Locicero 3rd J, Ponn RB, Rusch VW, editors. General thoracic surgery. Philadelphia, PA: Lippincott Williams & Wilkins; 2005. pp. 879-888.
- Christodoulou M, Ris HB, Pezzetta E. Video-assisted right supradiaphragmatic thoracic duct ligation for non-traumatic recurrent chylothorax Eur J Cardiothorac Surg 2006;29:810-814.[Abstract/Free Full Text]
- Lee FC. The establishment of collateral circulation following ligation of the thoracic duct Bull Johns Hopkins Hosp 1922;33:21-31.
- De Freitas V, Zorzetto NL, Prates JC, Seullner G. Collateral lymphatic circulation after thoracic duct ligature in dogs Anat Anz 1979;146:39-46.[Medline]
- Leggio L, Abenavoli L, Vonghia L, et al. Superior vena cava thrombosis treated by angioplasty and stenting in a cirrhotic patient with peritoneovenous shunt Ann Thorac Cardiovasc Surg 2008;14:60-62.[Medline]
- Ridruejo E, Mando OG. Chylous ascites as the main manifestation of left ventricular dysfunction: a case report BMC Gastroenterol 2005;5:25-28.[Medline]
- Amasyali B, Hepen G, Akkoc O, Yuksel UC, Kilic A, Isik E. Chylous ascites and pleural effusion secondary to constrictive pericarditis presenting with signs of lymphatic obstruction Jpn Heart J 2004;45:535-540.[Medline]
- Makino Y, Shimanuki Y, Fujiwara N, et al. Peritoneovenous shunting for intractable chylous ascites complicated with lymphangioleiomyomatosis Intern Med 2008;47:281-285.[Medline]
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Abstract
Introduction
