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Chylothorax as a rare complication after severe necrotizing pancreatitis and endoscopic pancreatic necrosectomy
At the Focal Point
mally invasive solution will be based on an endoscopic suturing device platform, but until that day comes, this Focal Point is a fine place to introduce the newest member of the endoclip family, affectionately known to some as the “bear claw.” The OTSC system provides significantly more strength for hemostasis (just be sure it’s for nonvariceal bleeding!) and closure of GI tract wall perforations in cases in which surgery is a suboptimal solution instead of the clips that dominated the market over the past decade. Made of highly elastic nitinol and easily delivered through a tip-mounted applicator, much like the familiar esophageal banding delivery system, this new “cub paw” is a remarkable one whose full potential to help endoscopists and surgeons get out of a jam has yet to be realized. Once deployed, its tenacity can result in permanent resident status, and that’s probably okay— but long-term safety data are still being collected; nonetheless, the “bear claw” clip is certainly safer than the real-life counterpart that was its inspiration. David Robbins, MD, MSc Assistant Editor for Focal Points
Chylothorax as a rare complication after severe necrotizing pancreatitis and endoscopic pancreatic necrosectomy A 72-year-old man was admitted with severe necrotizing pancreatitis and multiorgan failure. He was a nondrinker and was not taking medications associated with pancreatitis such as thiazide diuretics or corticosteroids. Blood tests revealed 498 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 3 : 2013
an elevated serum amylase of 2598 U/L and an elevated serum triglyceride value of 248 mg/dL (normal ⬍150 mg/dL). Serial CT scans showed acute pancreatitis with increasing peripancreatic collections and progressive nonenhancement www.giejournal.org
At the Focal Point
of the pancreas. No gallstones were present, and the cause of pancreatitis remained undetermined. Percutaneous pigtail drainage of the peripancreatic fluid was performed, and the drain track was dilated to allow for the introduction of a 9.8-mm water-jet endoscope (GIF-Q260J, Olympus, Tokyo, Japan) (A). Six sessions of endoscopic pancreatic necrosectomy were performed, during which the retroperitoneal cavity was irrigated with copious amounts of saline solution, and large amounts of turbid fluid were removed along with large pieces of necrotic pancreatic tissue (B). Culture of the necrotic tissue showed a heavy growth of Escherichia coli (C). Two weeks after the first endoscopic pancreatic necrosectomy, the patient experienced a right pleural effusion. Drainage was performed, and a milky pleural fluid was aspirated (D). The result of testing for chylomicrons was positive, thus confirming the diagnosis of chylothorax. The patient was treated conservatively by nil-per-oral, total parental nutrition, www.giejournal.org
and repeated pleural drainage. Output from the pleural drain slowly diminished, and follow-up CT scan at 6 months showed resolution of the peripancreatic collection and pancreatic necrosis. DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Jeremy Y. C. Teoh, MRCSEd, Anthony Y. B. Teoh, FRCSEd (Gen), Philip W. Y. Chiu, FRCS (Edin), Enders K. W. Ng, FRCS (Edin), Division of Upper Gastrointestinal Surgery, Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong SAR, China http://dx.doi.org/10.1016/j.gie.2012.10.030
Volume 77, No. 3 : 2013 GASTROINTESTINAL ENDOSCOPY 499
At the Focal Point
Commentary Chylothorax is defined as the presence of chyle (lymphatic fluid of intestinal origin) in the pleural space, and it develops either because of disruption or obstruction of the thoracic duct or its branches or from transdiaphragmatic passage of chylous ascites. Regardless of location, chyle must be distinguished immediately from pseudochyle because both have a milky white appearance. Chyle has high triglyceride content, contains lymphocytes as the predominant cell type, and often is rich in chylomicra (especially after ingestion of a meal rich in fat). In contrast, pseudochyle, which results from neoplasia, inflammation, or infection, has a high concentration of cholesterol or lecithin-globulin complexes and the cell types appropriate to the cause. Traumatic causes of chylothorax are probably slightly less common than nontraumatic causes, and of the traumatic causes, surgical procedures account for the majority of cases. Of the nontraumatic causes, malignancy predominates, especially lymphoma and chronic lymphocytic leukemia. Chylothorax also may result when chylous ascites passes through the diaphragmatic pores into the pleural space. I wonder whether that was the proximate cause of chylothorax in this case of pancreatitis, and whether it resulted from inflammatory obstruction of abdominal lymphatic vessels. Chylous ascites has been reported with acute and chronic pancreatitis of diverse causation, not just with hyperlipidemia-associated acute pancreatitis, although in this patient the one recorded triglyceride level was too low to be the cause of his pancreatitis. In terms of diagnosis, CT of the thorax and abdomen is performed in a search for lymphadenopathy, masses, and other lesions and to identify the thoracic duct. One important caveat: the absence of a milky appearance does not exclude chylothorax, especially if the patient is malnourished, fasting, or consuming a low-fat diet. The English lyricist William S. Gilbert (1836⫺1911) said, “Things are seldom what they seem, skim milk masquerades as cream.” The next time you see what appears to be a milky effusion, remind yourself to analyze it and see where it came from. Lawrence J. Brandt, MD Associate Editor for Focal Points
