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Ann Thorac Surg 2009;88:246-252. doi:10.1016/j.athoracsur.2009.03.083
© 2009 The Society of Thoracic Surgeons
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Original Articles: General Thoracic

Thoracic Duct Ligation for Persistent Chylothorax After Pediatric Cardiothoracic Surgery

Dilip S. Nath, MD, Jainy Savla, BS, Robinder G. Khemani, MD, Daniel P. Nussbaum, BS, Christina L. Greene, BS, Winfield J. Wells, MD*

Division of Cardiothoracic Surgery, Childrens Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California

Accepted for publication March 27, 2009.

* Address correspondence to Dr Wells, Childrens Hospital Los Angeles, Division of Cardiothoracic Surgery, 4650 Sunset Blvd; MS 66, Los Angeles, CA 90027 (Email: wwells{at}chla.usc.edu).

Presented at the Fifty-fifth Annual Meeting of the Southern Thoracic Surgical Association, Austin, TX, Nov 5–8, 2008.


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 Discussion
 References
 
Background: There is considerable literature on incidence and medical management of postsurgical chylothorax in children but little is known about outcomes of thoracic duct ligation (TDL) for patients refractory to medical therapy.

Methods: A retrospective review of patients undergoing TDL after cardiothoracic surgery (1992 through 2007) was done. Data on demographics including cardiac morphology, characteristics of chylous drainage, medical management, and post-TDL course were collected. When available, imaging studies of the upper body venous drainage vessels were examined.

Results: Twenty patients (median age, 0.65 years; range, 0.03 to 11 years; weight, 7.0 kg; range, 2.6 to 30 kg) had a diagnosis of chylothorax made 8.5 days (range, 2 to 118 days) after initial operation. Median duration of pre-TDL medical management was 17.5 days (range, 7 to 69 days). Median drainage for 5 days preceding TDL was 34.5 mL · kg–1 · d–1 (range, 15 to 135 mL · kg–1 · d–1) with maximal output of 65 mL · kg–1 · d–1 (range, 30 to 200 mL · kg–1 · d–1). After TDL, there was a decrease in median drainage to 13 mL · kg–1 · d–1 (range, 4 to 160 mL · kg–1 · d–1; p = 0.003). Chest tubes were removed 8.5 days (range, 4 to 34 days) after TDL. There were 4 deaths (none attributed to TDL), 2 treatment failures (post-TDL chest tube drainage > 2 mL · kg–1 · d–1 > 14 days), and 2 recurrences (after initial chylothorax resolution and hospital discharge). Three patients had documented upper body venous thrombosis. Univariate analysis demonstrated thrombosis of upper body venous vessels (p = 0.02) and prolonged post-TDL chest tube drainage (p = 0.01) were risk factors for death, treatment failure, or chylothorax recurrence.

Conclusions: Thoracic duct ligation leads to a major reduction in chest tube drainage and prompt tube removal in most pediatric patients and should be considered early in refractory postoperative chylothorax. Patients with upper body venous thrombosis associated with chylothorax are at a high risk for failure of TDL and mortality.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 Discussion
 References
 
Chylothorax after pediatric cardiac surgery is not uncommon with a reported incidence of 0.89% to 6.6% [1–5]. Although there is considerable literature describing the medical management of this problem, there is virtually no information on the role of thoracic duct ligation (TDL) and its impact on this potentially serious complication [1–4, 6]. Although there have been advocates for early TDL [7], the evidence base is quite limited and more often surgical intervention has been a measure of late resort with predictably poor results. This is the case despite considerable evidence that TDL can be performed safely in children using a standard thoracotomy or video-assisted thoracoscopic approach [8, 9].

This study was designed to look at the outcomes of all consecutive patients undergoing post–cardiac surgery TDL in our institution during the past 15 years. We hoped to validate the safety and efficacy of the procedure and identify variables that might suggest the appropriate timing for the operation.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 Discussion
 References
 
Demographics
A retrospective review of all patients younger than 18 years of age undergoing a TDL for persistent chylothorax at Childrens Hospital Los Angeles from 1992 to 2007 was performed. Both inpatient and outpatient charts were reviewed following guidelines established by the institutional review board. Demographic data regarding age, weight, time to diagnosis, presence of Down's syndrome, and index cardiac surgical procedure were tabulated.

