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Ann Thorac Surg 2001;71:450-451
© 2001 The Society of Thoracic Surgeons
a Department of Thoracic Surgery and Diseases of the Esophagus, Ste Marguerite University Hospital, 270 Bd Ste Marguerite, F-13274 Marseille, France
e-mail: pfuentes{at}mail.ap-hm.fr
Postoperative chylothorax remains an uncommon but potentially life-threatening complication of various intrathoracic procedures, and the ideal management of this condition is still controversial. Generally, so-called conservative therapy is tried first, and includes low-fat diet, total parenteral nutrition, and pleural drainage. Somatostatin and more recently Etilefrine [1], a sympathomimetic drug used in the management of postural hypotension, also causing smooth muscle contraction of the thoracic duct, have been reported as significant additives to this regimen. However, it usually takes several weeks for the chylothorax to resolve and it is almost always unsuccessful in patients with high flow leaks. Indeed, it has been clearly demonstrated that a high volume of chylous output could reliably predict the failure of continuing medical treatment [2]. The type of the initial operation is also predictive when the site and the mechanism of lymphatic vessels injury could be anticipated. As a matter of fact, chylothorax after radical esophagectomy for cancer is usually from direct injury to the thoracic duct, as it is also the case in those chylothoraces occurring after surgery of the thoracic aorta, and could hardly be managed without thoracic duct ligation [3]. Its incidence after pulmonary resection is low, but has increased recently as testified by the analysis of the medical literature, probably because of more extensive types of resections and radical lymph node dissections where high flow leaks may be encountered. Chylothorax is also emerging as a probably underestimated complication of coronary artery bypass grafting, especially when the left internal mammary artery is used, by reason of anatomical connection with the thoracic duct.
As impaired immune system and nutritional state tend to occur in those patients with the longest duration of drainage, reoperation, when performed as the last option, is logically associated with a high morbidity and mortality. The advent of video-assisted thoracic surgery has led the thoracic surgeon community to question the value of continuing medical treatment and to consider early reoperation via this minimally invasive approach in selected cases. To face the problem, the surgeon should satisfy two requisites: 1) to identify and control the chylous fistula, and 2) to obliterate the pleural space. The first issue is not always easy, particularly when dealing with multiple minor lymph channel leaks. Closure of the trunk of the thoracic duct may be undertaken, but a direct approach to the site of injury is more preferable, because the trunk may have collateral damage. Blind spraying of fibrin glue in the mediastinal region suspected for leakage is hazardous, thus emphasizing the need for an efficient pleurodesis. The method used should favor chemical pleurodesis or talc poudrage, and exclude pleural abrasion and pleurectomy, especially when a thoracic duct ligation has been performed. Indeed, the lymphatic collaterality involves the subpleural and intercostal lymphatic networks, the injury of which on the occasion of mechanical pleurodesis could lead to an intractable leak.
Fahimi and colleagues have to be commended for their valuable contribution to this topic. Their paper should be understood as a plea for an early reoperation in patients with this infrequent postoperative complication. I completely agree with the authors when they state that video-assisted thoracic surgery is certainly an interesting technical alternative to rethoracotomy, because these patients are unlikely to develop early pleural adhesions. In my opinion, however, their "2-week trial" offers few advantages in determining the therapeutic strategy for massive postoperative chylothorax (> 1,000 mL/day), where immediate reoperation should be undertaken to avoid needless loss of chyle and lengthy hospital stay. Finally, one should also emphasize the paramount importance of the prevention of potential chylous leaks at the time of original operation, especially in patients with malignancies.
References
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