Chylothorax: A Stepwise Approach to Diagnosis and Treatment

Chylothorax, a lymphatic flow disorder characterized by an abnormal circulation of lymph fluid into the pleural cavity, is the most common cause of pleural effusions during the neonatal period. This condition affects 1/15,000 neonates every year. Affected neonates often manifest with respiratory distress, electrolyte imbalances, sepsis, and even immunodeficiencies. Mortality risk is highest among neonates undergoing cardiac surgery as well as those with associated hydrops fetalis. Conservative treatment options include bowel rest with administration of parenteral nutrition, followed with medium-chain triglyceride enteral feedings, and octreotide therapy. Severe or persistent cases require surgical intervention. This can involve a unilateral or bilateral pleurectomy and thoracic duct ligation, with or without pleurodesis. Early identification and successful treatment of this condition is contingent upon awareness of the most current evidence and a timely cross-disciplinary approach to care.

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Diaphragmatic fenestration an effective treatment for refractory postoperative chylothorax: a case report

International Journal of Research in Medical Sciences ◽

10.18203/2320-6012.ijrms20200272 ◽

2020 ◽

Vol 8 (2) ◽

pp. 767

Author(s):

Oluwaseun R. Akanbi ◽

Swaminathan Vaidyanathan ◽

Prakash Agarwal ◽

Janeel Musthafa ◽

Neville A. G. Solomon

Keyword(s):

Thoracic Duct ◽

Medium Chain Triglyceride ◽

Cystic Lymphangioma ◽

Satisfactory Outcome ◽

Thoracic Duct Ligation ◽

Risk Of Mortality ◽

Duct Ligation ◽

Surgical Options ◽

Polytetrafluoroethylene Patch ◽

Substantial Morbidity

Postoperative chylothorax remains a clinical challenge to the surgeon with substantial morbidity and risk of mortality. Though an uncommon complication, it is known to complicate cardiac and non-cardiac thoracic surgeries. Conservative measures are first employed in managing this. Surgical options are adopted when the effusion is protracted, most recent of which includes diaphragmatic fenestration. A 9-year-old girl is presented who developed recurrent right chylothorax following thoracoscopic excision of a cystic lymphangioma. Following failed conservative therapy, she had thoracic duct ligation and right diaphragmatic fenestration (using fenestrated polytetrafluoroethylene patch) with satisfactory outcome. Aetio-pathologic mechanisms implicated in postoperative chylothorax have been classified into traumatic (iatrogenic injury to the thoracic duct or its branches) and non-traumatic. With initial conservative measures (repeated pleural aspirations and intercostal drainage, medium chain triglyceride/ low fat feeds or alternatively, fasting and total parenteral nutrition) spontaneous closure remains unpredictable. Diaphragmatic fenestration when employed resulted in faster resolution of effusion and earlier commencement of enteral feeding with no significant complication. Diaphragmatic fenestration is effective and safe for treating refractory post-operative chylothorax.

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Conservative treatment of postoperative chylothorax: a case report

Journal of Basic and Clinical Physiology and Pharmacology ◽

10.1515/jbcpp-2017-0082 ◽

2018 ◽

Vol 29 (4) ◽

pp. 417-419 ◽

Cited By ~ 1

Author(s):

Sachinkumar Wagh ◽

Sanjay Deshmukh ◽

Shrikant Ankolikar

Keyword(s):

Conservative Treatment ◽

Pleural Cavity ◽

Pleural Drainage ◽

Case Presentation ◽

Thoracic Duct Ligation ◽

Effective Manner ◽

Duct Ligation ◽

Elective Surgical Procedure ◽

Chronic Sequelae

Abstract Background Chylothorax is a well-documented complication of thoracic trauma and is associated with high rates of morbidity and mortality. Treatment for chylothorax includes conservative measures (total parenteral nutrition, pleural drainage, and pleurodesis) and surgery (thoracic duct ligation). Case presentation We present the case of a 65-year-old man who developed chylothorax after an elective surgical procedure. In this report conservative treatment aims to reduce chyle flow, to drain the pleural cavity in an effective manner, and to prevent chronic sequelae. Optimal conservative treatment, started immediately upon diagnosis, effectively reduces the need for reoperation and long-term hospitalization, and it might prevent further sequelae of chylothorax. Conclusions The chylothorax was successfully treated conservatively, which may reduce the need for reoperation.