Diagnosis
Chylothorax was suspected when persistent drainage from an existing chest tube became cloudy when the patient was fed, or when similar milky fluid was found after placing a tube into a newly discovered effusion. Diagnosis of chylothorax was confirmed based on the characteristics of pleural fluid recovered from each patient. Namely, a triglyceride level of more than 110 mg/dL or a white cell count of greater than 1,000 cell/µL with a significant lymphocyte fraction (>80%) in the fluid was used to make the diagnosis [3, 10]. In some instances, patients had an effusion seen on chest radiograph for some time before placement of a thoracostomy tube yielding diagnostic fluid. For the purposes of the study, the onset of chylothorax was considered to be the point at which diagnostic fluid was recovered. This was the point in time used to determine the interval between the initial cardiac procedure and the presence of a chylothorax.

Preoperative Management
During the period of this study, there was no standardized protocol for the management of postoperative chylothorax. As a general rule, treatment consisted of progressive stepwise dietary restriction beginning with a low-fat or nonfat diet, followed by clear fluids, with subsequent nothing by mouth or total parenteral nutrition status. The duration of each of these dietary measures was variable and at the discretion of the managing physician. Likewise, there was no protocol for the use of medications such as corticosteroids or somatostatin analogs. Dosing and duration of these drugs were based on individual physician preference. No patient had a procedural intervention such as pleurodesis or lymphangiographic gel embolization.

Our institutional preference has been to place chest tubes to suction during the medical management phase. Before chest tube removal (during medical management phase or post-TDL phase), we typically place the chest tube to water-seal for 24 hours before removal. Patients were on a first-generation cephalosporin for the duration of chest tube drainage.

Operative Description
All patients had a central venous catheter placed either through the internal jugular vein or the subclavian vein in the operating room. A low dose of dilute heparin was continuously infused through the most distal port of the central catheter.

All patients had their operation through a standard lateral right thoracotomy. The thoracic duct was identified near its point of entry into the chest through the aortic hiatus. In most instances, a definitive tubular structure was seen, although in some cases a network of finer channels was appreciated. Proximal and distal ligation of the duct and surrounding tissue in the space between the aorta and the azygous venous complex was carried out. Loculations, if present in the right hemithorax, were taken down, and a tube was positioned posteriorly and to the apex of the chest for optimal drainage.

Outcomes After Thoracic Duct Ligation
Typically we removed the central catheter within 1 week after the initial procedure. If the patient needed central access for parenteral nutrition (or otherwise) beyond this period, the catheter inserted at the time of initial cardiac operation was discontinued and a peripherally inserted (typically through the antecubital space) central venous catheter was placed. A low dose of dilute heparin was continuously infused through the most distal port of the peripherally inserted central venous catheter as well. For patients undergoing a completion Fontan, sodium warfarin (Coumadin) was started in the early postoperative period with a target international normalized ratio of 2. This was routine protocol for all Fontan patients.

Although there was no set protocol for replacement of the drainage, albumin was used to replace drainage usually in a concentrated form. On occasion, fresh-frozen plasma was used if coagulation factors suggested the need. In some patients with prolonged drainage, intravenous immunoglobulin was administered.

Hospital mortality was defined as any death within 30 days of TDL or any death occurring during the same hospitalization at which that procedure was performed. Chest tube drainage was documented after TDL, and a mean value was determined for the 5 days after the operation. Resolution of chylothorax was defined as chest tube drainage of less than 2 mL · kg–1 · d–1. Treatment failure was defined as chest tube drainage of greater than 2 mL · kg–1 · d–1 for more than 14 days. Time to chest tube removal was determined, but it should be noted that there was no standard protocol for when a tube should come out. Outpatient charts were accessed to determine patient status with regard to recurrent effusions, and records were available for all surviving patients within 6 months of collation of data.

