[Chylothorax]. / Chylothorax.

Chylothorax is a serious and potentially life-threatening condition of diverse etiology. This article provides a detailed overview of anatomy, physiology, etiology, diagnosis, and therapeutic options in the context of chylothorax.

Impact of fluorescent thoracic duct lymphography via intranodal approach in minimal access esophageal cancer surgery.

PURPOSE: Chyle leak resulting from thoracic duct (TD) injury poses significant morbidity and mortality challenges. We assessed the feasibility of using near-infrared (NIR) indocyanine green (ICG) imaging for intraoperative fluorescence TD lymphography during minimal access esophagectomy (MAE) in a semiprone position with inguinal nodal injection of ICG dye. METHODS: Ninety-nine patients with esophageal or gastroesophageal junctional cancer undergoing MAE received inguinal node injections of 2.5 mg ICG dye (total 5 mg) under sonographic guidance during anesthesia induction. Stryker's 1688 AIM HD system was used in 76 cases, Karl Storz OPAL 1 S in 20, and in three cases the Karl Storz Rubina. RESULTS: In 93 patients (94%), the TD was clearly delineated along its entire length; it was not visualized in 6 patients (6%). Fluorescence guidance facilitated TD ligation in 16 cases, while 3 cases required clipping of duct tributaries for oncological considerations. Twenty-eight patients exhibited minor duct variations. Fluorescence was sustained throughout surgery (median observation time 60 min post-injection; range 30-330). No patient experienced any chyle leak within 30 days post-surgery and no adverse reactions to ICG was evident. CONCLUSIONS: Intraoperative fluorescence TD lymphography using ICG during MAE in a semiprone position with inguinal nodal injection proved safe, feasible, and effective, allowing clear visualization of the TD in almost all cases. This approach aids safe ligation and reduces chyle leak risk. It offers real-time imaging of TD anatomy and variations, providing valuable feedback to surgeons for managing TD injuries during MAE procedures and represents an excellent educational tool.

Outcomes of Chylothorax Nonoperative Management After Cardiothoracic Surgery: A Systematic Review and Meta-Analysis.

INTRODUCTION: Chylothorax after thoracic surgery is a severe complication with high morbidity and mortality rate of 0.10 (95% confidence interval [CI] 0.06 - 0.02). There is no agreement on whether nonoperative treatment or early reoperation should be the initial intervention. This systematic review and meta-analysis aimed to evaluate the outcomes of the conservative approach to treat chyle leakage after cardiothoracic surgeries. METHODS: A systematic review was conducted in PubMed®, Embase, Cochrane Library Central, and LILACS (Biblioteca Virtual em Saúde) databases; a manual search of references was also done. The inclusion criteria were patients who underwent cardiothoracic surgery, patients who received any nonoperative treatment (e.g., total parenteral nutrition, low-fat diet, medium chain triglycerides), and studies that evaluated chylothorax resolution, length of hospital stay, postoperative complications, infection, morbidity, and mortality. CENTRAL MESSAGE: Nonoperative treatment for chylothorax after cardiothoracic procedures has significant hospital stay, morbidity, mortality, and reoperation rates. RESULTS: Twenty-two articles were selected. Pulmonary complications, infections, and arrhythmia were the most common complications after surgical procedures. The incidence of chylothorax in cardiothoracic surgery was 1.8% (95% CI 1.7 - 2%). The mean time of maintenance of the chest tube was 16.08 days (95% CI 12.54 - 19.63), and the length of hospital stay was 23.74 days (95% CI 16.08 - 31.42) in patients with chylothorax receiving nonoperative treatment. Among patients that received conservative treatment, the morbidity event was 0.40 (95% CI 0.23 - 0.59), and reoperation rate was 0.37 (95% CI 0.27 - 0.49). Mortality rate was 0.10 (95% CI 0.06 - 0.02). CONCLUSION: Nonoperative treatment for chylothorax after cardiothoracic procedures has significant hospital stay, morbidity, mortality, and reoperation rates.

Aggressive Management of a Bilateral Chylothorax Complicating an Orthotopic Heart-Kidney Transplantation.

