Supradiaphragmatic Ligation of the Thoracic Duct in Intractable Chylous Fistula

Supradiaphragmatic Ligation of the Thoracic Duct in Intractable Chylous Fistula G. A. Patterson, M.D., T. R. J. Todd, M.D., N. C. Delarue, M.D., R. Ilves, M.D., F. G. Pearson, M.D., and J. D. Cooper, M.D.

ABSTRACT Spontaneous closure of a chylous fistula is usual, but the rare intractable fistula may lead to disastrous nutritional and immunological consequences. We report the surgical management of 5 patients with intractable fistulas with daily drainage averaging 2,060 ml. Conservative therapy failing, the 5 patients underwent 6 ligations of the thoracic duct. A limited posterolateral thoracotomy was used in 3, full right thoracotomy in 2, and left thoracotomy in 1. Ligations were carried out immediately above the diaphragm, and not at the fistula site, by a mass ligature technique encircling all tissue between the azygos vein and aorta. The ligation achieved immediate cessation of drainage in four of five initial procedures and in the fifth patient, at a second operation. High-output thoracic duct fistulas may be handled by supradiaphragmatic ligation of the thoracic duct. Identification of the fistula site or the dissection of the thoracic duct itself is avoided by this technique.

Ligation of the thoracic duct has been a recognized form of treatment for intractable chylous fistula for three decades. In 1948, Lampson [1] reported use of a transthoracic mediastinal thoracic duct ligation. He described a supradiaphragmatic ligation, which avoided a direct approach to the site of the fistula. His report was followed by others [2-4] describing a similar technique. Despite these early descriptions, over the next two decades a more direct approach to the fistula was recommended by several authors [5-7]. Lam and colleagues [8] in 1979 reported 4 patients with chylothorax following esophageal resection. Three of these patients underwent direct fistula closure, and From the Division of Thoracic Surgery, Toronto General Hospital, Toronto, Ont, Canada. Accepted for publication Sept 29, 1980. Address reprint requests to Dr. Todd, Division of Thoracic Surgery, Eaton North 10-228, Toronto General Hospital, Toronto, Ont, Canada M5G 1L7.

44 0003-4975/81/070044-06$01.25

all died of shock or sepsis postoperatively. Noting the variability of results reported in the literature, we recently reviewed the experience at the Toronto General Hospital with supradiaphragmatic ligation of the thoracic duct to obtain closure of intractable chylous fistulas. Material and Methods Details of each patient are given in the following case reports and in the Table.

Case Reports 1. A 77-year-old woman was admitted on September 8, 1969, for resection of an anastomotic recurrence following a previous esophagogastrectomy. She underwent a left thoracotomy and local resection of the recurrent tumor. Two days later, copious amounts of fluid began draining from the left chest. Approximately 3,000 ml per day were lost over the next 9 days. As her diet increased, the fluid became opalescent and increased in volume. On the ninth postoperative day, through a right seventh interspace thoracotomy, a supradiaphragmatic ligation of the thoracic duct was performed. Postoperatively there was no persistent drainage. The patient was discharged on the nineteenth postoperative day. PATIENT 2. A 69-year-old woman underwent a total thoracic esophagectomy through a right thoracotomy, laparotomy, and right cervical incision. On the third postoperative day, the right chest drainage began to increase. On the fifth postoperative day, intravenous hyperalimentation was started but did nothing to diminish the loss of chyle, 3,000 ml per day. Two weeks postoperatively a limited right posterolateral thoracotomy through the bed of the ninth rib was carried out. The tissue between the azygos vein and aorta was ligated at the level of the ninth thoracic vertebra. The drainage was undiminished, and reexploration through a full posterolateral thoracotomy was PATIENT

© 1980 by The Society of Thoracic Surgeons

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Patterson et al: Supradiaphragmatic Ligation of Thoracic Duct in Chylous Fistula

Patient Data Corrective Procedure

Fistula Patient No., Age (yr), Sex

Timing (days)

Onset (days)

Side

Drainage (mllday)

Esophagogastrectomy

2

L

3,000

9

Carcinoma (esophagus)

Esophagectomy

3

R

3,000

14

3.67, M

Carcinoma (cardia)

Esophagogastrectomy

1

L

2,000

7

4.72, M

Fibrothorax

Decortication

2

R

700

31

5. 47, F

Granuloma

Supraclavicular node biopsy

3

L

200-300

21

Diagnosis

Cause

1. 77, F

Carcinoma (cardia)

2. 69, F

Method

Result

Thoracic duct ligation Thoracic duct ligation (mass) Thoracic duct ligation (mass) Thoracic duct ligation (mass) Thoracic duct ligation (isolated)

