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Persistent chylothorax
Persistent chylothorax Treatment by talc pleurodesis Two patients with persistent chylothorax resistant to therapy by special diet, thoracenteses, and tube thoracostomy drainage were successfully treated by talc pleurodesis. In one patient with advanced lymphosarcoma involving pleura and mediastinal nodes, the chylothorax was managed by open thoracotomy and talc powder. The other patient developed chylothorax following resection of a thoracic aortic aneurysm. She was successfully treated by talc suspension introduced through a thoracostomy tube. Pleurodesis with talc should be considered only when the chylothorax persists after an adequate period of medical treatment and pleural decompression. Intrapleural instillation of talc through a thoracostomy tube should be successful if the chylothorax can be evacuated and the underlying lung fully expanded.
Richard H. Adler, M.D., and Leon Levinsky, M.B.B.S., Buffalo, N. Y.
V-^hylothorax is an uncommon condition that has stimulated interest in both the medical and surgical literature. The management of chylothorax remains unsettled partially because of the variety of causes and the variable results from different methods of treatment. 1 " 3 This report describes two patients with persistent chylothorax of different origins, each of whom was treated by talc pleurodesis. Both patients failed to respond to medical management including dietary manipulation, multiple thoracenteses, and tube thoracostomy drainage. One patient with advanced lymphosarcoma and malnutrition secondary to loss of chyle was successfully treated by open thoracotomy and talc pleurodesis. The other patient developed chylothorax following resection of a thoracic aortic aneurysm. The persistent chylothorax was successfully managed after several tube thoracostomy failures by using talc suspension introduced through a thoracostomy tube.
Case reports CASE 1. A 61-year-old white woman was admitted to the Buffalo General Hospital on April 25, 1975, with a diagnosis of chronic refractory chylothorax of unknown origin. The patient had been well until 2Vi months prior to this date, when From the Department of Surgery, State University of New York at Buffalo, School of Medicine, and the Buffalo General Hospital, Buffalo, N. Y. Received for publication May 23, 1978. Accepted for publication June 19, 1978. Address for reprints: Richard H. Adler, M.D., Department of Surgery, 100 High St., State University of New York, Buffalo, N. Y. 14203.
she began having influenza-like symptoms that subsequently progressed to pneumonia and pleurisy on the right. Shortly thereafter, she experienced dyspnea, and a right pleural effusion was discovered. She was admitted to a local hospital in another community where thoracentesis produced 2,000 c.c. of milky fluid that tested positive for chyle. Despite treatment consisting of multiple thoracenteses, yielding approximately 14,000 c.c. of chyle over a period of 4 weeks, intercostal tube thoracostomy, and low fat diet, chyle continued to reaccumulate and the patient was then admitted to the Buffalo General Hospital. On admission, the patient appeared anemic and malnourished. She had lost 40 pounds and felt weak and tired. Her only respiratory symptom was dyspnea. Physical examination revealed no lymphadenopathy and the liver and spleen were not palpable. The hemoglobin value was 8.8 Gm. per 100 ml. with a hematocrit value of 26 percent. She had significant hypoproteinemia. A chest x-ray film showed fluid in the lower two thirds of the right side of the chest (Fig. 1). Liver and spleen scans were normal. Thoracentesis produced 1,400 c.c. of milky white fluid that tested positive for chyle. The patient was placed on a high-caloric diet with fat limited to medium-chain triglycerides (Portagen). She received albumin, blood, and electrolytes intravenously to correct anemia, hypoproteinemia, and abnormal electrolyte levels. A pleural biopsy taken at the time of thoracentesis showed clusters of small lymphocytes suggestive of lymphoma or leukemia. Bone marrow study was interpreted as a lymphoproliferative disorder, probably lymphosarcoma. It was the opinion of the consulting hematologist, oncologist, and radiotherapist that radiation therapy to the mediastinum in an effort to control the chylothorax, probably secondary to lymphosarcoma, was not advisable in this patient because bone marrow depression might follow which would interfere with subsequent chemotherapy. All agreed on the need for prompt open thoracotomy to control the chylothorax before beginning chemotherapy because of her
0022-5223/78/120859+06500.60/0 © 1978 The C. V. Mosby Co.