EUS-guided rendezvous pancreaticogastrostomy in a patient with central pancreatectomy A 53-year-old woman who had undergone a central pancreatectomy for an insulinoma 20 years previously presented with recurrent acute pancreatitis. The distal pancreas had been anastomosed to the posterior wall of the stomach. CT revealed a dilated pancreatic duct (5 mm) suggestive of a pancreaticogastrostomy (PG) stricture (A). Previous EGD failed to identify the opening to the anastomosis. The patient was scheduled for EUSguided pancreaticogastrostomy rendezvous. EUS was performed with a curved linear echoendoscope (GFUCT 2000; Olympus, Tokyo, Japan), and a shortsegment dilation of the pancreatic duct was identified in the body of the pancreas. The pancreatic duct was punctured with a 19-gauge needle (Echotip; WilsonCook, Bloomington, IN, USA), and the position was confirmed by pancreatography (B). A 0.035-mm Jagwire (Boston Scientific; Natick, MA, USA) was passed into the pancreatic duct, across the stenosis, and deeply into the gastric lumen. A therapeutic duodenoscope (TJFQ180V; Olympus, Japan) was then substituted by use of a wire exchange technique, and the exit site of the guidewire into the stomach was identified. The PG was
500 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 3 : 2013
freely cannulated while the wire was used as a guide, by use of a 25-mm sphincterotome (Clever Cut 3; Olympus, Japan) (C). The stenotic anastomosis was dilated with a 4-mm biliary dilator (Hurricane biliary balloon dilator, Boston Scientific), and a 7F, 5-cm pancreatic stent (GPSO-7-5, Wilson-Cook) was then placed across the anastomosis (D). During a 3-month follow-up, there were no further attacks of pancreatitis. DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Anthony Y. B. Teoh, FRCSEd (Gen), Enders K. W. Ng, FRCS (Edin), Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong SAR, China; Robert Hawes, MD, Florida Hospital Institute for Minimally Invasive Therapy, Center for Interventional Endoscopy, Florida Hospital, Orlando, FL, USA http://dx.doi.org/10.1016/j.gie.2012.10.032
www.giejournal.org
mally invasive solution will be based on an endoscopic suturing device platform, but until that day comes, this Focal Point is a fine place to introduce the newest member of the endoclip family, affectionately known to some as the “bear claw.” The OTSC system provides significantly more strength for hemostasis (just be sure it’s for nonvariceal bleeding!) and closure of GI tract wall perforations in cases in which surgery is a suboptimal solution instead of the clips that dominated the market over the past decade. Made of highly elastic nitinol and easily delivered through a tip-mounted applicator, much like the familiar esophageal banding delivery system, this new “cub paw” is a remarkable one whose full potential to help endoscopists and surgeons get out of a jam has yet to be realized. Once deployed, its tenacity can result in permanent resident status, and that’s probably okay— but long-term safety data are still being collected; nonetheless, the “bear claw” clip is certainly safer than the real-life counterpart that was its inspiration. David Robbins, MD, MSc Assistant Editor for Focal Points
Chylothorax as a rare complication after severe necrotizing pancreatitis and endoscopic pancreatic necrosectomy A 72-year-old man was admitted with severe necrotizing pancreatitis and multiorgan failure. He was a nondrinker and was not taking medications associated with pancreatitis such as thiazide diuretics or corticosteroids. Blood tests revealed 498 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 3 : 2013
an elevated serum amylase of 2598 U/L and an elevated serum triglyceride value of 248 mg/dL (normal ⬍150 mg/dL). Serial CT scans showed acute pancreatitis with increasing peripancreatic collections and progressive nonenhancement www.giejournal.org
At the Focal Point
of the pancreas. No gallstones were present, and the cause of pancreatitis remained undetermined. Percutaneous pigtail drainage of the peripancreatic fluid was performed, and the drain track was dilated to allow for the introduction of a 9.8-mm water-jet endoscope (GIF-Q260J, Olympus, Tokyo, Japan) (A). Six sessions of endoscopic pancreatic necrosectomy were performed, during which the retroperitoneal cavity was irrigated with copious amounts of saline solution, and large amounts of turbid fluid were removed along with large pieces of necrotic pancreatic tissue (B). Culture of the necrotic tissue showed a heavy growth of Escherichia coli (C). Two weeks after the first endoscopic pancreatic necrosectomy, the patient experienced a right pleural effusion. Drainage was performed, and a milky pleural fluid was aspirated (D). The result of testing for chylomicrons was positive, thus confirming the diagnosis of chylothorax. The patient was treated conservatively by nil-per-oral, total parental nutrition, www.giejournal.org
