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.

Sarcoidosis with secondary recurrent right-sided chylothorax and chylous ascites in a Caucasian male patient

ABSTRACT Sarcoidosis is a rare multisystem autoimmune disease characterized by the presence of non-caseating granulomas in involved organs. We report a novel case of a 61-year-old Caucasian male with sarcoidosis presenting with recurrent chylothorax and chylous ascites. Pleural and ascitic fluid analysis revealed high triglyceride levels, consistent with chylothorax and chylous ascites, respectively. Common etiologies of chylous fluid such as thoracic duct surgical trauma, malignancy and infection were all excluded. Sarcoidosis was confirmed by the presence of non-caseating granulomas on a mediastinal lymph node biopsy. Conservative treatment with low-fat diet, prednisone, octreotide and multiple thoracenteses failed to effectively resolve the chylothorax. Surgical interventions with pleurodesis and thoracic duct ligation were performed, leading to the complete resolution of the chylous effusion and ascites.

Effect of Thoracic Duct Ligation During VATS Esophagectomy On T Cell Subset and DFS in Squamous Cell Carcinoma Patients With T1b-3N0M0 Stage

Objective: To study whether the ligation of thoracic duct during video-assisted thoracic surgery esophagectomy will cause damage to the immune system, thus affecting the disease-free survival(DFS) of patients with cT1b-3N0M0 stage. Methods: We studied the esophageal squamous cell carcinoma confirmed by endoscopic ultrasound biopsy and PET-CT. They were randomly divided into thoracic duct ligation group and non ligation group. In addition to thoracoscopic resection of esophageal cancer, thoracic duct ligation was also performed in the experimental group. The peripheral blood T lymphocyte subsets were detected by flow cytometry during perioperation. All patients were reexamined regularly after operation in order to find recurrence or metastasis early. The Chi-square test and t-test were employed for statistical analysis with statistical significance at p<0.05.The effect of thoracic duct ligation on DFS curves were calculated by the Kaplan–Meier method and compared by the log-rank test. A Cox regression model with stepwise selection was used for the multivariate analyses.Result: After early screening and late exclusion, a total of 67 patients entered the study and completed the follow-up. There was no significant difference in gender, age, tumor location, depth of invasion, degree of differentiation and presence of tumor thrombus between the ligation group (32 cases) and the non ligation group (35 cases). There was no significant difference in T lymphocyte subsets before and 3 weeks after operation, but there was significant difference on the 1st days after operation. Cox regression analysis showed that depth of invasion (P= 0.0020), degree of differentiation (P= 0.0262), presence of tumor thrombus (P = 0.0158) and thoracic duct ligation (P= 0.0036) were independent factors affecting DFS.Conclusion: Thoracic duct ligation can affect the short-term immune function after thoracoscopic esophagectomy in squamous cell carcinoma patients with pT1b-3N0M0 stage, and the thoracic duct ligation, depth of invasion, degree of differentiation and presence of tumor thrombus are independent factors affecting DFS. Trial registration: Chinese Clinical Trial Registry, ChiCTR-IOR-17010437 . Registered 15 January 2017, https://www.chictr.org.cn/edit.aspx?pid=17254&htm=4

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

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.

Effect of Prophylactic Ligation of the Thoracic Duct on Long-Term Survival in Patients Undergoing Esophagectomy: A Meta-Analysis

Objective: To evaluate the existing literature by comparing long-term survival between patients who underwent prophylactic thoracic duct ligation (PLG) and non-prophylactic thoracic duct ligation (NPLG) during esophagectomy for esophageal cancer, a meta-analysis of relevant studies was conducted.Background: The effect of PLG and NPLG on the long-term survival in patients undergoing esophagectomy for treatment of esophageal cancer has not been established.Methods: All articles searches were performed in PubMed, Cochrane, Embase, and Web of Science, and the deadline is August 31, 2020. The search terms included esophagectomy AND thoracic duct. The selected articles compared the long-term survival of patients undergoing esophagectomy to treat esophageal cancer with prophylactic thoracic duct ligation (PLG) and non-prophylactic thoracic duct ligation (NPLG). The I2 test and X2 test were used to determine statistical heterogeneity. Publication bias was assessed using the Egger test. The results are presented as hazard ratios (HRs) with 95% confidence intervals (CIs). All data analysis was performed using Stata12.0 software.Result: A total of 4418 patients from eight studies were included in this meta-analysis. Pooled analysis revealed that a high overall survival (OS) was significantly associated with NPLG (HR=0.81, 95% CI: 0.74-0.88, P<.001), while the recurrence- free survival (RFS) and disease-free survival (DFS) were not significantly different (HR=1.02, 95% CI: 0.71-1.45, P<.001). There was no statistical difference in long-term survival among patients with different stages of esophageal cancer, while patients who underwent esophagectomy after 2019 had a better long-term prognosis (HR=0.57, 95% CI: 0.57-0.79). In addition, there was no significant difference in prognosis and survival between patients in Japan and China based on regional analysis.Conclusions: Our meta-analysis showed that NPLG was associated with better long-term survival. Thus, we should preserve the thoracic duct during esophageal cancer surgery.

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

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.

A Case Report on the Management of Intractable Chyle Leakage after Left Neck Level V Lymph Node Biopsy

Chyle leakage from the neck, which usually occurs after iatrogenic injury of the thoracic or lymphatic duct, is an uncommon complication of head and neck surgeries, which include neck dissection or thyroidectomy. A small amount of chyle leakage can be treated with conservative approaches, such as nutritional limitation, somatostatin analogues, and wound compression. However, massive or uncontrolled chyle leakage requires surgical exploration of the wound and thoracic duct ligation via the chest or transabdominal thoracic duct embolization can be applied. Here, we report a case of intractable massive chyle leakage in a 78-year-old male after a left neck level V lymph node biopsy, which was not controlled after conservative management and explorative surgery. Various treatment approaches were attempted and successful management of chyle leakage was ultimately achieved by thoracic duct embolization.

Chylopericardium Effusion in a Lac Alaotra Bamboo Lemur (Hapalemur alaotrensis)

An 11-year-old female Hapalemur alaotrensis was evaluated following a history of dyspnea of 15 days’ duration. Thoracic radiography performed by the referring veterinarian revealed a large cardiac silhouette and dorsal deviation of the trachea. Heart sounds were muffled. Echocardiographic findings were indicative of severe pericardial effusion without cardiac tamponade. No pleural effusion was identified. A computed tomography (CT) exam confirmed the presence of severe pericardial effusion and allowed identification of a parenchymatous mediastinal lesion sited at the level of the left hemithorax. To delineate the thoracic duct, lymphoCT was also performed by injection of iodinated contrast medium in the perianal subcutaneous tissue. Pericardiocentesis yielded a considerable amount of effusion with chylous biochemical and cytological properties. A diagnosis of chylopericardium with absence of pleural effusion was made. Initially, the chylopericardium was managed conservatively with two centesis and oral treatment with prednisolone. Medical treatment did not result in complete resolution of effusion and clinical signs; therefore, subtotal pericardiectomy and thoracic duct ligation were recommended. After the second pericardiocentesis, the subject died and the pericardiectomy could not be performed. To the authors’ knowledge, this is the first report of the development of chylopericardium in a Hapalemur alaotrensis.