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Treatment of Congenital Chylothorax Using High-Dose Octreotide

Iranian Journal of Pediatrics ◽

10.5812/ijp.107155 ◽

2020 ◽

Vol In Press (In Press) ◽

Author(s):

Jinkyung Seo ◽

Sook Kyung Yum

Keyword(s):

Treatment Options ◽

Medium Chain Triglyceride ◽

Intestinal Secretion ◽

Bottle Feeding ◽

High Dose ◽

Optimal Dosage ◽

Severe Respiratory Distress ◽

Threatening Condition ◽

Octreotide Therapy ◽

Congenital Chylothorax

Introduction: Neonatal chylothorax is a rare and potentially life-threatening condition with a reported incidence of 1 in 5,800 - 24,000 and a high mortality rate of up to 64%. Octreotide is one of the treatment options available to reduce both the splanchnic blood flow and the intestinal secretion of electrolytes and water. However, there is no uniform guideline for the optimal dosage of octreotide in the treatment of congenital chylothorax. Case Presentation: We present the case of a neonate diagnosed with congenital chylothorax. At birth, the neonate manifested severe respiratory distress warranting cardiopulmonary resuscitation for 25 min. During admission, intravenous octreotide treatment was initiated and feeding was changed from breast milk to a medium-chain triglyceride-enriched formula. Bilateral hilar enlargement and diffusely increased opacities waxed and waned, and we gradually increased the octreotide dosage daily by 1 ~ 2 mcg/kg/h. After 3 days of octreotide administration at the rate of 20 mcg/kg/h, chest x-ray showed regression of pleural effusion. The patient was discharged with full bottle feeding achieved. Conclusions: High-dose octreotide therapy (with doses up to 20 mcg/kg/h) may be recommended for patients with idiopathic congenital chylothorax. However, patients should be carefully monitored for side-effects such as hyperglycemia, necrotizing enterocolitis, transient hypothyroidism, and ileus.

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Case Report: Management of idiopathic chylothorax

F1000Research ◽

10.12688/f1000research.6694.1 ◽

2015 ◽

Vol 4 ◽

pp. 1049 ◽

Cited By ~ 1

Author(s):

Maher Abouda ◽

Yangui Ferdaous ◽

Miriam Triki ◽

Mehdi Charfi ◽

Mohamed Ridha Charfi

Keyword(s):

Case Report ◽

Pleural Fluid ◽

Medical Therapy ◽

Thoracic Duct ◽

Medium Chain Triglyceride ◽

Pleural Space ◽

Low Fat Diet ◽

Thoracic Duct Ligation ◽

Bilateral Chylothorax ◽

Duct Ligation

Chylothorax is characterized by the presence of chyle in the pleural space and results from lesion or obstruction of the thoracic duct. We present two cases of non-traumatic, idiopathic chylothorax in two females that were treated differently. The first is a 42 year old female who presented with a symptomatic right chylothorax. Treatment by a low-fat diet supplemented with medium chain triglyceride and evacuation of the pleural fluid was sufficient. The second patient is a 25 year old female admitted for a bilateral chylothorax. Despite optimal medical therapy, chylothorax continued to persist. Finally thoracic duct ligation was performed, which resulted in resolution of the effusion. These two cases illustrate that the management of idiopathic chylothorax can be surgical or nonsurgical.

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Diagnosis and management of traumatic bilateral chylothorax: a clinical conundrum

BMJ Case Reports ◽

10.1136/bcr-2019-229400 ◽

2019 ◽

Vol 12 (7) ◽

pp. e229400

Author(s):

Rohit Jindal ◽

Jaspal Singh ◽

Loveleen Garg ◽

Mayank Gupta

Keyword(s):

Road Traffic ◽

Prior History ◽

Diagnosis And Management ◽

Fluid Analysis ◽

Thoracic Duct Ligation ◽

Bilateral Chylothorax ◽

Duct Ligation ◽

Traumatic Chylothorax ◽

Octreotide Therapy ◽

History Of

A 35-year-old man was admitted in the emergency department with a complaint of progressive dyspnoea and 4-day prior history of a road traffic accident. An initial evaluation was inconspicuous and he was discharged. Clinical examination and radiological imaging suggested bilateral pleural effusion for which bilateral intercostal drains were inserted. Further pleural fluid analysis aided the diagnosis of bilateral chylothorax. A conservative approach consisting of a fat-free diet, total parenteral nutrition and octreotide therapy was started. Upon failure of conservative management, thoracic duct ligation by thoracotomy was done. Chylous output decreased dramatically and subsequently, and the patient was discharged in a healthy condition. This case illustrates intricacies involved in the diagnosis and management of traumatic chylothorax. Also, conservative treatment forms the first line of management, but if ineffective, then early surgical intervention should be considered. Early diagnosis and timely intervention are keystone factors for a better outcome.

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CONGENITAL CHYLOTHORAX: CURRENT EVIDENCE-BASED PRENATAL AND POST-NATAL DIAGNOSIS AND MANAGEMENT

Lymphology ◽

10.2458/lymph.4632 ◽

2020 ◽

Vol 52 (3) ◽

Author(s):

LC De Angelis ◽

T Bellini ◽

MH Witte ◽

RI Kylat ◽

M Bernas ◽

...