and repeated pleural drainage. Output from the pleural drain slowly diminished, and follow-up CT scan at 6 months showed resolution of the peripancreatic collection and pancreatic necrosis. DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Jeremy Y. C. Teoh, MRCSEd, Anthony Y. B. Teoh, FRCSEd (Gen), Philip W. Y. Chiu, FRCS (Edin), Enders K. W. Ng, FRCS (Edin), Division of Upper Gastrointestinal Surgery, Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong SAR, China http://dx.doi.org/10.1016/j.gie.2012.10.030
Volume 77, No. 3 : 2013 GASTROINTESTINAL ENDOSCOPY 499
At the Focal Point
Commentary Chylothorax is defined as the presence of chyle (lymphatic fluid of intestinal origin) in the pleural space, and it develops either because of disruption or obstruction of the thoracic duct or its branches or from transdiaphragmatic passage of chylous ascites. Regardless of location, chyle must be distinguished immediately from pseudochyle because both have a milky white appearance. Chyle has high triglyceride content, contains lymphocytes as the predominant cell type, and often is rich in chylomicra (especially after ingestion of a meal rich in fat). In contrast, pseudochyle, which results from neoplasia, inflammation, or infection, has a high concentration of cholesterol or lecithin-globulin complexes and the cell types appropriate to the cause. Traumatic causes of chylothorax are probably slightly less common than nontraumatic causes, and of the traumatic causes, surgical procedures account for the majority of cases. Of the nontraumatic causes, malignancy predominates, especially lymphoma and chronic lymphocytic leukemia. Chylothorax also may result when chylous ascites passes through the diaphragmatic pores into the pleural space. I wonder whether that was the proximate cause of chylothorax in this case of pancreatitis, and whether it resulted from inflammatory obstruction of abdominal lymphatic vessels. Chylous ascites has been reported with acute and chronic pancreatitis of diverse causation, not just with hyperlipidemia-associated acute pancreatitis, although in this patient the one recorded triglyceride level was too low to be the cause of his pancreatitis. In terms of diagnosis, CT of the thorax and abdomen is performed in a search for lymphadenopathy, masses, and other lesions and to identify the thoracic duct. One important caveat: the absence of a milky appearance does not exclude chylothorax, especially if the patient is malnourished, fasting, or consuming a low-fat diet. The English lyricist William S. Gilbert (1836⫺1911) said, “Things are seldom what they seem, skim milk masquerades as cream.” The next time you see what appears to be a milky effusion, remind yourself to analyze it and see where it came from. Lawrence J. Brandt, MD Associate Editor for Focal Points
EUS-guided rendezvous pancreaticogastrostomy in a patient with central pancreatectomy A 53-year-old woman who had undergone a central pancreatectomy for an insulinoma 20 years previously presented with recurrent acute pancreatitis. The distal pancreas had been anastomosed to the posterior wall of the stomach. CT revealed a dilated pancreatic duct (5 mm) suggestive of a pancreaticogastrostomy (PG) stricture (A). Previous EGD failed to identify the opening to the anastomosis. The patient was scheduled for EUSguided pancreaticogastrostomy rendezvous. EUS was performed with a curved linear echoendoscope (GFUCT 2000; Olympus, Tokyo, Japan), and a shortsegment dilation of the pancreatic duct was identified in the body of the pancreas. The pancreatic duct was punctured with a 19-gauge needle (Echotip; WilsonCook, Bloomington, IN, USA), and the position was confirmed by pancreatography (B). A 0.035-mm Jagwire (Boston Scientific; Natick, MA, USA) was passed into the pancreatic duct, across the stenosis, and deeply into the gastric lumen. A therapeutic duodenoscope (TJFQ180V; Olympus, Japan) was then substituted by use of a wire exchange technique, and the exit site of the guidewire into the stomach was identified. The PG was
500 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 3 : 2013
freely cannulated while the wire was used as a guide, by use of a 25-mm sphincterotome (Clever Cut 3; Olympus, Japan) (C). The stenotic anastomosis was dilated with a 4-mm biliary dilator (Hurricane biliary balloon dilator, Boston Scientific), and a 7F, 5-cm pancreatic stent (GPSO-7-5, Wilson-Cook) was then placed across the anastomosis (D). During a 3-month follow-up, there were no further attacks of pancreatitis. DISCLOSURE All authors disclosed no financial relationships relevant to this publication. Anthony Y. B. Teoh, FRCSEd (Gen), Enders K. W. Ng, FRCS (Edin), Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong SAR, China; Robert Hawes, MD, Florida Hospital Institute for Minimally Invasive Therapy, Center for Interventional Endoscopy, Florida Hospital, Orlando, FL, USA http://dx.doi.org/10.1016/j.gie.2012.10.032
www.giejournal.org