859
860
Adler and
The Journal of Thoracic and Cardiovascular Surgery
Levinsky
©
ICB: Fig. 1. Posteroanterior (A) and right lateral (B) chest roentgenograms showing chylothorax on the right.
progressively deteriorating nutritional state. This would also permit assessment of the extent of mediastinal and pleural involvement and would supply tissue for suitable histologic study. Standard right posterolateral thoracotomy was carried out on May 2, 1975. Approximately 1,400 c.c. of milky, slightly yellow chyle was found in the pleural space. The parietal pleura was diffusely thickened and granular. The middle and superior parts of the mediastinum contained a number of moderately enlarged lymph nodes. Both the nodes and excised sections of parietal pleura were found to be infiltrated with lymphosarcoma on microscopic examination. Careful mediastinal dissection over the eleventh and twelfth vertebrae failed to reveal the thoracic duct or any chylous leak despite the administration of olive oil and methylene blue preoperatively. After a number of loculated pockets of clots and chyle had been evacuated, 10 Gm. of sterile USP talc powder was introduced; a flexible dural spoon was used to sprinkle the talc lightly over the area of thoracic duct dissection and the entire lung surface. Two large-caliber plastic chest tubes had been inserted through separate stab wounds prior to introducing the talc. The lung was then expanded, the protective wound drapes removed, and the chest closed. The patient had an uneventful postoperative course. Chest drainage decreased progressively the first day and the tubes were removed on the fifth postoperative day. Chemotherapy with Cytoxan and vincristine was started one week following the operation. The patient was discharged on the tenth postoperative day on a high-caloric regular diet to continue chemotherapy as an outpatient. There has been no recurrence of the chylothorax. When last seen 2'/2 years later, her general
nutritional state had returned to normal and her chest was clear throughout with no fluid recurrence (Fig. 2). CASE 2. A 64-year-old white woman underwent operation for Type III dissecting aortic aneurysm on Jan. 13, 1975 (Dr. T. Z. Lajos). The aneurysm was excised by use of a Gott shunt and replaced with a Dacron graft just distal to the left subclavian artery. At no time during the operation was injury to the thoracic duct suspected. The patient's condition improved postoperatively after initial difficulties associated with pneumonitis. A chest x-ray film on the eleventh postoperative day showed a large hydrothorax (Fig. 3); thoracentesis yielded 1,150 c.c. of turbid blood-tinged fluid. Three days later, an intercostal chest tube was inserted and drained 1,500 c.c. of white chylous fluid. The fluid was sterile and tested positive for chyle. Drainage gradually decreased. The tube was removed 2 weeks after insertion when drainage stopped, and she was discharged to her home on Feb. 12, 1975. The patient was readmitted to the hospital on Feb. 21, 1975, because of dyspnea and recurrence of the chylothorax (Fig. 4). She was referred to us after failure of treatment by tube thoracostomy and median-chain triglyceride diet plus intravenous fluid supplementation to control the persistent chylous leakage. Her general nutritional state was poor and she was not considered to be a suitable risk for thoracotomy with ligation of the thoracic duct; thus it was decided to perform talc pleurodesis with the thoracostomy tube already in place. This was carried out by instilling 10 Gm. of sterile USP talc suspended in 250 c.c. of saline as described recently for treating malignant pleural effusions.3' The tube was then clamped for a 2 hour period while the patient was maintained
Volume 76 Number 6 December, 1978
