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J Thorac Cardiovasc Surg 2001;121:401-402
© 2001 The American Association for Thoracic Surgery

Letters to the Editor

A new approach to managing chylothorax complicating esophagectomy

Department of Surgery
St Mary's Hospital, Paddington London W2 1NY, United Kingdom

To the Editor:

We read with interest the article by Merigliano and associates (J Thorac Cardiovasc Surg 2000;119:453-7) concerning a plea for early reoperation to ligate the thoracic duct for chylothorax complicating esophagectomy. We agree that early intervention is necessary in patients with this condition. Chylothorax is a potentially life-threatening disorder that has profound respiratory, nutritional, and immunologic consequences. However, we disagree that reoperation by open thoracotomy is the first and best option in managing this complicated problem. A second major operation cannot be an ideal treatment in a patient having a cancer with a relatively poor prognosis. Also, the benefits of a transhiatal approach might be lost if a thoracotomy was performed for this uncommon complication, which may well be associated with significant morbidity and a prolonged hospital stay. There is tendency toward delay in reoperation or intervention in these seriously ill patients. This is reflected to a certain extent in this article. Conservative management was unsuccessful in 7 (64%) of the 11 group A patients, and they underwent reoperation with a high incidence of postoperative complications (4/7 = 57%; 1 death and 3 infectious complications). The 8 most recent patients (group B) underwent early reoperation with no major complications.

In our opinion, the treatment of choice would be early intervention by a minimally invasive procedure. We suggest a new approach in managing chylothorax. Percutaneous catheterization and embolization of the thoracic duct is a new procedure described by Cope ^1-4 from the Hospital of the University of Pennsylvania. Lymphangiography followed by needle puncture of a major retroperitoneal lymphatic trunk or the cisterna chyli and catheterization over a very small guide wire is followed by embolization with platinum coils. This procedure has been shown to be feasible and curative in patients with a demonstrable duct leak. We recently had our first success with this procedure. Thoracoscopic duct ligation is yet another option with minimal trauma to the patient.

The only reliable criterion predictive of successful nonoperative management is the amount of chyle leak by the fifth to seventh days. A leak of more than 1000 mL a day ^5,6 and the ratio of chylous output to body weight ⁷ seem to reliably predict the success of continuing conservative treatment. However, this has not been proven by controlled studies, which are unlikely to be performed because of the rarity of this complication.

In conclusion, a logical approach would be early radiologic intervention with duct embolization or thoracoscopic duct ligation by a surgeon experienced in minimally invasive techniques. Open thoracotomy for duct ligation would then be the final approach if these methods failed. Patients undergoing surgery for carcinoma of the esophagus have limited long-term survival, and a major indication for surgery is improvement in the quality of life.

12/8/111171

doi:10.1067/mtc.2001.111171

References

1. Cope C, Salem R, Kaiser LR. Management of chylothorax by percutaneous catheterization and embolization of the thoracic duct: prospective trial. J Vasc Interv Radiol 1999;10:1248-54.[Medline]
   
2. Cope C. Diagnosis and treatment of postoperative chyle leakage via percutaneous transabdominal catheterization of the cisterna chyli: a preliminary study. J Vasc Interv Radiol 1998;9:727-34.[Medline]
   
3. Cope C. Percutaneous transabdominal embolization of thoracic duct lacerations in animals. J Vasc Interv Radiol 1996;7:725-31.[Medline]
   
4. Cope C. Percutaneous thoracic duct cannulation: feasibility study in swine. J Vasc Interv Radiol 1995;6:559-64.[Medline]
   
5. Cerfolio RJ, Allen MS, Deschamps C, Trastek VF, Pairolero PC. Postoperative chylothorax. J Thorac Cardiovasc Surg 1996;112:1361-6.[Abstract/Free Full Text]
   
6. Browse NL, Allen DR, Wilson NM. Management of chylothorax. Br J Surg 1997;84:1711-6.[Medline]
   
7. Dugue L, Sauvanet A, Farges O, Goharin A, Le Mee J, Belghiti J. Output of chyle as an indicator of treatment for chylothorax complicating oesophagectomy. Br J Surg 1998;85:1147-9.[Medline]
   

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Patel, B. Articles by Rosin, R. D. Search for Related Content PubMed PubMed Citation Articles by Patel, B. Articles by Rosin, R. D.