management ofofof chylothorax

ManagementManagementManagement Management ofofof of

ChylothoraxChylothoraxChylothoraxChylothorax

S bilS bil V l MDV l MDSybileSybile Val, MDVal, MD

December 5 , 2008December 5 , 2008

www.downstatesurgery.org

Case PresentationCase PresentationHi tHi tHistoryHistory

• HPI: • PSH:– 13 YOM with

Waldmann’s di d i d

– LIHR– Mediport (albumin)

disease admitted for increasing LE swelling for past 2

– Chest tube/PT drainage x 3

M dswelling for past 2 months

• PMH:

• Meds:– Aldactone

Aquadek– Asthma– Primary Intestinal

lymphangiectasia

– Aquadek– Lasix– Xopenexlymphangiectasia

– Protein losing enteropathy

Xopenex– Calcium


Case PresentationCase PresentationPh i l E & L bPh i l E & L b

• Physical Exam:

Physical Exam & LabsPhysical Exam & LabsPhysical Exam:– AAO x 3 in NAD, 53kg

Decreased BS right > left– Decreased BS right > left– Abdominal ascities

Pitting edema from b/l LE genitalia and lower– Pitting edema from b/l LE, genitalia and lower abdomen

Labs:• Labs:– CBC: 4/10/29/382– Chem: 144/4.7/113/24/27/0.4/96– LFTs: 3.7/2.9/15/6/74/0.3


Case PresentationCase PresentationR di l i I iR di l i I iRadiologic ImagingRadiologic Imaging


Case PresentationCase PresentationHospital CourseHospital CourseHospital CourseHospital Course

• HD# 2:HD# 2:– Right sided pigtail placed by VIR

Started on TPN– Started on TPN– Pleural fluid Analysis

• Glucose 96• Glucose -- 96 • Protein -- <2• Triglyceride -- 291Triglyceride 291• LDH -- 76• WBC -- 161


Case PresentationCase PresentationR di l i I iR di l i I iRadiologic ImagingRadiologic Imaging


Case PresentationCase PresentationH it l CH it l CHospital CourseHospital Course

• HD#3-7HD#3 7– Pleural drainage monitored

Treatment with albumin lasix and electrolyte– Treatment with albumin, lasix and electrolyte supplementation initiated

• HD#7• HD#7– Cardiothoracic surgery consultation obtained


Sorry Ri i I

Sybile did you hear

Ricci…I think

CHEESE!!!

yme?

CHEESE!!!


Case PresentationCase PresentationO tiO ti Th i d t li tiTh i d t li tiOperationOperation: Thoracic duct ligation: Thoracic duct ligation


Case PresentationCase PresentationPathologPathologPathologyPathology

Lymphatic vessel wall showing edema,

h i i fl tichronic inflammation, marked congestion with recent and oldwith recent and old

hemorrhage and focal fibrosis


Immediately Post-OpImmediately Post Opwww.downstatesurgery.org

Post OperativelyPost Operatively

• POD #1:POD #1:– Pain controlled,

tolerated diettolerated diet

– Decreased drainage

POD#4/6:• POD#4/6:– Chest tubes removed

• POD#7:– Discharged home


Then what?


Post Post-OpPost Post Op

• POD#9POD#9– Found to have fever of 101 in clinic

Admitted urine culture +ve for E coli– Admitted, urine culture +ve for E. coli– Dx: Urosepsis, discharged 2 days later

CXR: Negative– CXR: Negative• POD#39

– Routinely scheduled echo large effusion– Underwent pericardial window (POD#48)– Doing well…


YesterdayYesterday…

• Admitted for regularlyAdmitted for regularly scheduled albumin infusion… last albumin level 2.2

• Reports decrease in LE swelling

• Increased exercise ltolerance

• Overall…happy


Questions??Questions??