Fig. 2. Chest roentgenograms 12 months following right thoracotomy with talc pleurodesis in patient with lymphosarcoma involving the mediastinum and pleura. There has been no recurrence of chylothorax. She remains well after a follow-up period of 2 years, 10 months. in several positions to distribute the talc. Suction drainage was then resumed. Drainage decreased over the next few days and the tube was removed 6 days after talc instillation. The patient was discharged on April 23, 1975, with no further fluid recurrence after a follow-up period of 3 years (Fig. 5). Discussion Because chylothorax is uncommon, a physician encountering the condition may have little or no prior experience upon which to formulate a treatment program. No one method of treatment may be successful or free from complications in an individual patient because of a number of variables such as cause, age range, magnitude, persistence of chylous fistula, and the general condition of the patient. Prior to the report of Lampson4 in 1948 describing the successful surgical approach of transthoracic ligation of the thoracic duct, the over-all mortality rate of chylothorax was approximately 50 percent.5 A review of the literature on chylothorax by Goorwitch6 in 1955 revealed a drop in mortality rate to 10 percent following the introduction of thoracic duct ligation. Some cautioned against the growing enthusiasm for thoracic duct ligation stating that many patients with chylothorax could be successfully managed with a longer course of conservative treatment—4 weeks rather than 2 weeks.7 A number of authors, however, more recently have stressed the need for earlier operative treatment so as to
Persistent chylothorax
86 1
Fig. 3. Chest roentgenogram 11 days following resection of thoracic aortic aneurysm showing chylothorax on the left. avoid local intrathoracic complications and general nutritional disturbances that may be seen in association with longer periods of conservative treatment.8"12 Today, with the general availability of two relatively recent methods for supplying adequate nutrition while keeping the thoracic duct at rest, one may more safely continue with conservative treatment for a longer period hoping for closure of the chylous fistula. The two nutritional advances are (1) parenteral hyperalimentation13' 14 and (2) medium-chain triglycerides, a source of oral fat that is absorbed into the portal venous system rather than the intestinal and thoracic lymphatics. 15-18 Chylothorax is best managed when the cause in an individual patient is known and the specific pathogenesis understood. The literature contains a wide variety of conditions that either directly or indirectly lead to the development of chylothorax. Various classifications of causes of chylothorax have been proposed.1 In terms of therapeutic considerations, most chylothoraces seen in the neonate 19-23 or after operation and direct trauma2' 24,25 r e S p o n c i t 0 medical treatment and pleural decompression. Another group of adult patients with chylothorax have generally been considered to have a poor prognosis because of the underlying malignancy commonly present. 26-28 Since lymphoma is the usual malignancy, chylothorax may occasionally respond following effective treatment of the primary underlying disease. Within the remaining miscellaneous group of
8 6 2 Adler and Levinsky
The Journal of Thoracic and Cardiovascular Surgery
Fig. 4. Chest roentgenogram showing recurrent chylothorax on the left with newly inserted intercostal tube. patients, chylothorax may disappear when the underlying causes of elevated central venous pressure are treated. This may be accomplished at times through the simple use of diuretics and digitalis.29 The persistence of the chylous leak and the amount of flow are related to two general factors; namely, the volume of lymph flow and pressure within the thoracic lymphatic ducts and the presence of a free pleural space. With persistent chylothorax, the second factor is probably the more important. Flow from the chylous fistula will cease with obliteration of the pleuromediastinal space.30 Randolph and Gross22 recommended the local application of iodine within the mediastinum in the area of the dissection when they could not find the thoracic duct. The literature contains a variety of substances and procedures that have been tried in an effort to produce a generalized pleural symphysis. These have included radiation therapy, intrapleural instillation of sterile broth, Azochloramid, hypertonic glucose, nitrogen mustard, talc, and pleurectomy. Talc has had the longest and most successful usage of any of the agents used for the production of pleural symphysis, both experimentally and clinically.31 Its main clinical use has been in the treatment of recurrent malignant pleural effusions, but it has also been used in the treatment of recurrent pneumothoraces.31 Gingell32 in 1965 reported on three patients with chylothorax successfully treated by insufflation of iodinized talc under general anesthesia. Maloney and Spencer7 also mentioned the addition of talc at the time of open thoracostomy in a 7-year-old patient with chylothorax. Talc pleurodesis should be reserved only for those