Statistical Analysis
Statistical analysis was performed using Statistica v. 5.5 (StatSoft, Tulsa, OK) and Stata v. 10 (StataCorp, College Station, TX). Descriptive statistics regarding preoperative and intraoperative factors and survival were first performed. The preoperative risk factors evaluated included male sex, age, presence of single-ventricle physiology, surgery for Fontan completion, presence of heterotaxy, and documentation of upper extremity vascular thrombosis. Specific tube thoracostomy drainage characteristics were also assessed.

Next, univariate analysis was performed examining the variables of interest against the outcome of TDL. Continuous variables were analyzed with a Wilcoxon rank-sum test, as assumptions of normality could not always be satisfied. Dichotomous outcomes were analyzed using Fisher's exact test. Correlation coefficients were reported, with a significance level for the parameter estimates of 0.05.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 Discussion
 References
 
Demographics
Among the 20 patients that met criteria, median age and weight at TDL was 7.8 months and 7 kg, respectively. Roughly half the patients had single-ventricle morphology, and the procedure that preceded the onset of chylothorax was either a Fontan (n = 5) or Glenn (n = 4) in 9 of the 20 patients. All single-ventricle patients met pre-Fontan hemodynamic criteria with mean pulmonary artery pressure of 18 mm Hg or less. All 5 patients had a nonfenestrated Fontan, and 1 patient required a fenestration for protein-losing enteropathy several months after discharge from resolution of chylothorax after TDL. Table 1 summarizes these findings.


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  		Table 1 Demographics
 
Preoperative Management
The median interval from initial operation to the diagnosis of chylothorax was 8.5 days, although the range was wide (2 to 118 days). Median triglyceride level was 244 mg/dL (range, 133 to 1,465 mg/dL), and white cell count was 5,120 cells/µL (range, 460 to 30,900 cells/µL). The percentage of lymphocytes in fluid was 87% (range, 37% to 97%). All but 1 patient was diagnosed with a chylous effusion less than 6 weeks after the initial operation. One patient was diagnosed nearly 4 months (118 days) after the initial operation. The patient was an 11-year-old boy whose initial operation was a mediastinal mass resection for lymphoma with internal jugular vein reconstruction. He was discharged home and readmitted to the hospital nearly 3 months later with a diagnosis of chylothorax. Thoracic duct ligation was performed after a short course of medical management.

Chylous effusion was unilateral in 70% (14 of 20 patients), and a concomitant pericardial fluid collection was present in only 2 patients. Table 2 summarizes the preoperative tube thoracostomy findings. Patients were conservatively managed with dietary and, in some cases, pharmacologic measures for more than 2 weeks (median, 17.5 days; range, 17 to 69 days) before being taken to the operating room for TDL. Table 3 documents the type and duration of these medical management measures. Of note, only half the patients received a somatostatin analog before operation for TDL. As demonstrated in Table 2, pre-TDL drainage was substantial, with a volume of 35 mL · kg–1 · d–1 (range, 15 to 135 mL · kg–1 · d–1) averaged during the 5 days before ligation. The median value for maximal drainage before TDL was 65 mL · kg–1 · d–1 (range, 30 to 200 mL · kg–1 · d–1).


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  		Table 2 Preoperative Tube Thoracostomy Characteristics
 

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  		Table 3 Preoperative Medical Management
 
Outcomes After Thoracic Duct Ligation
There were a total of 4 deaths among the 20 patients in this series. Two were hospital deaths and 2 occurred later. None of the deaths were attributed to the TDL procedure itself but rather were related to the comorbidities. Both patients who died while still in the hospital failed to resolve their chylous effusions, and in both instances, superior vena caval (SVC) thrombosis was documented. Although there was an attempt at SVC reconstruction, in neither case was the patient salvaged. The 2 late deaths occurred at 2 and 4 months after hospital discharge. Both patients had resolved the chylothorax before initial hospital discharge. At the time of readmission, 1 patient was a heterotaxy who presented with extreme sepsis and was documented to have an SVC thrombosis before demise. The other patient had Down's syndrome and presented with a small bowel obstruction. The patient underwent resection of necrotic small bowel and ultimately succumbed to complications of the abdominal procedure.