Chylothorax after an orthotopic heart transplant is a rare but potentially detrimental occurrence. This is the first reported case of bilateral chylothorax complicating a heart-kidney transplant patient. No universally accepted protocol exists for the management of chylothorax in general population, let alone the immunocompromised transplant patient. This case presents unique challenges to the management of postoperative chylothorax given heart-kidney transplant's effect on the patient's volume status and immunocompromised state. We make the argument for aggressive treatment of chylothorax in an immunocompromised heart-kidney transplant patient to limit complications in a patient population predisposed to infection.

Chylothorax secondary to subcutaneous cervical lipoma in a dog.

An 8-year-old male neutered American English Coonhound was presented for a 2-day history of increased respiratory effort and rate with an occasional cough. Thoracic radiographs noted pleural effusion, which was chylous based on cytological and chemical evaluation. The dog also had a 2-year history of a slow growing fatty mass in the right cervical region. A CT scan confirmed the large cervical fat attenuating mass extending from the base of the skull to the cranial thorax and right axillary region with compression of vascular structures. Severe bilateral effusion and secondary pulmonary atelectasis was noted within the thoracic cavity. It was elected to surgically remove the cervical mass and place a PleuralPort within the thoracic cavity. The mass was diagnosed as a lipoma and its removal led to rapid and complete resolution of chylothorax. Based on the literature search, this is the first case report of chylothorax secondary to a cervical mass or subcutaneous lipoma.

Therapeutic effect of lymphography in the postoperative chylothorax - case reports and literature review.

Postoperative chylothorax is a well-known rare complication of thoracic surgery. It is a serious complication that is fatal in cases of inadequate treatment. The authors present 2 cases of postoperative chylothorax that were successfully treated by performing pedal and/or intranodal lymphography. In one case, the patient underwent lymphography after previous unsuccessful surgical ligation of the thoracic duct. The presented case reports describe therapeutic importance of conventional lymphography as a minimally invasive treatment of the postoperative chylothorax.

[Postoperative Chylothorax Following Gastric Tube Cancer Surgery Cured after Pneumonia and Empyema-A Case Report].

A 74-year-old man was under follow-up after esophageal cancer surgery and CRT for hypopharyngeal cancer. Follow-up endoscopy revealed an ulcerative lesion in the lower gastric tube, and biopsy showed group 5(tub1). Endoscopic resection was difficult, and surgery was decided. Gastric tube resection and subcutaneous jejunum reconstruction were performed. Postoperatively, chylothorax was observed. Enteral nutrition was discontinued, and the patient was managed with TPN, and continuous subcutaneous octreotide and continuous intravenous etyrefrine were started. Even after conservative treatment was started, the pleural effusion of about 2,000 mL/day was observed from the right thoracic drain. On postoperative day 14, lymphangiography was performed with lipiodol from the left inguinal lymph node. The pleural fluid was temporarily decreased to less than 500 mL/day, but it began to drain again at a rate of 1,000 mL/day. On postoperative day 30, the patient developed fever and elevated inflammatory findings due to pneumonia and empyema, and drain drainage gradually decreased. The drain was removed on postoperative day 41. The patient was discharged home on postoperative day 72.

Prediction Model with External Validation for Early Detection of Postoperative Pediatric Chylothorax.

Earlier diagnosis of chylothorax following pediatric cardiac surgery is associated with decreased duration of chylothorax. Pleural fluid testing is used to diagnosis chylothorax which may delay detection in patients who are not enterally fed at time of chylothorax onset. Our aim was to develop and externally validate a prediction model to detect chylothorax earlier than pleural fluid testing in pediatric patients following cardiac surgery. A multivariable logistic regression model was developed to detect chylothorax using a stepwise approach. The model was developed using data from patients < 18 years following cardiac surgery from Primary Children's Hospital, a tertiary-care academic center, between 2017 and 2020. External validation used a contemporary cohort (n = 171) from Lucille Packard Children's Hospital. A total of 763 encounters (735 patients) were analyzed, of which 72 had chylothorax. The final variables selected were chest tube output (CTO) the day after sternal closure (dichotomized at 15.6 mL/kg/day, and as a continuous variable) and delayed sternal closure. The highest odds of chylothorax were associated with CTO on post-sternal closure day 1 > 15.6 mL/kg/day (odds ratio 11.3, 95% CI 6,3, 21.3). The c-statistic for the internal and external validation datasets using the dichotomized CTO variable were 0.78 (95% CI 0.73, 0.82) and 0.84 (95% CI, 0.78, 0.9) and performance improved when using CTO as a continuous variable (OR 0.84, CI: 95% CI 0.80, 0.87). Using the models described, chylothorax after pediatric cardiac surgery may be detected earlier and without reliance on enteral feeds.