patients in whom more conservative measures fail to control persistent chylothorax. The therapeutic approach must be individualized for each patient, but a therapeutic outline leading up to talc pleurodesis is presented. Conservative therapy. This consists of two parts: (1) decompression of the thoracic lymphatics and (2) rest and decompression of the pleural space. 1. The thoracic lymphatics can be kept empty by maintaining nutrition through parenteral hyperalimentation and by an oral diet of essentially medium-chain triglycerides. The smaller-chain triglyceride molecules are absorbed into the portal system rather than into the intestinal and thoracic lymphatics. For this reason this mode of alimentation has been successful in the management of chylothorax, particularly in infants. Lowering central venous pressure by medical means also lowers the pressure within the thoracic lymphatics. 2. Thoracocentesis may decompress the pleural space, but if multiple thoracenteses are required for removal of chyle, tube thoracostomy with suction drainage should be substituted. Pleural decompression by intercostal tube or needle aspirations in combination with medical "rest" of the thoracic lymphatics will be effective in the majority of chylothoraces of infancy, trauma, and following surgical procedures that injure the thoracic duct. Pleurodesis with talc. This should generally be considered only after 3 or 4 weeks of treatment as outlined. Persistent chylothorax resistent to treatment will be encountered most often in the presence of malignancy, lymphosarcoma in particular. When pleural
Volume 76 Number 6 December, 1978
Persistent chylothorax
863
® Fig. 5. Posteroanterior (A) and left lateral (B) chest roentgenograms 8 months following thoracostomy talc pleurodesis. There has been no recurrence of chylothorax. There is a density in the upper left paramediastinum from aneurysm surgery and aortic graft replacement. The patient remains well after a follow-up period of 3 years. complications have not occurred and the lung is capable of full expansion, intrapleural instillation of talc suspension through the thoracostomy tube should be successful. Open thoracotomy may be indicated earlier in a good risk patient to ligate a surgically severed thoracic duct or to evacuate a loculated pleural space so as to permit complete lung expansion. Pleural symphysis should then be promoted either by pleurectomy in the young or by talc pleurodesis in the adult, particularly in the presence of malignancy. This is done by lightly sprinkling a fine layer of 5 to 10 Gm. of talc powder over the mediastinal site of the thoracic duct as well as over the entire visceral pleural surface. In the presence of a large chylous leak that persists despite medical therapy and pleural decompression, intrapleural instillation of talc suspension should be considered, particularly in the adult with suspected malignancy, before pleural loculations and adhesions form and the lung becomes trapped. 33 REFERENCES 1 Bessone LN, Ferguson TB, Burford TH: Chylothorax. Collective review. Ann Thorac Surg 12:527, 1971 2 Cevese PG, Vecchioni R, D'Amico DF, Cordiano C, Biasiato R, Favia G, Farrelo GA: Postoperative chylothorax. Six cases in 2,500 operations, with a survey of the world literature. J THORAC CARDIOVASC SURG 69:966,
1975
3 Williams KR, Burford TH: The management of chylothorax. Ann Surg 160:131, 1964 4 Lampson RS: Traumatic chylothorax—a review of the literature and report of a case treated by mediastinal ligation of the thoracic duct. J THORAC SURG 17:778, 1948 5 Shackelford RT, Fisher AM: Traumatic chylothorax. South Med J 31:766, 1938 6 Goorwitch J: Traumatic chylothorax and thoracic duct ligation. J THORAC SURG 29:467, 1955
7 Maloney JV Jr, Spencer FC: The nonoperative treatment of traumatic chylothorax. Surgery 40:121, 1956 8 Higgins CB, Mulder DG: Chylothorax after surgery for congenital heart disease. J THORAC CARDIOVASC SURG
61:411, 1971 9 Roy PH, Carr DT, Payne WS: The problem of chylothorax. Mayo Clinic Proc 42:457, 1967 10 Ross JK: A review of the surgery of the thoracic duct. Thorax 16:12, 1961 11 Schmidt A: Chylothorax. Review of 5 years' cases in the literature and report of a case. Acta Chir Scand 118:5, 1959 12 Selle JG, Snyder WH, Schreiber JT: Chylothorax. Indications for surgery. Ann Surg 177:245, 1973 13 Dudrick SJ, Wilmore DW, Vars HM, Rhoades JE: Can intravenous feeding as the sole means of nutrition support growth in the child and restore weight loss in an adult. Ann Surg 169:974, 1969 14 Wiener ES, Owens L, Salzberg AM: Chylothorax after