Closure

Closure on second attempt

Closure

Closure; died 25 days postop

Closure

done 2 days later. A mass ligature was placed tory of pulmonary tuberculosis underwent a between the azygos vein and aorta just above the right pulmonary decortication. On the second diaphragm, to encompass an auxiliary duct not postoperative day, milky fluid began to drain noted at the limited thoracotomy, and identified from the right chest drain. Volumes ranged on the second occasion by an infusion of in- from 500 to 800 ml per day despite his being tralipid through the nasogastric tube. This sec- placed on an elemental diet (Vivonex). Four ond procedure resulted in complete cessation of weeks later a lymphangiogram demonstrated a drainage, and the patient was discharged two leak from the thoracic duct at the level of the ninth thoracic vertebra. By this time the drainweeks postoperatively. PATIENT 3. A 67-year-old man was admitted age had become purulent. The patient underfor resection of a carcinoma of the cardia, and went a right thoracotomy, drainage of the emunderwent a left thoracotomy and esopha- pyema, and supradiaphragmatic ligation of the gogastrectomy. Beginning on the first post- thoracic duct using a mass ligature technique. operative day, 2,000 ml per day of serous The drainage ceased immediately. However, fluid drained from the chest drain. A Hypaque the patient had several episodes of respiratory (diatrizoate sodium) swallow 6 days later re- distress; a diffuse pneumonia developed, and vealed an anastomotic leak. On the seventh he died three weeks later. postoperative day, a right thoracotomy was perPATIENT 5. A 47-year-old woman underwent formed to carry out anastomotic reconstruction. a left supraclavicular node biopsy during an A fistula was noted from the thoracic duct. This investigation of a left upper lobe density. A was effectively managed by supradiaphragma- cervical chylous fistula developed postoperatic ligation. The postoperative course was com- tively. She was transferred to this institution plicated by a continued small anastomotic leak, where a lymphangiogram was performed. A which closed spontaneously during a brief defect seen in the cervical portion of the period of hyperalimentation, but no further thoracic duct communicated with a poorly lymphatic drainage was noted at the conclusion draining subcutaneous cavity. The patient was of the operation. intermittently pyrexial and had continued PATIENT 4. A 72-year-old man with a past hisdrainage. A diagnosis was lacking for the upper

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lobe density. Through a left thoracotomy, the thoracic duct was ligated under direct vision just above the diaphragm. An upper lobectomy was done also for what proved to be a granulomatous lesion. There was no drainage postoperatively, and the patient was discharged 10 days later. Comment Chylous fistula or chylothorax can be seen in a wide variety of etiological circumstances, which are well documented in the literature [9]. In all of our patients it occurred postoperatively, the largest number, 3, following esophagectomy. Although chylothorax has been reported to occur following cervical procedures [10, 11], injury to the thoracic duct by a cervical procedure usually produces a cervical chylous fistula [12]. These are more common on the left but 25% of cervical chylous fistulas are right sided [13]. The metabolic, nutritional, and immunological consequences of a continuous chylous leak can be quite serious [1, 14] and may have contributed to the fatal outcome in Patient 4. The rate of flow in the thoracic duct can be in excess of 2 ml per minute [15]. Bearing in mind that the lymphatic fluid in the duct has electrolyte concentrations similar to plasma, the potential for major extracellular fluid loss is obvious. In addition, the majority of dietary fat after its absorption through intestinallacteals in the form of chylomicrons and long-chain fatty acids, is introduced into the systemic circulation by way of the thoracic duct [9]. Only fatty acids of 10 to 12 carbon atoms or less are able to be absorbed directly into the portal venous system. The thoracic duct is also the route of entry of absorbed vitamin K [16]. Nix and coworkers [17] reported that the total protein in thoracic duct lymph is usually about one-half that found in plasma. Therefore, prolonged losses from the thoracic duct could produce major alterations in nitrogen balance. The most abundant cellular element in the thoracic duct is the lymphocyte. Yoffey and Courtice [18] demonstrated that a range of 400 to 6,000 lymphocytes per milliliter can be present in the thoracic duct fluid. Ninety percent of these are T cells [19]. The role of the T cell in cellular immunity is well

