With respect to chylothorax in the critically ill:
a) Define chylothorax. (10% marks)
b) Outline how it should be diagnosed. (40% marks)
c) Describe the principles of management. (50% marks)
Not available.
This question is virtually identical to Question 5 from the first paper of 2019, except in 2019 diagnosis and management were rolled together into one big question worth 90% of the marks. If one inspects the marking rubric from 2019, one will note that the marks are allocated in the same way.
a) The definition of chylothorax:
b) Diagnosis of chylothorax:
Diagnostic methods (from Maladonado et al, 2009):
c) Management of chylothorax from Bender et al (2015):
Conservative measures:
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)
Secretion inhibitors such as octreotide and somatostatin
Vasocosntrictrs, eg. etilefrine
Surgical options:
Thoracic duct ligation (just proximal to the aortic hiatus)
Talc pleurodesis
Percutaneous lymphography and embolisation
Pleuroperitoneal shunt - where, for whatever reason, thoracic duct ligation is impossible
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.
Maldonado, Fabien, et al. "Pleural fluid characteristics of chylothorax." Mayo Clinic Proceedings. Vol. 84. No. 2. Elsevier, 2009.
Light, Richard W., et al. "Pleural effusions: the diagnostic separation of transudates and exudates."Annals of Internal Medicine 77.4 (1972): 507-513.
McGrath, Emmet E., Zoe Blades, and Paul B. Anderson. "Chylothorax: aetiology, diagnosis and therapeutic options." Respiratory medicine 104.1 (2010): 1-8.
Shah, Rachit D., et al. "Postesophagectomy chylothorax: incidence, risk factors, and outcomes." The Annals of thoracic surgery 93.3 (2012): 897-904.
Ngan, H., M. Fok, and J. Wong. "The role of lymphography in chylothorax following thoracic surgery."The British journal of radiology 61.731 (1988): 1032-1036.
Buyukcelik, Mithat, et al. "An unusual cause of pleural effusion, urinothorax in a child with urinary stone disease." Pediatric Nephrology 20.10 (2005): 1487-1489.
Cellan-Jones, C. J., and William Murphy. "Traumatic chylothorax." British medical journal 2.4165 (1940): 590.
Watts, Stephen H. "Traumatic chylothorax." Annals of surgery74.6 (1921): 691.
Mishin, Igor, Gheorghe Ghidirim, and Marin Vozian. "Acute spontaneous chylous peritonitis: report of a case." Journal of Gastrointestinal & Liver Diseases 19.3 (2010).
Bender, Bradley, Vijayashree Murthy, and Ronald S. Chamberlain. "The changing management of chylothorax in the modern era." European Journal of Cardio-Thoracic Surgery 49.1 (2015): 18-24.
Guillem, Philippe, et al. "Etilefrine use in the management of post-operative chyle leaks in thoracic surgery." Interactive Cardiovascular and thoracic surgery 3.1 (2004): 156-160.
Itkin, Maxim, et al. "Nonoperative thoracic duct embolization for traumatic thoracic duct leak: experience in 109 patients." The Journal of thoracic and cardiovascular surgery 139.3 (2010): 584-590.