8 6 4 Adler and Levinsky
Bochdalek herniorraphy in a neonate. Treatment with intravenous hyperalimentation. J THORAC CARDIOVASC SURG 65:200, 1973
15 Hashim SA, Roholt MB, Babayan VK, et al: Treatment of chyluria and chylothorax with medium chain triglycerides. N Engl J Med 270:756, 1964 16 Kosloske AM, Martin LW, Schubert WK: Management of chylothorax in children by thoracentesis and medium chain triglyceride feedings. J Pediatr Surg 9:365, 1974 17 Lichter I, Hill GL, Nye ER: The use of medium chain triglycerides in the treatment of chylothorax in a child. Ann Thorac Surg 5:352, 1968 18 Nonaka K, Nakao R, Kitagawa A, et al: Therapy in chylothorax following open heart surgery, Jpn J Thorac Surg 26:28, 1973 19 Bensoussan AL, Braun P, Guttman FM: Bilateral spontaneous chylothorax of the newborn. Arch Surg 110:1243, 1975 20 Chemiak V, Reed MH: Pneumothorax and chylothorax in the neonatal period. J Pediatr 76:624, 1970 21 Gershanik JJ, Johnson HT, Riopel DA, et al: Dietary management of neonatal chylothorax. Pediatrics 53:400, 1975 22 Randolph JG, Gross RE: Congenital chylothorax. Arch Surg 74:405, 1957 23 Craenen JM, Williams TE, Kilman JW: Simplified management of chylothorax in neonates and infants. Ann Thorac Surg 24:275, 1977
The Journal of Thoracic and Cardiovascular Surgery
24 Joyce LD, Lindsay WG, Nicoloff DM: Chylothorax after median stemotomy for intrapericardial cardiac surgery. J THORAC CARDIOVASC SURG 71:476, 1976
25 Thurer RJ: Chylothorax. A complication of subclavian vein catheterization and parenteral hyperalimentation. J THORAC CARDIOVASC SURG 71:465, 1976
26 Bruneau R, Rubin P: The management of pleural effusions and chylothorax in lymphoma. Radiology 85:1085, 1965 27 Frank BW, Kern F Jr, Franks JJ, et al.: Failure of medium chain triglycerides in the treatment of persistent chylous ascites secondary to lymphosarcoma. Gastroenterology 50:677, 1966 28 Lowe DK, Fletcher WS, Horowitz IT, et al: Management of chylothorax secondary to lymphoma. Surg Gynecol Obstet 135:35, 1972 29 MacFarlane JR, Holman CW: Chylothorax. Am Rev Respir Dis 105:287, 1972 30 HeppnerGJ: Bilateral chylothorax and chyloperitoneum. JAMA 102:1294, 1934 31 Adler RH, Sayek I: Treatment of malignant pleural effusion. A method using tube thoracostomy and talc. Ann Thorac Surg 22:8, 1976 32 Gingell JC: Treatment of chylothorax by producing pleurodesis using iodized talc. Thorax 20:261, 1965 33 Meade RA Jr, Head JR, Moen CW: The management of chylothorax. J THORAC SURG 19:709, 1950
Richard H. Adler, M.D., and Leon Levinsky, M.B.B.S., Buffalo, N. Y.
V-^hylothorax is an uncommon condition that has stimulated interest in both the medical and surgical literature. The management of chylothorax remains unsettled partially because of the variety of causes and the variable results from different methods of treatment. 1 " 3 This report describes two patients with persistent chylothorax of different origins, each of whom was treated by talc pleurodesis. Both patients failed to respond to medical management including dietary manipulation, multiple thoracenteses, and tube thoracostomy drainage. One patient with advanced lymphosarcoma and malnutrition secondary to loss of chyle was successfully treated by open thoracotomy and talc pleurodesis. The other patient developed chylothorax following resection of a thoracic aortic aneurysm. The persistent chylothorax was successfully managed after several tube thoracostomy failures by using talc suspension introduced through a thoracostomy tube.
Case reports CASE 1. A 61-year-old white woman was admitted to the Buffalo General Hospital on April 25, 1975, with a diagnosis of chronic refractory chylothorax of unknown origin. The patient had been well until 2Vi months prior to this date, when From the Department of Surgery, State University of New York at Buffalo, School of Medicine, and the Buffalo General Hospital, Buffalo, N. Y. Received for publication May 23, 1978. Accepted for publication June 19, 1978. Address for reprints: Richard H. Adler, M.D., Department of Surgery, 100 High St., State University of New York, Buffalo, N. Y. 14203.