ChylothoraxChylothoraxwww.downstatesurgery.org

Thoracic ductThoracic duct

• Ascends fromAscends from cisterna chyli

• Enters thorax via aortic hiatus

• Lies between aorta and azygous until T5

• Crosses over to left behind aortic arch


Thoracic ductThoracic duct

• Arches overArches over subclavian artery in anteriolateral superior mediastinum

• Empties into the venous circulation at junction of left jugular and subclavian veinsand subclavian veins


ChylothoraxChylothorax

Traumatic Non-TraumaticTraumatic

Blunt

Non Traumatic

CongenitalBluntPenetrating

Diagnostic/VIR

CongenitalNeoplasmsInfectiousDiagnostic/VIR

proceduresPost-Operative

InfectiousVenous thrombosis

Autoimmune DiseasePost-Operative Autoimmune DiseaseRadiation exposure


Waldmann’s Disease

• Rare disorderRare disorder• Dilated intestinal

lactealslacteals• Protein losing

t thenteropathy– Lymphopenia– Hypoalbuminemia– Hypogammaglobin

emia


Waldmann’s Disease

• Symptoms:Symptoms:– B/L LE edema– Anasarca– Pleural effusion– Pericarditis– Chylous ascities

• Diagnose with dendoscopy

• Confirmatory test:24 h l t d– 24 hour elevated alpha-antitrypsin


Clinical PresentationClinical Presentation

• Symptoms induced by mechanical effectsSymptoms induced by mechanical effects– Gradual decrease in exercise tolerance

Dyspnea– Dyspnea– Fatigue

Metabolic/Immunologic deficiencies– Metabolic/Immunologic deficiencies

F d h t i lFever and chest pain rarely occurs!


Clinical PresentationClinical Presentation

• Pleural Fluid AnalysisPleural Fluid Analysis– Initial diagnostic test– Sample evaluated for: p

• Cell count• pH• Triglycerides 110• Triglycerides • Cholesterol• Glucose

110

• Lactic dehydrogenase• Total protein• Cytology/culture


Work UpWork Up

Unknown etiology Known etiologyUnknown etiology

CT scan

Known etiology

Lymphangiography/CT scan thorax/abdomen

Lymphangiography/Lymphoscintigraphy

Lymphangiography/LymphoscintigraphyLymphoscintigraphy


LymphangiographyLymphangiography

• Main imagingMain imaging modality

• Allows precise pdefinition and location of chylous leak

• Identifies anatomic aberrations

• Allows for selective duct ligation

Porziella et al, Lymphangiography in recurrent spontaneous chyothorax, Eur J CT. 2007;32:536


Treatment OptionsTreatment Options

• ConservativeConservative– Chest tube drainage

Low fat medium chain TGs– Low fat, medium chain TGs– Complete bowel rest and TPN

Other considerations?Other considerations? – Octreotide

D GI ti d• Decreases GI secretions and lymphatic flow by increasing resistance to splanchnic blood flowresistance to splanchnic blood flow

Nicholas et al, Somatostatin in the treatment of Chylothorax, Chest. 2001;119:964-966


Treatment OptionsTreatment Options

• PleurodesisPleurodesis– Bleomycin

Talc– Talc– Tetracyline

*Sapylin– *Sapylin • Biological preparation of streptococcus• Activates NKT cells• Activates NKT cells• Induces production of TNF, IL-6, VEGF, TGF-beta

Xu et al Case Report: A case of chylothorax treated curatively with Sapylin aXu et al, Case Report: A case of chylothorax treated curatively with Sapylin, a streptococcus preparation, J Zhejiang Univ Sci B 2007; 8(12):885-887


Well Sybile, when do weWell Sybile, when do we operate!?


Surgical IndicationsSurgical Indications

• Failure of conservative managementFailure of conservative management• Recurrence after conservative mgmt

Ti i f d b t bl– Timing of surgery debatable– Usually between 1 – 3 weeks

E li i t ti ith l l f d i• Earlier intervention with large volumes of drainage (>1Liter/day)

– Drainage >200 – 500ml/day– Drainage >200 – 500ml/day


Surgical OptionsSurgical Options

Mechanical PleurodesisPl tPleurectomy

Right SD Thoracic duct ligationPleuro-peritoneal shunting


Surgical OptionsSurgical Options

Christodoulou et al, Video –assisted right supradiaphragmatic thoracic duct ligation for non-traumatic recurrent chylothorax. EJCTS 2006;29:810-814


Right VATS TDLRight VATS, TDL

• Six patients with recurrent/persistentSix patients with recurrent/persistent chylothorax

• Mean operative time 102 min• Mean operative time – 102 min• No complications• Mean time of CT drainage 7 days• 90 day post-op morbidity – zeroy p p y• No recurrence after 41 month f/u (5/6)

Christodoulou et al, Video –assisted right supradiaphragmatic thoracic duct ligation for non-traumatic recurrent chylothorax. EJCTS 2006;29:810-814


Doc, is there a less invasive option?