Chylothorax and chylopericardial tamponade following lobectomy and lymphadenectomy: a rare presentation.

BACKGROUND: Although postoperative chylothorax following lung cancer surgery is rare, it is a recognized complication in 0.25-3% of patients. However, cases of cardiac tamponade caused by chylopericardium after lung cancer surgery are extremely rare. CASE PRESENTATION: We describe hitherto unreported sequelae of chyle leak following lobectomy and systematic mediastinal lymph node dissection (SLND) causing pericardial tamponade and cardiovascular compromise. The patient was successfully treated with minimally invasive surgical repair and ligation. We also discuss the development of chylopericardium as a potential complication of lobectomy and SLND. CONCLUSIONS: The anatomical characteristics of the thoracic duct warrant special attention in postoperative chyle leak management in patients who undergo definitive mediastinal lymph node dissection. Surgeons should be aware that chylopericardium is a rare but potential complication of lobectomy and SLND as it may help with early diagnosis, management, and prevention of cardiac tamponade.

Management of Congenital and Postoperative Chylothorax: Use of Thoracoscopic Lymphatic Leak Ligations with Intraoperative ICG Lymphangiography.

BACKGROUND: Congenital chylothorax (CCT) and postoperative chylothorax (POCT) are rare and difficult to treat. We report our treatment strategy and outcomes for chylothorax, including thoracoscopic surgery with indocyanine-green (ICG) near-infrared fluorescence lymphangiography. METHODS: A retrospective review of patients with CCT and POCT from 2014 to 2021 was performed. After definitive diagnosis, conservative treatments with octreotide, followed by intravenous steroids as needed, were performed. Patients who were refractory to conservative treatment were transferred to surgical treatment, consisting of thoracoscopic lymphatic leak ligations using ICG intraoperative lymphangiography. The effectiveness of conservative and surgical treatment was then examined. RESULTS: We included 19 cases of CCT and 31 cases of POCT. The 31 POCT patients included 23 of 84 postoperative patients with congenital diaphragmatic hernia (CDH), 7 of 54 postoperative patients with esophageal atresia (EA), and 1 of 3 postoperative patients with lymphatic malformation. The efficacy of conservative treatment was 12/19 for CCT, 22/23 for CDH, and 4/7 for EA. Surgical intervention was performed in 10 patients, and the rate of resolution of chylothorax within 3 weeks after surgery was 90%. CONCLUSION: Thoracoscopic lymphatic leak ligations with intraoperative ICG lymphangiography are feasible and useful in patients with chylothorax refractory to conservative treatment. LEVEL OF EVIDENCE: Level IV.

Near-infrared fluorescence imaging of thoracic duct in minimally invasive esophagectomy.

Chylothorax is a serious complication after esophagectomy and there are unmet needs for new intraoperative navigation tools to reduce its incidence. The aim of this study is to explore the feasibility and effectiveness of near-infrared fluorescence imaging (NIR-FI) with indocyanine green (ICG) to identify thoracic ducts (TDs) and chyle leakage during video-assisted thoracoscopic esophagectomy. We recruited 41 patients who underwent thoraco-laparoscopic minimally invasive esophagectomy (MIE) for esophageal cancer in this prospective, open-label, single-arm clinical trial. ICG was injected into the right inguinal region before operations, after which TD anatomy and potential chyle leakage were checked under the near-infrared fluorescence intraoperatively. In 38 of 41 patients (92.7%) using NIR-FI, TDs were visible in high contrast. The mean signal-to-background ratio (SBR) value of all fluorescent TDs was 3.05 ± 1.56. Fluorescence imaging of TDs could be detected 0.5 hours after ICG injection and last up to 3 hours with an acceptable SBR value. The optimal observation time window is from about 1 to 2 hours after ICG injection. Under the guidance of real-time NIR-FI, three patients were found to have chylous leakage and the selective TD ligations were performed intraoperatively. No patient had postoperative chylothorax. NIR-FI with ICG can provide highly sensitive and real-time assessment of TDs as well as determine the source of chyle leakage, which might help reduce TD injury and direct selective TD ligation. It could be a promising navigation tool to reduce the incidence of chylothorax after minimally invasive esophagectomy.