she began having influenza-like symptoms that subsequently progressed to pneumonia and pleurisy on the right. Shortly thereafter, she experienced dyspnea, and a right pleural effusion was discovered. She was admitted to a local hospital in another community where thoracentesis produced 2,000 c.c. of milky fluid that tested positive for chyle. Despite treatment consisting of multiple thoracenteses, yielding approximately 14,000 c.c. of chyle over a period of 4 weeks, intercostal tube thoracostomy, and low fat diet, chyle continued to reaccumulate and the patient was then admitted to the Buffalo General Hospital. On admission, the patient appeared anemic and malnourished. She had lost 40 pounds and felt weak and tired. Her only respiratory symptom was dyspnea. Physical examination revealed no lymphadenopathy and the liver and spleen were not palpable. The hemoglobin value was 8.8 Gm. per 100 ml. with a hematocrit value of 26 percent. She had significant hypoproteinemia. A chest x-ray film showed fluid in the lower two thirds of the right side of the chest (Fig. 1). Liver and spleen scans were normal. Thoracentesis produced 1,400 c.c. of milky white fluid that tested positive for chyle. The patient was placed on a high-caloric diet with fat limited to medium-chain triglycerides (Portagen). She received albumin, blood, and electrolytes intravenously to correct anemia, hypoproteinemia, and abnormal electrolyte levels. A pleural biopsy taken at the time of thoracentesis showed clusters of small lymphocytes suggestive of lymphoma or leukemia. Bone marrow study was interpreted as a lymphoproliferative disorder, probably lymphosarcoma. It was the opinion of the consulting hematologist, oncologist, and radiotherapist that radiation therapy to the mediastinum in an effort to control the chylothorax, probably secondary to lymphosarcoma, was not advisable in this patient because bone marrow depression might follow which would interfere with subsequent chemotherapy. All agreed on the need for prompt open thoracotomy to control the chylothorax before beginning chemotherapy because of her
0022-5223/78/120859+06500.60/0 © 1978 The C. V. Mosby Co.
859
860
Adler and
The Journal of Thoracic and Cardiovascular Surgery
Levinsky
©
ICB: Fig. 1. Posteroanterior (A) and right lateral (B) chest roentgenograms showing chylothorax on the right.
progressively deteriorating nutritional state. This would also permit assessment of the extent of mediastinal and pleural involvement and would supply tissue for suitable histologic study. Standard right posterolateral thoracotomy was carried out on May 2, 1975. Approximately 1,400 c.c. of milky, slightly yellow chyle was found in the pleural space. The parietal pleura was diffusely thickened and granular. The middle and superior parts of the mediastinum contained a number of moderately enlarged lymph nodes. Both the nodes and excised sections of parietal pleura were found to be infiltrated with lymphosarcoma on microscopic examination. Careful mediastinal dissection over the eleventh and twelfth vertebrae failed to reveal the thoracic duct or any chylous leak despite the administration of olive oil and methylene blue preoperatively. After a number of loculated pockets of clots and chyle had been evacuated, 10 Gm. of sterile USP talc powder was introduced; a flexible dural spoon was used to sprinkle the talc lightly over the area of thoracic duct dissection and the entire lung surface. Two large-caliber plastic chest tubes had been inserted through separate stab wounds prior to introducing the talc. The lung was then expanded, the protective wound drapes removed, and the chest closed. The patient had an uneventful postoperative course. Chest drainage decreased progressively the first day and the tubes were removed on the fifth postoperative day. Chemotherapy with Cytoxan and vincristine was started one week following the operation. The patient was discharged on the tenth postoperative day on a high-caloric regular diet to continue chemotherapy as an outpatient. There has been no recurrence of the chylothorax. When last seen 2'/2 years later, her general
nutritional state had returned to normal and her chest was clear throughout with no fluid recurrence (Fig. 2). CASE 2. A 64-year-old white woman underwent operation for Type III dissecting aortic aneurysm on Jan. 13, 1975 (Dr. T. Z. Lajos). The aneurysm was excised by use of a Gott shunt and replaced with a Dacron graft just distal to the left subclavian artery. At no time during the operation was injury to the thoracic duct suspected. The patient's condition improved postoperatively after initial difficulties associated with pneumonitis. A chest x-ray film on the eleventh postoperative day showed a large hydrothorax (Fig. 3); thoracentesis yielded 1,150 c.c. of turbid blood-tinged fluid. Three days later, an intercostal chest tube was inserted and drained 1,500 c.c. of white chylous fluid. The fluid was sterile and tested positive for chyle. Drainage gradually decreased. The tube was removed 2 weeks after insertion when drainage stopped, and she was discharged to her home on Feb. 12, 1975. The patient was readmitted to the hospital on Feb. 21, 1975, because of dyspnea and recurrence of the chylothorax (Fig. 4). She was referred to us after failure of treatment by tube thoracostomy and median-chain triglyceride diet plus intravenous fluid supplementation to control the persistent chylous leakage. Her general nutritional state was poor and she was not considered to be a suitable risk for thoracotomy with ligation of the thoracic duct; thus it was decided to perform talc pleurodesis with the thoracostomy tube already in place. This was carried out by instilling 10 Gm. of sterile USP talc suspended in 250 c.c. of saline as described recently for treating malignant pleural effusions.3' The tube was then clamped for a 2 hour period while the patient was maintained