known, and the results of organ transplantation vary greatly depending upon the state of the immune system. Extensive work in both dogs [20] and humans [21, 22] demonstrated that creation of a thoracic duct fistula prior to homograft renal transplantation afforded substantial improvement in graft acceptance. It is clear, then, that prolonged drainage from a thoracic duct fistula can markedly impair a previously intact immune system. The diagnosis of chylous fistula is facilitated by the determination of electrolytes, protein, and fat in the fluid. The identification of fat droplets by Sudan staining is also helpful. Radiographic demonstration of the site of the leak may be important for the management of chylothorax [23, 24]. In addition to defining the site and magnitude of the disruption, the finding of contrast medium in the main trunk above the leak may be of importance as this would indicate either adequate collateral flow or incomplete disruption of the duct. Chavez and Conn [23] wrote that either of these two conditions is more likely to result in spontaneous closure. A modification of standard lymphangiography was used in Patients 4 and 5. * This modification involves the introduction of a small volume of standard contrast medium into the pedallymphatics in the usual manner. This is followed by an immediate flush with 500 ml of saline solution. Contrast medium then is visualized almost immediately in the region of the thoracic duct (Figs I, 2). In addition to considerably shortening the time necessary for the procedure, this modification allowed a marked diminution in the volume of contrast medium used. A smaller volume is of benefit in patients with pulmonary dysfunction since the amount of lipoid dye used for routine studies has been associated with temporary pulmonary dysfunction [25]. The poor results of nonoperative management, which were originally described by Shackelford and Fisher [14] and Dorsey and Morris [26] as approaching 50% mortality, are perhaps not applicable in this era of improved fluid and nutritional management. Maloney and Spencer [4] tempered an initial enthusiasm "Thompson eLP: Personal communication, 1979.

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Patterson et al: Supradiaphragmatic Ligation of Thoracic Duct in Chylous Fistula

Fig 1. Lymphangiogram in patient with left-sided chylous fistula demonstrating extravasation of contrast medium just above the diaphragm. Because of failure to visualize the thoracic duct above the leak, surgical interven tion was required.

Fig 2. Lymphangiogram in a patient with a left-sided chylous fistula following a left lower lobectomy. Note the presence of contrast medium in the thoracic duct (arrow) entering the left chest. It was from this duct that the leak occurred, and closure was obtained with conservati v e therapy.

for thoracic duct ligation. They discussed 13 patients with chylothorax. Nonoperative therapy consisting of oral nutrition and intermittent aspiration resulted in spontaneous closure in 11 patients after a maximum of four weeks. Only 2 patients required surgical closure . It thus was pointed out that complete and aseptic drainage along with satisfactory nutritional support would achieve closure in the majority of patients. At the present time, initial nonoperative management seems most appropriate. Satisfactory nutrition can be maintained intravenously or with special diet. The availability of preparations containing medium-chain triglycerides allows the intake of oral fat while simultaneously maintaining a decreased rate of flow through the thoracic duct [27]. However, the integrity of the immune system still remains a concern in those patients with prolonged drainage as the patient is at risk of lymphocyte depletion while drainage persists [28].

A certain small number of patients will require closure. Persistent volumes of drainage with its accompanying morbidity are indications for closure. We believe that if drainage of more than 1,000 ml per day continues (with no indication of diminution) after 7 days, the patient should undergo duct ligation . It was demonstrated by Loe [29] that thoracic duct ligation was safe and effective. Lampson [1] reported a supradiaphragmatic approach to duct ligation for the treatment of chylothorax in 1948. Despite the support of others [30] for supradiaphragmatic ligation, the trend since the early 1950s was toward direct ligation of the fistula site [6, 7]. Recent proponents of this technique have reported good results also [5, 9, 31] . The results of Lam and associates [8] cast some doubt on the method and illustrate the difficulties of duct fistula closure in a previous operative field . An attempt at thoracic duct ligation must be supported by a sound knowledge of the surgical

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The Annals of Thoracic Surgery Vol 32 No 1 July 1981

MESO·OES. OESOPHAGUS

~;,.:...r;---

"""""~--l-T-'-i::::-::-:-;.;--:n-

Fig 3. The posterior mediastinum (in transverse section). (Adapted from Basmajian JV (ed): Grant's Method of Anatomy. Ninth edition, p 578.1975, The Williams & Wilkins Co., Baltimore.)

tulas. As with thoracic fistulas, the majority of these will close spontaneously if the neck has not been previously irradiated [13]. Ligation of the duct has been shown to be safe and effective when complete ligation is achieved [29]. However, attempts at local control may be very difficult because of problems in identification of the actual luminal defect. In lengthy reviews of the management of cervical chylous fistulas, neither Crumley and Smith [13] nor Myers and Dinerman [35] mention intrathoracic ligation as a method of closure. The result in Patient 5 illustrates that this is a very effective method of closure of a cervical leak. Our experience with operative management of adult chylous fistulas supports the use of the supradiaphragmatic mass ligature technique. While the majority of chylous fistulas will close spontaneously with nonoperative drainage and nutritional support, this operative technique should be considered as a therapeutic option in any patient when the leak shows no sign of early spontaneous closure with conventional nonoperative therapy.