Pre-operative oil ingestion reduces the probability of thoracic duct trunk ligation during esophagectomy.

Chylothorax is an important complication after esophagectomy. Ligation of the injured thoracic duct is the main method to prevent chylothorax after esophagectomy, but may be associated with adverse effects. Whether ligation of the injured tributary alone, keeping the main trunk intact, may suffice to prevent post-operative chylothorax is not well known. Since March 2017, 40 mL of olive oil was administered to patients posted for esophagectomy. We compared patients admitted between March 2017 and December 2019 with patients admitted between July 2014 and February 2017, who had not received pre-operative oil. The outcome measures were the need for thoracic duct main trunk or tributary ligation, development of chylothorax and missed ligation. There were 371 patients in the oil ingestion group and 308 patients in the standard control group. Chylothorax in the oil ingestion group was significantly lower than that in the standard control group (1.3% vs. 4.5%, P = 0.012). Chyle leak from thoracic duct tributaries was diagnosed in a significantly higher percentage (5.7% vs. 0.0%, P < 0.001) and missed ligation of the injured thoracic duct was significantly lower (0.3% vs. 3.9%, P = 0.002) in the oil ingestion group compared with the standard control group. The incidence of post-operative chylothorax was not statistically different (6.3% vs. 10.0%, P = 1.000) between the tributary and the trunk ligation group. Pre-operative oil ingestion can help visualize the thoracic duct trunk and its tributaries during esophagectomy. Thus, non-selected thoracic duct trunk ligation and missed ligation during esophagectomy can be reduced. Precise ligation of the injured tributary while the main trunk is intact can also prevent post-operative chylothorax.

Resolution, recurrence, and chyle redistribution after thoracic duct ligation with or without pericardiectomy in dogs with naturally occurring idiopathic chylothorax.

OBJECTIVE: To document outcomes of thoracoscopic treatment of idiopathic chylothorax (IC) in dogs with and without constrictive pericardial physiology (CPP) and evaluate patterns of chyle flow redistribution after thoracic duct ligation (TDL). ANIMALS: 26 client-owned dogs. PROCEDURES: In this prospective cohort study, echocardiography and cardiac catheterization were performed to document CPP in dogs with IC. Thoracoscopic TDL with pericardiectomy was performed if CPP was present (TDL/P group). Dogs without evidence of CPP underwent thoracoscopic TDL alone (TDL group). Dogs underwent preoperative, immediate postoperative, and 3-month postoperative CT lymphangiography studies when possible. Perioperative morbidity, resolution and late recurrence rates, and long-term outcome were recorded. RESULTS: 17 dogs underwent TDL, and 9 underwent TDL/P. Twenty-five of 26 (96%) survived the perioperative period. One dog died from ventricular fibrillation during pericardiectomy. Resolution rates for TDL and TDL/P were 94% and 88%, respectively (P = .55), with 1 late recurrence occurring in the TDL group in a median follow-up of 25 months (range, 4 to 60 months). On 3-month postoperative CT lymphangiography studies, ongoing chyle flow past the ligation site was demonstrated in 5 of 17 dogs, of which 1 dog developed recurrence at 13 months postoperatively. In 15 of 17 dogs, chylous redistribution after TDL was principally by retrograde flow to the lumbar lymphatic plexus. CLINICAL RELEVANCE: In dogs without evidence of CPP, TDL alone was associated with a very good prognosis for treatment of IC. In the absence of CPP, the additional benefit of pericardiectomy in the treatment of IC is questionable.

[Clinical Characteristics of 30-day Unplanned Reoperations after Thoracic Surgery].