Volume 76 Number 6 December, 1978
Fig. 2. Chest roentgenograms 12 months following right thoracotomy with talc pleurodesis in patient with lymphosarcoma involving the mediastinum and pleura. There has been no recurrence of chylothorax. She remains well after a follow-up period of 2 years, 10 months. in several positions to distribute the talc. Suction drainage was then resumed. Drainage decreased over the next few days and the tube was removed 6 days after talc instillation. The patient was discharged on April 23, 1975, with no further fluid recurrence after a follow-up period of 3 years (Fig. 5). Discussion Because chylothorax is uncommon, a physician encountering the condition may have little or no prior experience upon which to formulate a treatment program. No one method of treatment may be successful or free from complications in an individual patient because of a number of variables such as cause, age range, magnitude, persistence of chylous fistula, and the general condition of the patient. Prior to the report of Lampson4 in 1948 describing the successful surgical approach of transthoracic ligation of the thoracic duct, the over-all mortality rate of chylothorax was approximately 50 percent.5 A review of the literature on chylothorax by Goorwitch6 in 1955 revealed a drop in mortality rate to 10 percent following the introduction of thoracic duct ligation. Some cautioned against the growing enthusiasm for thoracic duct ligation stating that many patients with chylothorax could be successfully managed with a longer course of conservative treatment—4 weeks rather than 2 weeks.7 A number of authors, however, more recently have stressed the need for earlier operative treatment so as to
Persistent chylothorax
86 1
Fig. 3. Chest roentgenogram 11 days following resection of thoracic aortic aneurysm showing chylothorax on the left. avoid local intrathoracic complications and general nutritional disturbances that may be seen in association with longer periods of conservative treatment.8"12 Today, with the general availability of two relatively recent methods for supplying adequate nutrition while keeping the thoracic duct at rest, one may more safely continue with conservative treatment for a longer period hoping for closure of the chylous fistula. The two nutritional advances are (1) parenteral hyperalimentation13' 14 and (2) medium-chain triglycerides, a source of oral fat that is absorbed into the portal venous system rather than the intestinal and thoracic lymphatics. 15-18 Chylothorax is best managed when the cause in an individual patient is known and the specific pathogenesis understood. The literature contains a wide variety of conditions that either directly or indirectly lead to the development of chylothorax. Various classifications of causes of chylothorax have been proposed.1 In terms of therapeutic considerations, most chylothoraces seen in the neonate 19-23 or after operation and direct trauma2' 24,25 r e S p o n c i t 0 medical treatment and pleural decompression. Another group of adult patients with chylothorax have generally been considered to have a poor prognosis because of the underlying malignancy commonly present. 26-28 Since lymphoma is the usual malignancy, chylothorax may occasionally respond following effective treatment of the primary underlying disease. Within the remaining miscellaneous group of
8 6 2 Adler and Levinsky
The Journal of Thoracic and Cardiovascular Surgery
Fig. 4. Chest roentgenogram showing recurrent chylothorax on the left with newly inserted intercostal tube. patients, chylothorax may disappear when the underlying causes of elevated central venous pressure are treated. This may be accomplished at times through the simple use of diuretics and digitalis.29 The persistence of the chylous leak and the amount of flow are related to two general factors; namely, the volume of lymph flow and pressure within the thoracic lymphatic ducts and the presence of a free pleural space. With persistent chylothorax, the second factor is probably the more important. Flow from the chylous fistula will cease with obliteration of the pleuromediastinal space.30 Randolph and Gross22 recommended the local application of iodine within the mediastinum in the area of the dissection when they could not find the thoracic duct. The literature contains a variety of substances and procedures that have been tried in an effort to produce a generalized pleural symphysis. These have included radiation therapy, intrapleural instillation of sterile broth, Azochloramid, hypertonic glucose, nitrogen mustard, talc, and pleurectomy. Talc has had the longest and most successful usage of any of the agents used for the production of pleural symphysis, both experimentally and clinically.31 Its main clinical use has been in the treatment of recurrent malignant pleural effusions, but it has also been used in the treatment of recurrent pneumothoraces.31 Gingell32 in 1965 reported on three patients with chylothorax successfully treated by insufflation of iodinized talc under general anesthesia. Maloney and Spencer7 also mentioned the addition of talc at the time of open thoracostomy in a 7-year-old patient with chylothorax. Talc pleurodesis should be reserved only for those