Keyword(s):

Pleural Effusion ◽

Therapeutic Approach ◽

Neonatal Period ◽

Treatment Options ◽

Evidence Base ◽

Current Evidence ◽

Treatment Timing ◽

Current Evidence Base ◽

Uncommon Condition ◽

Congenital Chylothorax

Congenital chylothorax is an uncommon condition but represents the main cause of congenital pleural effusion during the neonatal period. It usually appears before birth, both as an isolated disorder or in association with hydrops fetalis, negatively affecting the subsequent neonatal outcome. Prenatal treatment is usually considered to ensure a satisfactory lung development in case of moderate to severe pleural effusion or in the presence of hydrops, although consensus on treatment timing and modalities has not been reached to date. Both medical and surgical therapeutic strategies are available to treat this condition and novel treatment options have been recently attempted with acceptable results in both prenatal and post-natal setting. The heterogeneous clinical presentation of congenital chylothorax together with its rarity, its numerous etiologies and the absence of a highly effective treatment renders the diagnostic and therapeutic approach difficult to standardize. In addition, adequate visualization of the lymphatic system is complex, especially in small neonates, although new promising techniques have been developed lately and may contribute to improved management of this serious but infrequent condition. This review focuses on the current evidence base for the diagnosis and treatment options for congenital chylothorax, suggesting a rational diagnostic and therapeutic approach both in the prenatal and in the neonatal period.

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Thoracic duct injury after decortication of lung, new technique to repair thoracic duct in this challenging situation: A case report

Asian Cardiovascular and Thoracic Annals ◽

10.1177/0218492321997080 ◽

2021 ◽

pp. 021849232199708

Author(s):

Nandkishore Kapadia ◽

Saumya Sekhar Jenasamant ◽

Ganesh Sohan Singh Rawat ◽

Shailesh Kamkhedkar ◽

Pratik Shah ◽

...

Keyword(s):

Thoracic Duct ◽

Left Lung ◽

Lower Lobe ◽

Late Complications ◽

Patch Repair ◽

Double Lumen Tube ◽

Complex Case ◽

Thoracic Duct Injury ◽

Thoracic Duct Ligation ◽

Duct Ligation

Background Chylothorax is a rare form of pleural effusion that can be associated with both traumatic and non-traumatic causes. Very few patients respond to conservative line of therapy. Thoracic duct ligation is often the treatment of choice in post-surgical patients; however, the optimal treatment of this disease process after traumatic injury remains unclear. Case presentation: We present the case of a 46-year-old woman with thoracic duct injury secondary to decortication for post-pneumonic empyema. Conservative therapy and pleurodesis done twice failed. She developed severe cachexia losing 15 kg in 30 days. She was referred to our center for ligation of thoracic duct. Preoperative lymphangiography located the duct injury in upper part of mediastinum. Computerized tomography scan of chest showed collapse of left lower lobe and thickened left pleura, indicating a significant pericardial effusion. She underwent decortication of left lung, pericardial window, and native pericardial patch repair of thoracic duct. Results and Conclusions: In this unusual and complex case, successful resolution of the chyle leak was achieved with new surgical technique of patch repair. The patient recovered well and was now on a normal diet. She has put on 12 kg in four months. We have avoided late complications of thoracic duct ligation by this technique. This nouvelle technique may be recommended as it is simple and effective. Ligation of thoracic duct carries late complications. Isolating right lung by double lumen tube may cause severe hypoxia as left-sided lung is not expanded as in this case.

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From Rheumatoid Factor to Anti-Citrullinated Protein Antibodies and Anti-Carbamylated Protein Antibodies for Diagnosis and Prognosis Prediction in Patients with Rheumatoid Arthritis

International Journal of Molecular Sciences ◽

10.3390/ijms22020686 ◽

2021 ◽

Vol 22 (2) ◽

pp. 686

Author(s):

Chao-Yi Wu ◽

Huang-Yu Yang ◽

Shue-Fen Luo ◽

Jenn-Haung Lai

Keyword(s):

Rheumatoid Arthritis ◽

Treatment Options ◽

Clinical Manifestations ◽

Bone Destruction ◽

Response To Therapy ◽

Current Evidence ◽

Prognosis Prediction ◽

Diagnosis And Prognosis ◽

Systemic Inflammatory Disease ◽

Citrullinated Protein

Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease mainly involving synovial inflammation and articular bone destruction. RA is a heterogeneous disease with diverse clinical presentations, prognoses and therapeutic responses. Following the first discovery of rheumatoid factors (RFs) 80 years ago, the identification of both anti-citrullinated protein antibodies (ACPAs) and anti-carbamylated protein antibodies (anti-CarP Abs) has greatly facilitated approaches toward RA, especially in the fields of early diagnosis and prognosis prediction of the disease. Although these antibodies share many common features and can function synergistically to promote disease progression, they differ mechanistically and have unique clinical relevance. Specifically, these three RA associating auto-antibodies (autoAbs) all precede the development of RA by years. However, while the current evidence suggests a synergic effect of RF and ACPA in predicting the development of RA and an erosive phenotype, controversies exist regarding the additive value of anti-CarP Abs. In the present review, we critically summarize the characteristics of these autoantibodies and focus on their distinct clinical applications in the early identification, clinical manifestations and prognosis prediction of RA. With the advancement of treatment options in the era of biologics, we also discuss the relevance of these autoantibodies in association with RA patient response to therapy.

