Thoracoscopic management of thoracic duct injury: Is there a place for conservatism?

Thoracic duct injury is a rare but serious complication following chest surgeries and major neck dissections. Clinically, it can present as cervical chylous fistula, chylothorax or chylopericardium. Without treatment, the mortality is up to 50% and thus, early aggressive therapy is indicated. Traditional conservative management includes low-fat diet, parenteral nutrition, careful monitoring of fluid and electrolytes, and drainage of the neck wound or chylothorax. Patients with failed conservative management require definitive treatment in the form of ligation of the thoracic duct, which has traditionally been done by thoracotomy. The advent of Video-Assisted-Thoracoscopic-Surgery (VATS) over the last decade has changed the approach towards the management of numerous chest diseases. Thoracoscopic ligation of the thoracic duct has also been reported. We report herein a case of postoperative cervical chylous fistula managed successfully by VATS thoracic duct ligation and present a systematic analysis of the English literature to highlight the current trends in the management of thoracic duct injury.

Effect of epidural morphine on minimum alveolar concentration of isoflurane in humans.

BACKGROUND AND AIMS: The anaesthetic potency of volatile anaesthetic agents is measured by the minimum alveolar concentration (MAC) required to suppress response in 50% of subjects. We studied the effect of epidural morphine on MAC of isoflurane in humans. SETTINGS AND DESIGN: A prospective single-blind study designed to study the effect of epidural morphine on MAC of isoflurane. SUBJECTS AND METHODS: Forty-eight patients were randomly divided into two groups - Group I patients received 3 mg morphine in 10 ml saline, and Group II patients received 10 ml saline epidurally. Anaesthesia was induced with isoflurane in oxygen and nitrous oxide. Later nitrous oxide was discontinued and MAC of isoflurane determined using modified Dixon's method of sequential sampling. RESULTS: Epidural morphine resulted in a significant reduction in MAC of isoflurane, 0.98 vs. 1.14 in control group (p<0.05). CONCLUSIONS: Epidural administration of 3 mg morphine in 10 ml saline decreased the MAC of isoflurane.