Impact on Chylous Effusion
In 90% of patients (18 of 20 patients), TDL resolved the problem of persistent chylous effusion during the initial hospitalization (Table 4). The 2 patients with treatment failures expired during the same hospital stay as described above. Median drainage for the 5 days after TDL was 13 mL · kg–1 · d–1, which was significantly less than the volume of 34.5 mL · kg–1 · d–1 seen before ligation (p = 0.003). Chest tubes were removed at a median of 8.5 days after the operation (range, 4 to 34 days).


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  		Table 4 Postoperative Tube Thoracostomy Characteristics
 
Of 18 patients who were discharged home, 2 experienced a recurrent chylothorax within a month and were hospitalized for further management. Table 5 documents these findings. Interestingly, both patients came in with echocardiographic evidence of a combined pericardial and pleural fluid collection that proved chylous at the time of drainage. In both instances, the effusions resolved after a period of medical management that included nothing by mouth or total parenteral nutrition.


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  		Table 5 Efficacy and Safety of Thoracic Duct Ligation
 
Medical Management After Thoracic Duct Ligation
Table 6 documents the medical measures taken to reduce lymph production after TDL. It should be noted that these were essentially the same treatments used before duct ligation to try and suppress chyle.


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  		Table 6 Postoperative Medical Management
 
Risk Factors for Treatment Failure
Table 7 documents those variables thought to be potentially related to death, treatment failure, or recurrence after TDL. Of 20 patients, 14 (70%) had a favorable outcome after TDL; there were 2 hospital deaths (both of whom were treatment failures), 2 recurrences, and 2 late deaths. Two factors were found to be significant, including the presence of upper body venous thrombosis (as documented by vascular ultrasound examination) and drainage persisting for more than 10 days after TDL.


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  		Table 7 Univariate Analysis of Death or Treatment Failure a
 

   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
Discussion
 References
 
Prior studies suggest that the incidence of persistent chylous effusions in the pleural or pericardial spaces after cardiothoracic surgery in children is in the range of a fraction of 1% to more than 6% [1, 5, 11–13]. The cause is most likely trauma to lymphatic channels or elevated pressure in the upper body venous system owing to thrombosis or physiologic obstruction [3]. High venous pressures in the upper body may be associated with the Glenn and Fontan procedures. These operations had been performed in nearly half the patients in this series before their chylothorax. Increased pressure in the venous system leads to a resistance to lymphatic drainage through the thoracic duct with subsequent lymphatic leak into the pleural or pericardial cavities [11, 13, 14]. The consequences of a persistent major chylous leak may be serious, including lipid and protein loss, compromise of the immune system from the loss of immune proteins and lymphocytes, weight loss, and failure to thrive. This complication may also extend hospital stay by as much as 2 to 3 weeks [1]. Recognition of a chylous leak may occasionally occur at the time of operation, and in such instances oversewing of the site, often with a pledgetted suture, may avoid the consequences of a persisting effusion [15].

Treatment for chylothorax has historically proceeded in a stepwise fashion once adequate drainage has been established [1]. The first line of therapy is focused on decreasing lymph flow by restricting the patient to a low-fat, preferably medium-chain triglyceride-enriched diet [16]. If chyle production does not decrease with this level of dietary restriction, most clinicians would then impose a period of nothing by mouth or total parenteral nutrition [1, 4]. During this time, pharmacologic therapy may be undertaken, most commonly with a somatostatin analog, octreotide. There is some evidence that octreotide increases lymphatic vessel contraction, and in some patients with a less severe leak, this may lead to a resolution of the problem [17, 18]. Steroids have been used [1], although there is no clear mechanism to explain how this may resolve a lymphatic leak and no definitive guidelines for dosing exist. An argument has been made that if a pericardial effusion is not improved with a course of antiinflammatory agents, the effusion is more likely to be chylous [11].

