Tension chylothorax following pneumonectomy

Chylothorax: pathophysiology, diagnosis, and management-a comprehensive review

Chylothorax is a rare condition characterized by the accumulation of chyle in the pleural space. While it accounts for a small percentage of pleural effusions, chylothorax can lead to significant morbidity and mortality. This article provides a comprehensive overview of chylothorax, covering its relevant anatomy, aetiology, pathophysiology, clinical features, diagnosis, and management. Injury or disruption to the thoracic duct (which is responsible for chyle transport) leads to the development of chylothorax. This may result from trauma, such as iatrogenic injury during surgery, or non-traumatic causes, including malignancy, lymphatic disorders, and heart failure. Recognition of the underlying cause is essential to tailor management. Clinical presentation varies, with symptoms linked to rate of chyle accumulation and the causative condition. Diagnosis relies on pleural fluid analysis, with demonstration of elevated triglyceride levels (>110 mg/dL) and reduced cholesterol levels (<200 mg/dL) being the key diagnostic criteria employed in clinical practice. Various imaging modalities, including computed tomography (CT) scans and lymphatic-specific investigations, may be utilised to aid identification of the site of chyle leak, as well as determine the likely underlying cause. Chylothorax management is multifaceted, with conservative approaches such as dietary modification and pharmacological interventions often initiated as first-line treatment. Drainage of chylous effusion may be necessary for symptom relief. When conservative methods fail, interventional procedures like thoracic duct ligation or embolization can be considered. Due to the diverse aetiological factors and patient characteristics associated with chylothorax, individualized management strategies are recommended. Nonetheless, management of chylothorax is an evolving field with a paucity of high-quality evidence or standardized guidelines, highlighting the importance of ongoing research and a multidisciplinary approach to optimize individual patient care.

Tensioned space after pneumonectomy for cancer with mediastinal shift and cardiac tamponade‑causes and treatment (Review)

Regarding the pleural space after pneumonectomy for malignancy, a vast number of studies have assessed early drop in the fluid level, suggesting a broncho-pleural fistula, but only a small number of studies reported on the abnormal increase in the fluid level-a potentially lethal complication. In the present study, the available databases worldwide were screened and 19 cases were retrieved, including 14 chylothorax and 3 hydrothorax cases, 1 pneumothorax and 1 haemothorax case. Tension chylothorax is caused by mediastinal lymph node dissection as an assumed risk in radical cancer surgery. For tensioned haemothorax, the cause has not been elucidated, although lymphatic stasis associated with deep venous thrombosis was suspected. Tensioned pneumothorax was caused by chest wall damage after extrapleural pneumonectomy combined with low aspiration pressure on the chest drain. No cause was determined for none of the tensioned hydrothorax-all 3 cases had the scenario of pericardial resection in addition to pneumonectomy in common. Tensioned space after pneumonectomy for cancer manifests as cardiac tamponade. Initial management is emergent decompression of the heart and mediastinum. Final management depends on the fluid type (chyle, transudate, air, blood) and the medical context of each case. Of the 19 cases, 12 required a major surgical procedure as the definitive management.

Differential diagnosis of chylothorax in therapeutic practice

The article is devoted to the differential diagnosis of chylous pleural effusion. The spectrum of traumatic and non-traumatic causes of chylothorax is discussed in detail. Examples of necessary diagnostic measures are given for the accumulation of milky fluid in the pleural cavity in order to verify chylothorax.

[What is Result: Short-term Medium Chain Triglyceride Diet Effective on Postoperative Outcome in Lung Cancer Surgery? A Prospective Randomized Study]

背景与目的

中链甘油三酯(medium chain triglyceride, MCT)饮食有助于外科手术患者快速康复，本研究将短期MCT食谱应用于肺癌患者术后早期饮食，探讨肺癌患者术后应用MCT的临床效果。

方法

2015年12月-2016年3月四川大学华西胸外科单个医疗组肺癌切除术患者纳入研究患者117例，随机分为MCT组(62例)和常规饮食组(routine diet group, RDG)(55例)。分析两组患者术后白蛋白、肛门排气时间、胸腔闭式引流量及胸腔闭式引流管留置时间、术后住院日、住院费用。

结果

MCT组患者术后肛门排气时间[(27.87±14.38) h]短于RDG组[(45.18±8.62) h](P < 0.001)；术后胸腔引流管留置时间在MCT组[(75.40±48.41) h]少于RDG组[(110.64±94.19) h](P=0.025)；术后胸腔引流量在MCT[395mL]组少于RDG组[590mL](P=0.027)。术后住院日在MCT组[(5.26±2.96) d)]短于RDG组[(6.73±3.99) d](P=0.030)。血浆白蛋白术后MCT组[(37.26±2.70) g/L]高于RDG组[(35.92±3.12) g/L](P=0.023)。

结论

肺癌患者术后短期应用MCT饮食有助于改善胃肠功能快速恢复，且缩短术后住院时间。

[Chylothorax in practice of thoracic and cardiovascular surgeon]

AIM

to improve the results and current pathogenetic treatment of chylorrhea.

MATERIAL AND METHODS

Thirty seven patients with chylothorax have been treated for the period 2004-2014. In 34 cases traumatic chylothorax developed after surgery and in 3 cases - after intensive care for therapeutic diseases and great veins catheterization. Chylothorax was predominantly diagnosed by X-ray method. Herewith, hydrothorax was established and its nature was defined using laboratory survey. Presence of neutral fat in pleural drainage is the sign of chylothorax. Pathogenetic treatment was often delayed (up to 4.5 months) due to poor awareness of physicians about this pathological process. 6 patients underwent thoracic duct ligation above diaphragm due to ineffective therapy.

RESULTS

Medical therapy had good clinical effect in 83.8% of cases. Postoperatively 1 patient died for single lung inflammation on background of postoperative chylothorax after right-sided pneumonectomy. In other cases chylothora was eliminated with no recurrence in remote postoperative period. It is difficult to recognize injury of thoracic duct or its great branches during surgery. In these cases prolonged thoracic duct ligation above diaphragm is indicated.