Question 10.2
A 75-year-old male is a patient in your ICU, day three following an elective oesophagectomy.
Examine the photograph provided.
a) What complication has occurred?
b) What is your management of this complication?
College Answer
a) Chylothorax secondary to thoracic duct damage.
NB: Both parts needed for whole mark.
b) Conservative management with drainage, octreotide and TPN. Surgical management with pleurodesis or thoracic duct ligation
Discussion
The picture abode is of a drain with chyle in it, which was not part of the original college paper. Indeed, nobody knows what precisely the college depicted in their version.
I have attempted to provide the candidate with a picture which has in it an unambiguously creamy opaque fluid, sitting in some obvious chest drain tubing.
And yes, chylothorax is a frequent complication of oesophagectomy.
Diagnosis of chylothorax:
- Lipoprotein content of pleural drain fluid
- Chylomicron content of pleural fluid
- Fasting test and fat challenge
- CT and lymphangiography may be helpful but practically speaking this could be difficult.
Management of chylothorax
- Low fat diet - or at least a diet rich in medium-chain triglycerides (hoping with reduced chyle flow the defect will close on its own)
- TPN may be required - but is not an essential part of management. If one were to use TPN, one may wish to use medium-chain fatty acids - i.e. anything with a chain length shorter than laurate (12 carbon atoms)
- It seems octreotide is an effective treatment option
- Surgical ligation is always an option, and some say it should be the first option.
References
Fahimi, Hossein, et al. "Current management of postoperative chylothorax." The Annals of thoracic surgery 71.2 (2001): 448-450.
Fujita, Takeo, and Hiroyuki Daiko. "Efficacy and Predictor of Octreotide Treatment for Postoperative Chylothorax After Thoracic Esophagectomy." World Journal of Surgery (2014): 1-7.
Seriff, NATHAN S., et al. "Chylothorax: diagnosis by lipoprotein electrophoresis of serum and pleural fluid." Thorax 32.1 (1977): 98-100.
Hillerdal, G. "Chylothorax and pseudochylothorax." European Respiratory Journal 10.5 (1997): 1157-1162.
Shah, Rachit D., et al. "Postesophagectomy chylothorax: incidence, risk factors, and outcomes." The Annals of thoracic surgery 93.3 (2012): 897-904.
Merigliano, Stefano, et al. "Chylothorax complicating esophagectomy for cancer: a plea for early thoracic duct ligation." The Journal of thoracic and cardiovascular surgery 119.3 (2000): 453-457.
Valentine, Vincent G., and Thomas A. Raffin. "The management of chylothorax." CHEST Journal 102.2 (1992): 586-591.
Nair, Sukumaran K., Matus Petko, and Martin P. Hayward. "Aetiology and management of chylothorax in adults." European journal of cardio-thoracic surgery 32.2 (2007): 362-369.
Hashim, Sami A., et al. "Treatment of chyluria and chylothorax with medium-chain triglyceride." New England Journal of Medicine 270.15 (1964): 756-761.