The natural history of postsurgical chylothorax has been documented in a number of studies [1, 3, 4, 6, 14]. A recent paper from Toronto [1] describes the course of 48 such patients, with 71% resolving their problem with dietary changes at a median interval of 15 days. The authors offer an algorithm with progression of medical therapy during a 3-week period after which TDL might be considered. In their experience, only 4 of 48 patients or 8% underwent duct ligation with what they considered to be a marginal impact on chyle leak, and 3 of these patients ultimately died. Although we would agree with the Toronto group and the many other authors who suggest that conservative medical management is the appropriate initial treatment for postsurgical chylothorax, there remains a question regarding how long such treatment should continue before considering TDL. Based on our experience, we would suggest that owing to the low risk and high success rate of the procedure, TDL should be considered much earlier in the treatment course of patients who are not responding to diet and medication regimens.

The optimal timing of initiating octreotide in addition to dietary measures has not been clearly defined. In a recent report [13], early use of this medication was advocated based on findings in 51 patients with prolonged chylous drainage despite dietary measures. After 15 days of treatment with octreotide, 83% had resolution of chylothorax and only 5 patients required a surgical intervention. Our current approach has been to introduce aggressive escalation of dietary restriction and octreotide use at the onset of treatment for postoperative chylothorax, with the intent of early TDL in patients who have not responded within roughly 2 weeks.

The efficacy of TDL in the management of persisting postsurgical chylothorax has been documented by numerous authors [1, 3, 4, 7, 8, 14, 15, 19]. Despite this, most authors have treated the procedure as a measure of last resort. Cerfolio and associates [15] reported a series of postsurgical adult patients with chylous drainage of greater than 1000 mL/d who underwent TDL with prompt resolution of drainage in more than 90%. Similar favorable results have led other authors [7, 8] to recommend early surgical treatment for pediatric patients, although most studies include a very small number of patients.

Alternative therapies for persisting chylothorax have been advocated, including the use of pleurodesis [20] and externalized pleuroperitoneal shunts [21–23]. In adults, embolization and blockage of lymphatic vessels has been reported [24]. In light of the success of TDL in the pediatric populations, it is unclear what advantages these therapies may offer.

We found that not only was TDL successful in decreasing postoperative drainage, it led to a sharp and almost immediate cessation of all drainage in a short period. In our study, we defined treatment failure as persistent drainage for more than 14 days. Clearly the choice of 14 days is an arbitrary one. As the literature contains successful conservative treatment after a 4-week period of nonoperative management, we decided to use a course of 14 days to determine whether indeed TDL was successful. In fact, we were rather conservative in continuing to leave in the tube thoracostomy in the postoperative patient. As a result, the number of days a chest tube was left in after surgery was longer than what is considered standard treatment at Childrens Hospital Los Angeles. No chest tube, however, was removed when the drainage was more than 2 mL · kg–1 · d–1.

In our study, the presence of central venous thrombosis was a risk factor for death after TDL. It has been previously suggested that central venous thrombus is a factor in failure of conservative management [14, 25], and such patients typically are prone to having a bilateral chylothorax [25]; however, to our knowledge, upper extremity venous thrombosis being a significant risk factor after TDL has not been noted by other investigators.

We have had very limited success in treating this problem, and among the patients in this study, there were 3 patients who had a documented SVC thrombosis. Two of the patients had an attempt at SVC reconstruction and in neither case was the patient salvaged. In both instances, the patients died with continued drainage at the time of demise. In the third patient, chylothorax was resolved before initial hospital discharge. The patient died of sepsis nearly 2 months after hospital discharge, and at the time of death, SVC thrombosis was documented.

In our experience, the best hope for resolution of this problem is to identify the problem early and treat with a thrombolytic such as tissue plasminogen activator. This has yielded a few successes and a number of bad outcomes linked to bleeding complications. We have a limited experience with surgical intervention for upper body venous thrombosis, but as a general rule, we have attempted bypass with a Gore-Tex tube. This was attempted unsuccessfully in 2 patients in the series. As noted, we currently look for evidence of venous thrombosis in any patient with a persistent chylous effusion in hopes that if the clot is found early, it will be more amenable to tissue plasminogen activator therapy.