anatomy of the thoracic duct. The embryology and anatomy of the thoracic duct have been dealt with in many reviews [4, 6, 8, 9]. The important anatomical relationships relevant to supradiaphragmatic duct ligation are depicted in Figure 3. The tissue posterior to the esophagus lying between the azygos vein and aorta References just above the diaphragm contains the thoracic 1. Lampson RS: Traumatic chylothorax. J Thorac Surg 17:778, 1948 duct (or ducts). Selle and co-workers [32] stated that the thoracic duct is always single between 2. Goorwitch J: Traumatic chylothorax and thoracic duct ligation. J Thorac Surg 29:467, 1955 the eighth and twelfth thoracic vertebrae. Van 3. Klepser RG, Berry JF: The diagnosis and surgical Pernis [33], however, found in 1,081 cadaver management of chylothorax with the aid of dissections a 38.7% incidence of duplication of lipophilic dyes. Dis Chest 25:409, 1954 4. Maloney JV, Spencer FC: The new non-operative the mediastinal thoracic duct in its caudal portreatment of traumatic chylothorax. Surgery tion. We think that the possibility'of missing a 40:121, 1956 major channel is appreciable if a single duct is 5. Engevik L: Traumatic chylothorax. Scand J found and ligated (as in Patient 2). We concur Thorac Cardiovasc Surg 10:77, 1976 with Murphy and Piper [34] that mass ligature 6: Seaman JB: Rationale and a new surgical techin the area between the azygos vein and the nique in traumatic chylothorax. J Thorac Surg 27:529, 1954 aorta just above the diaphragm is effective. The 7. Schumacker HB, Moore TC: Surgical manageefficacy of this mass ligature technique can be ment of traumatic chylothorax. Surg Gynecol improved by the preoperative administration of Obstet 93:46, 1951 oral fat (cream), as in Patient 2. This enables 8. Lam KH, Lim STK, Wong J, Ong GB: one to be certain that all ascending lymphatics Chylothorax following resection of the esophagus. Br J Surg 66:105, 1979 are within the confines of the ligature. It is clear 9. Bessone LN, Ferguson TB, Burford TH: that a safe and effective supradiaphragmatic Chylothorax (collective review). Ann Thorac ligation can be carried out from either side of Surg 12:527, 1971 the chest [29, 34]. 10. Coates HL, DeSanto LW: Bilateral chylothorax as Patient 5 provides interesting information a complication of radical neck dissection. J regarding management of cervical chylous fisLaryngol Otol 90:967, 1976

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Patterson et al: Supradiaphragmatic Ligation of Thoracic Duct in Chylous Fistula

11. Fitz-Hugh SG, Dowgill R: Chylous fistula. Arch Otolaryngol 91:543, 1970 12. Skinner DB: Scalene lymph node biopsy: reappraisal of risks and indications. N Engl J Med 268:1324, 1963 13. Crumley RL, Smith JD: Post-operative chylous fistula, prevention and management. Laryngoscope 86:804, 1976 14. Shackelford RT, Fisher AM: Traumatic chylothorax. South Med J 31:766, 1938 15. Baldridge RR, Lewis RV: Traumatic chylothorax. Ann Surg 128:1956, 1948 16. Kausel HW, Reeve TS, Stein AA, et al: Anatomic and pathologic studies on the thoracic duct. J Thorac Surg 34:63, 1957 17. Nix JT, Alber M, Dugas JE, Wendt DL: Chylothorax and chylous ascites: a study of 302 selected cases. Am J GastroenteroI28:40, 1957 18. Yoffey JM, Courtice FC: Lymphatics, Lymph and Lymphoid Tissue. Second edition. London, Arnold, 1956 19. Hyde PVB, Jersky J, Gishen P: Traumatic chylothorax. S Afr J Surg 12:57, 1974 20. Singh LM, Vega RE, Makin GS, Howard JM: External thoracic duct fistula and canine renal homograft. Transplantation 171:137, 1965 21. Starzl TE, Weil R, Koep LJ, et al: Thoracic duct drainage before and after cadaveric kidney transplantation. Surg Gynecol Obstet 149:815, 1979 22. Tilney NL, Murray JE: Chronic thoracic duct fistula. Ann Surg 167:1, 1968 23. Chavez CM, Conn JH: Thoracic duct laceration: closure under conservative management based

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32. 33. 34. 35.

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