TreatmentTreatment

• Percutaneous catheterizationPercutaneous catheterization– First described by Cope an colleagues in

19991999

– Hoffer and colleagues described a modifiedHoffer and colleagues described a modified technique in 2001

• 11 patients– 5 underwent embolization– 45% success rate– No morbidityNo morbidity


Hoffer et al, Treatment of Chylothorax: Percutaneous Catheterization of Embolization of the Thoracic Duct, AJR 2001;176:1040-2


SummarySummary

• Chylothorax rare but clinically devastatingChylothorax rare but clinically devastating entity with mortality rate as high as 50%

• Diagnosis made with presence of >110 TG• Diagnosis made with presence of >110 TG • Conservative management is initial

t t ttreatment• Surgical intervention after 1-3 weeks or

drainage >500-1000/day• Perc intervention…wave of the future


QuestionsQuestions…


This Weeks’ ACS QuestionsThis Weeks ACS Questions

1 A 62 YOF presents to the ER for evaluation of a productive cough She1. A 62 YOF presents to the ER for evaluation of a productive cough. She states that her coughing began 6 weeks ago and she has been worsening; it is now associated with bloody sputum. She feels well otherwise and denies having any recent fever or illness. Her medical history is significant g y y gfor a 40 pack-year history of smoking. The patient’s vital signs are normal. PE reveals course rhonchi throughout.

Which of the following radiographic studies is most recommended for the evaluation of the patient’s hemoptysis?

MRIa. MRIb. Chest CT with contrastc. Routine CXRd Ult dd. Ultrasound

Answer: B


This Weeks’ ACS QuestionsThis Weeks ACS Questions2. A 65 YOF in the ICU is experiencing the acute onset of bleeding at her

tracheal stoma site. Her tracheostomy tube has been in place for over 6 weeks. The bleeding worsens throughout the day. Bronchoscopy reveals a tracheoinnominate fistula.

Which of the following treatments is most recommended for this patients condition?

a. Stabilization with rigid bronchoscopy followed by fistula resectionb. Placement of a tracheobronchial stentc Bronchial biopsy to confirm diagnosisc. Bronchial biopsy to confirm diagnosisd. None of the above

Answer: AAnswer: A


This Weeks’ ACS QuestionsThis Weeks ACS Questions3. A 35 year old airline pilot has acute shortness of breath and on physical

examination he is found to have decreased breath sounds on the right side. CXR reveals a pneumothorax and a chest tube is placed.

Th t i t t iThe most appropriate management is

a. Serial CXRb Ch i l l d ib. Chemical pleurodesisc. Axillary thoracotomyd. VATS

P t i l t l th te. Posterior lateral thoracotomy

A DAnswer: D


This Weeks’ ACS QuestionsThis Weeks ACS Questions4. A 43 year old woman presents with a 2 day history of fever, shortness of breath

d h d ti f ll t O i ti h h d dand cough production of yellow sputum. On examination she has decreased breath sounds at base of left lung. CXR reveals opacification of the left diaphragm with a large pleural effusion. CT scan shows a well circumscribed pleural collection without loculation. Diagnostic thoracentesis yields frank pus with gram

ti b t i t inegative bacteria on gram stain.

Appropriate management would include IV antibiotics and a Needle drainagea. Needle drainageb. Ultrasound guided pigtailc. Bedside thoracostomyd. VATS decorticatione. Open decortication

A CAnswer: C


This Weeks’ ACS QuestionsThis Weeks ACS Questions5. Which of the following about lung cancer is true

a. Most common type of noncutaneous cancer in men and womenb. Most common cause of cancer death in men and womenc. Death reduced by 25% in smokers undergoing annual screening with CXRd Metastatic disease to regional or distant sites already present in one fourth ofd. Metastatic disease to regional or distant sites already present in one fourth of patientse. Overall 5 year survival rate 25%

Answer: B


The EndThe End


ReferencesReferenceswww.downstatesurgery.org

management ofofof chylothorax

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