Objective To investigate the clinical characteristics of 30-day unplanned reoperations after thoracic surgery. Methods We retrospectively analyzed the clinical data of patients with unplanned reoperations within 30 days after thoracic surgery in Peking Union Medical College Hospital from May 2016 to May 2021. Results The 30-day unplanned reoperations showed the incidence of 0.75%(79/10 543),the median hospital stay of 19(12,37) days,and the median hospitalization cost of 109 929.11(80 549.46,173 491.87) yuan.Twenty-two(27.85%) patients received blood transfusion and 26(32.91%) underwent intensive care.The period between May 2016 and May 2017 witnessed the most unplanned reoperations.The main causes of unplanned reoperations after thoracic surgery were bleeding(21.52%),chylothorax(17.72%),pulmonary air leakage(16.46%),atelectasis(13.92%),and gastroesophageal fistula(11.39%).Specifically,the main causes of unplanned reoperations in the patients of non-esophagus/cardia group were bleeding,pulmonary air leakage,atelectasis,and chylothorax,and those in the patients of esophagus/cardia group were gastroesophageal fistula,incision infection and poor healing,bleeding,and chylothorax.Among all the patients with unplanned reoperations,4 patients died,17 improved,and 58 recovered. Conclusions The patients who underwent unplanned reoperations after thoracic surgery had a long hospital stay and high hospitalization costs. Bleeding,chylothorax,pulmonary air leakage,atelectasis,and gastroesophageal fistula were the main reasons for the unplanned reoperations.

Invasive treatment of persistent postoperative chylothorax secondary to thoracic duct variation injury: Two case reports and literature review.

RATIONALE: Postoperative chylothorax is a rare complication after pulmonary resection. Thoracic duct variations may play a key role in postoperative chylothorax occurrence and make treatment difficult. No studies in the literature have reported the successful treatment of chylothorax second to thoracic duct variation by lipiodol-based lymphangiography. PATIENT CONCERNS: A 63-year-old male and a 28-year-old female with primary lung adenocarcinoma were treated by video-assisted thoracoscopic cancer resection, and suffered postoperative chylothorax. Conservative treatment was ineffective, including nil per os, persistent thoracic drainage, fatty food restriction, and somatostatin administration. DIAGNOSIS: Postoperative chylothorax. INTERVENTIONS: Patients received lipiodol-based lymphangiography under fluoroscopic guidance. Iatrogenic injuries were identified at thoracic duct variations, including an additional channel in case 1 and the lymphatic plexus instead of the thoracic duct in case 2. OUTCOMES: Thoracic duct variations were identified by lipiodol-based lymphangiography, and postoperative chylothorax was successfully treated by lipiodol embolizing effect. LESSONS: Thoracic duct variations should be considered after the failure of conservative treatment for postoperative chylothorax secondary to pulmonary resection. Lipiodol-based lymphangiography is valuable for identifying the thoracic duct variations and embolizing chylous leakage.

Post-esophagectomy chylothorax refractory to mass ligation of thoracic duct above diaphragm: a case report.

BACKGROUND: Post-esophagectomy chylothorax is a relatively rare but potentially lethal complication. The treatment strategy of post-esophagectomy chylothorax remains a subject of debate which mainly focuses on the indication and timing of surgical intervention. For cases in which the leakage site is not localized, a mass ligation of the thoracic duct above diaphragm is advocated as the surgical procedure is believed to ensure sealing all the accessory ducts that could be the source of the chylothorax. But in this paper, we report a case of post-esophagectomy chylothorax which was refractory to mass ligation of thoracic duct above diaphragm. CASE PRESENTATION: A 59-year old man suffered from high output chylothorax (> 1000 ml/24 h for more than 30 days) after esophagectomy through left thoracotomy. Considering the failure of lymphangiography, we performed mass ligation of thoracic duct above diaphragm. However, we failed to close the chylous leakage. Finally, we found that a rare variated tributary of thoracic duct was the resource of the chylous output. Both the variation of lymphatic system and the coincidence of injured site lead to the invalidness of reoperation. After definitely ligating the variated tributary, chylothorax was cured. CONCLUSION: This case supplies a direct evidence that mass ligation of thoracic duct is of no avail in some refractory chylothorax, which indicates the importance of chylous leakage localization.