This is a retrospective study with a relatively small number of patients. Follow-up was limited to the early postoperative period without an emphasis on the long-term outcome of the patient population. There was no standard protocol used in the management of each patient with a postoperative chyle leak. Furthermore, not all of the patients underwent ultrasonographic evaluation for the presence of upper extremity vascular thrombosis.


   Discussion
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Discussion
References
 
DR MICHAEL HINES (Winston-Salem, NC): Doctor Nath, I congratulate you on a nice presentation on what is a challenging and, frankly, annoying problem for patients, parents, and congenital heart surgeons who function in a "fix-it" mode, and this is clearly something that is very difficult to fix. In reviewing your manuscript, your 20 patients over 15 years really constitute a very heterogeneous group in diagnosis, in treatment protocols, and length of observation, and this, along with a retrospective approach over 15 years, makes it somewhat difficult to make firm conclusions. However, you define success as 70%, or 14 out of the 20 in the group, although the chest tube still remained an average of 8.5 days and up to 34 days after thoracic duct ligation. There were 13 right-sided effusions, 3 left, and 6 bilateral effusions, and almost half the patients were post-Fontan or post–bidirectional Glenn. It is also unclear how many other patients had redo sternotomies and extensive dissections. Nonetheless, you have a lot of data, and I suspect you have used it to formulate your future protocols.

I will mention, at our institution we divide our patients into physiologic or hydrostatic chylothoraces and traumatic chylothoraces. In the latter group, we usually see mediastinal or pleural chyle early with the initiation of feeds and immediately institute transpyloric medium-chain triglyceride formulations and usually see a rapid drop in volume and sealing of the lymphatic leak, only occasionally having to use octreotide. We do believe that electrocautery dissection may minimize these types of traumatic leaks, especially in redo operations, taking care to avoid the nerves, obviously.

In the physiologic group, usually these are single-ventricle patients, as with Fontan and bidirectional Glenn patients, and we believe the chylothorax is frequently secondary to elevated venous pressure, and therefore in addition to transpyloric feeds with medium-chain triglycerides, we direct therapy at lowering the pulmonary vascular resistance with gentle diuresis, pulmonary toilet, and aggressive afterload reduction to lower ventricular end-diastolic pressure and improve AV (atrioventricular) valve regurgitation, as well as the use of oxygen and, on occasion, nitric oxide therapy. We strongly avoid hyperalimentation and long-term central lines as we are concerned about the thrombus formation and contribution to the problem we already had, in addition to the risk of infection. On several occasions we have actually discharged patients on transpyloric feeds and nasal cannula oxygen without chest tubes and without effusions and watched them for another month and had no return of chylothoraces and to date have been able to avoid thoracic duct ligation as well as long hospitalization with the exception of 1 child who was in the hospital for about 5 weeks.

I have three quick questions for you. With your aggressive approach to thoracic duct ligation, have you seen any development of chylous ascites, particularly in the kids in your series who had heterotaxy? Number two, with your aggressive approach, have you considered VATS (video-assisted thoracoscopic surgery) to reduce the morbidity of the operation? And the final question, were any of the patients who developed SVC (superior vena caval) thrombosis in your series on TPN (total parenteral nutrition) through a superior central line and do you think this could have contributed? And finally, I would appreciate any comments you might have on our physiologic approach to the problem.

DR NATH: Thank you for your comments, Dr Hines. In our study, none of the patients developed chylous ascites post thoracic duct ligation although I do appreciate the possibility that this may happen.

A VATS approach for thoracic duct ligation is clearly an accepted option. It has been described by many centers, including yours, I believe, but we have no experience with this. Our approach has been to use a standard thoracotomy, and our operative time has been half an hour to 45 minutes in length. Given the benefits of minimally invasive approaches including reduction in postoperative hospital stay, et cetera, I do agree it is a valid approach and it is something our institution is considering using in the future.