patients in whom more conservative measures fail to control persistent chylothorax. The therapeutic approach must be individualized for each patient, but a therapeutic outline leading up to talc pleurodesis is presented. Conservative therapy. This consists of two parts: (1) decompression of the thoracic lymphatics and (2) rest and decompression of the pleural space. 1. The thoracic lymphatics can be kept empty by maintaining nutrition through parenteral hyperalimentation and by an oral diet of essentially medium-chain triglycerides. The smaller-chain triglyceride molecules are absorbed into the portal system rather than into the intestinal and thoracic lymphatics. For this reason this mode of alimentation has been successful in the management of chylothorax, particularly in infants. Lowering central venous pressure by medical means also lowers the pressure within the thoracic lymphatics. 2. Thoracocentesis may decompress the pleural space, but if multiple thoracenteses are required for removal of chyle, tube thoracostomy with suction drainage should be substituted. Pleural decompression by intercostal tube or needle aspirations in combination with medical "rest" of the thoracic lymphatics will be effective in the majority of chylothoraces of infancy, trauma, and following surgical procedures that injure the thoracic duct. Pleurodesis with talc. This should generally be considered only after 3 or 4 weeks of treatment as outlined. Persistent chylothorax resistent to treatment will be encountered most often in the presence of malignancy, lymphosarcoma in particular. When pleural
Volume 76 Number 6 December, 1978
Persistent chylothorax
863
® Fig. 5. Posteroanterior (A) and left lateral (B) chest roentgenograms 8 months following thoracostomy talc pleurodesis. There has been no recurrence of chylothorax. There is a density in the upper left paramediastinum from aneurysm surgery and aortic graft replacement. The patient remains well after a follow-up period of 3 years. complications have not occurred and the lung is capable of full expansion, intrapleural instillation of talc suspension through the thoracostomy tube should be successful. Open thoracotomy may be indicated earlier in a good risk patient to ligate a surgically severed thoracic duct or to evacuate a loculated pleural space so as to permit complete lung expansion. Pleural symphysis should then be promoted either by pleurectomy in the young or by talc pleurodesis in the adult, particularly in the presence of malignancy. This is done by lightly sprinkling a fine layer of 5 to 10 Gm. of talc powder over the mediastinal site of the thoracic duct as well as over the entire visceral pleural surface. In the presence of a large chylous leak that persists despite medical therapy and pleural decompression, intrapleural instillation of talc suspension should be considered, particularly in the adult with suspected malignancy, before pleural loculations and adhesions form and the lung becomes trapped. 33 REFERENCES 1 Bessone LN, Ferguson TB, Burford TH: Chylothorax. Collective review. Ann Thorac Surg 12:527, 1971 2 Cevese PG, Vecchioni R, D'Amico DF, Cordiano C, Biasiato R, Favia G, Farrelo GA: Postoperative chylothorax. Six cases in 2,500 operations, with a survey of the world literature. J THORAC CARDIOVASC SURG 69:966,
1975
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15 Hashim SA, Roholt MB, Babayan VK, et al: Treatment of chyluria and chylothorax with medium chain triglycerides. N Engl J Med 270:756, 1964 16 Kosloske AM, Martin LW, Schubert WK: Management of chylothorax in children by thoracentesis and medium chain triglyceride feedings. J Pediatr Surg 9:365, 1974 17 Lichter I, Hill GL, Nye ER: The use of medium chain triglycerides in the treatment of chylothorax in a child. Ann Thorac Surg 5:352, 1968 18 Nonaka K, Nakao R, Kitagawa A, et al: Therapy in chylothorax following open heart surgery, Jpn J Thorac Surg 26:28, 1973 19 Bensoussan AL, Braun P, Guttman FM: Bilateral spontaneous chylothorax of the newborn. Arch Surg 110:1243, 1975 20 Chemiak V, Reed MH: Pneumothorax and chylothorax in the neonatal period. J Pediatr 76:624, 1970 21 Gershanik JJ, Johnson HT, Riopel DA, et al: Dietary management of neonatal chylothorax. Pediatrics 53:400, 1975 22 Randolph JG, Gross RE: Congenital chylothorax. Arch Surg 74:405, 1957 23 Craenen JM, Williams TE, Kilman JW: Simplified management of chylothorax in neonates and infants. Ann Thorac Surg 24:275, 1977
The Journal of Thoracic and Cardiovascular Surgery
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