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Treatment options in moderate and severe depression: decision analysis supporting a clinical guideline

The British Journal of Psychiatry ◽

10.1192/bjp.bp.105.014571 ◽

2006 ◽

Vol 189 (6) ◽

pp. 494-501 ◽

Cited By ~ 34

Author(s):

Judit Simon ◽

Stephen Pilling ◽

Rachel Burbeck ◽

David Goldberg

Keyword(s):

Combination Therapy ◽

Decision Analysis ◽

Secondary Care ◽

Treatment Options ◽

Severe Depression ◽

Cost Effective ◽

Current Evidence ◽

Resource Utilisation ◽

Moderate Depression ◽

The Cost

BackgroundTreatment options for depression include antidepressants, psychological therapy and a combination of the two.AimsTo develop cost-effective clinical guidelines.MethodSystematic literature reviews were used to identify clinical, utility and cost data. A decision analysis was then conducted to compare the benefits and costs of antidepressants with combination therapy for moderate and severe depression in secondary care in the UK.ResultsOver the 15-month analysis period, combination therapy resulted in higher costs and an expected 0.16 increase per person in the probability of remission and no relapse compared with antidepressants. The cost per additional successfully treated patient was £4056 (95% CI 1400–18 300); the cost per quality-adjusted life year gained was £5777 (95% CI 1900–33 800) for severe depression and £14 540 (95% CI 4800–79 400) for moderate depression.ConclusionsCombination therapy is likely to be a cost-effective first-line secondary care treatment for severe depression. Its cost-effectiveness for moderate depression is more uncertain from current evidence. Targeted combination therapy could improve resource utilisation.

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665 PROPHYLACTIC THORACIC DUCT OBSTRUCTION DURING ESOPHAGECTOMY: THE IMPACT ON PERIOPERATIVE RISKS AND LONG-TERM SURVIVAL. A SYSTEMATIC REVIEW AND META-ANALYSIS

Diseases of the Esophagus ◽

10.1093/dote/doab052.665 ◽

2021 ◽

Vol 34 (Supplement_1) ◽

Author(s):

Clara Santos ◽

Laura Santos ◽

Leticia Datrino ◽

Guilherme Tavares ◽

Luca Tristão ◽

...

Keyword(s):

Systematic Review ◽

Overall Survival ◽

Postoperative Complications ◽

Thoracic Duct ◽

Meta Analysis ◽

Term Survival ◽

Long Term Survival ◽

Thoracic Duct Ligation ◽

Duct Ligation

Abstract During esophagectomy for cancer, there is no consensus if prophylactic thoracic duct ligation (TDL), with or without thoracic duct resection (TDR), could influence the perioperative outcomes and long-term survival. This systematic review and meta-analysis compared patients who went through esophagectomy associated or not to ligation or resection of the thoracic duct. Methods A systematic review was conducted in PubMed, Embase, Cochrane Library Central and Lilacs (BVS). The inclusion criteria were: (1) studies that compare thoracic duct ligation, with or without resection, and non-thoracic duct ligation; (2) involve adult patients with esophageal cancer; (3) articles that analyses the outcomes—perioperative complications, perioperative mortality, chylothorax development and overall survival; (4) only clinical trials and cohort were accepted. A 95% confidence interval (CI) was used, and random-effects model was performed. Results Fifteen articles were selected, comprising 6,249 patients. TDL did not reduce the risk for chylothorax (Risk difference [RD]: -0.01; 95%CI: −0.02, 0.00). Also, TDL did not influence the risk for complications (RD: -0.02; 95%CI: −0.11, 0.07); mortality (RD: 0.00; 95%CI: −0.00, 0.00); and reoperation rate (RD: -0.01; 95%CI: −0.02, 0.00). TDR was associated with higher risk for postoperative complications (RD: 0.1; 95%CI 0.00, 0.19); chylothorax (RD: 0.02; 95%CI 0.00, 0.03). Both TDL and TDR did not influence the overall survival rate (TDL: HR: 1.17; 95%CI: 0.86, 1.48; and TDR: HR: 1.16; 95%CI: 0.8, 1.51). Conclusion Thoracic duct obliteration with or without its resection during esophagectomy does not change long term survival. Nonetheless, TDR increased the risk for postoperative complications and chylothorax.

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