One predisposing factor to developing SVC thrombosis is having central venous catheters and particularly so with the concomitant infusion of TPN. In our study, all patients had a central line placed via the internal jugular or subclavian vein in the operating room at the time of initial cardiac surgery. Low-dose heparin was infused through the most distal port continuously to reduce the risk of clot formation. If central access was required after 1 week for continued TPN use or otherwise, the neck line was removed and a PICC (peripherally inserted central venous catheter) line was placed through the antecubital space. Again in this case, low-dose heparin was infused through the most distal port.

Some centers use a diet composed of medium-chain triglycerides once the patients fail a low-fat diet. This enables patients to receive enteral feeds without initiating intravenous TPN and thereby the risks of prolonged central line/TPN use are diminished.

Most studies group patients with a chylothorax based on etiology; some have direct trauma to the thoracic duct or its tributaries while others have a disruption in the lymphatic system due to increasing venous pressure. While we did not make the distinction in our manuscript, I do agree that in the literature, patients with a direct injury seem to do better with thoracic duct ligation.

Patients in the other subset, those who develop chylothorax due to elevated venous pressures, do worse with all forms of treatment, be it conservative management or surgical therapy such as thoracic duct ligation, pleura-peritoneal shunts, or pleurodesis.

So I agree that what we have to do is try to address decreasing the venous hypertension through medical management (oxygen, nitric oxide, et cetera) and, in the case of SVC thrombosis, perhaps consider catheter-directed thrombolytics.

DR ANDREW C. FIORE (St. Louis, MO): Dilip, a very nice presentation. As you know, the fluid drained contains lymphocytes, which predisposes the patient to sepsis, as you pointed out; but the fluid also contains protein C, protein S, and antithrombin III, which predisposes the patient to thrombosis. Please give us guidelines on what you use to replace that fluid. Albumin? FFP (Fresh-frozen plasma)? What are your guidelines on anticoagulation management particularly when the patient has central intravenous lines in the presence of a chylothorax?

DR NATH: Thank you, Dr Fiore. I agree that persistent chylothorax is a risk factor for infectious and thrombotic complications. We typically use albumin infusion in concentrated doses to replace fluid losses. Based on the patient's coagulation parameters, we also utilize fresh-frozen plasma (FFP) to address coagulation factors lost in the chylous fluid. Furthermore, in some cases, we have infused intravenous immunoglobulins (IVIG) in those patients with persistent chylothorax.

We had 3 patients who had a documented SVC thrombosis. In two cases, the diagnosis was made during the initial hospital stay and an SVC reconstruction was attempted. Both patients died with continued drainage at the time of demise. In the third patient, chylothorax was resolved prior to initial hospital discharge. The patient died of sepsis 2 months later, and SVC thrombosis was documented at the time of death.

We have limited experience with surgical intervention for SVC thrombosis, and in 2 cases in our study, we unsuccessfully attempted bypass with a Gore-Tex tube. In our experience, the best hope is to identify the problem early and treat with catheter-directed thrombolytic such as tPA (tissue plasminogen activator). Obviously, there are limitations particularly with respect to bleeding complications, which may prevent its use in some patients. We currently look for evidence of venous thrombosis in any patient with a persistent chylothorax with the intent that if the clot is found early, it may be more amenable to tPA therapy.

DR JAMES S. TWEDDELL (Milwaukee, WI): That was a great presentation. Did you use mechanical pleurodesis at all? That is my question. And one thing I would like to add to what Dr Hines mentioned also, I think the strategy for limiting pleural effusions, particularly in those that are pressure-driven, is very important, in addition to oxygen and Aldactone, limiting fluids, and so on. And I would also caution that central lines, even without thrombosis, can sometimes be associated with a pleural effusion. I would be interested in hearing your thoughts. Did you use mechanical pleurodesis in addition to duct ligation at surgery?

DR NATH: Thank you, Dr Tweddell. We did not utilize pleurodesis in any of our patients in this study.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Discussion
 References
 

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