RESUMEN
Chylothorax is the accumulation of lymphatic fluid (chyle) within the pleural space. There are multiple causes, including traumatic and non-traumatic mechanisms. Trauma can cause disruption of the thoracic duct either by direct damage or indirect crushing or avulsion mechanisms. Non-traumatic causes include infections, inflammatory processes, malignancies, and iatrogenic injury (during surgery or central venous access). The traditional management of traumatic chylothorax has been either a conservative approach, including complete Nil Per Os (NPO), or a low-fat diet with medium-chain triglyceride supplementation with the administration of somatostatin or its analog, octreotide, versus a surgical approach consisting of thoracic duct ligation. Recently a less invasive approach via thoracic duct embolization has gained popularity. There have been a few reports of the successful use of an α 1-adrenergic agonist (midodrine) as an adjunct in the conservative approach. We describe the utility of midodrine in three cases of chylothorax and propose a management algorithm. LEARNING POINTS: The initial diagnosis of chylothorax is based on clinical suspicion and proper imaging.The clinical success of midodrine use as a first-line medical treatment for chylothorax will support the use of midodrine before considering invasive procedures.We propose a management algorithm for patients with chylothorax that will stimulate researchers to conduct prospective studies to assess its efficacy.
RESUMEN
Isolated pancreatic transection is a rare surgical condition that occurs more commonly following blunt abdominal trauma. It carries a high degree of morbidity and mortality, and the management remains a source of debate as universally accepted guidelines are not well established owing to the paucity in clinical experience and large series. We presented a case of an isolated pancreatic transection following blunt abdominal trauma. The surgical management of pancreatic transection has evolved over the decades from aggressive approaches to more conservative measures. Given the lack of large series and clinical experience, no universal consensus exists, except for applying damage control surgery and resuscitation principles in critically unstable patients. For transections of the main pancreatic duct, most recommend excision of the distal pancreas. Concerns over the iatrogenic complications of wide excisions, particularly diabetes mellitus, have led to reconsideration and more conservative approaches, but it may fail in some cases.