Eur J Cardiothorac Surg 2005;27:153-155
© 2005 Elsevier Science NL
VATS thoracic-duct division for aortic surgery-related chylous leakage
Toshiya Ohtsukaa,*,
Mikio Ninomiyaa,
Jotaroh Kobayashib,
Yukihiro Kanekob
a Department of Cardiovascular Surgery, Tokyo Metropolitan Fuchu General Hospital, 2-9-2 Musashidai, Fuchu-shi, Tokyo 183-0042, Japan
b Japanese Red Cross Medical Center, Tokyo, Japan
Received 29 July 2004;
received in revised form 9 September 2004;
accepted 17 September 2004.
* Corresponding author. Tel.: +81 42 323 5111; fax: +81 42 323 9209. (E-mail: ootsuka-cvs{at}fuchu-hp.fuchu.tokyo.jp).
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Abstract
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Traumatic chylothorax is a serious morbidity due to aortic surgery. We treated this complication successfully by supradiaphragmatic thoracic-duct division in five adults (three men, two women, aged 61.5±19.5 years) and a 3-year-old male infant after an average interval of 4.1±1.8 days following initial aortic surgery: graft-replacement of subclavian or descending aortic aneurysm in the adults, and correction of aortic coarctation in the infant. A right thoracoscopic approach was used in the adults and the left thoracotomy was re-used in the infant. Individual exposure and division of the thoracic duct was accomplished using an ultrasonic coagulator. The operating time was 22±5.5min for the thoracoscopy cases, and 70min for the infant. There was no mortality and no procedure-related morbidity, and chylous leakage ceased immediately in all patients. There was no recurrence of chylothorax during a mean follow-up period of 17±9.7 months. Despite our limited experience, we conclude that the present supradiaphragmatic thoracic duct division technique (right thoracoscopy in adults) is safe and perfectly effective, and therefore prompt application of this method is recommendable for treatment of aortic surgery-related traumatic chylo-leakage, particularly in vulnerable elderly or infant patients.
Key Words: Chylothorax • Thoracic duct • Aortic surgery • Thoracoscopy
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1. Introduction
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Persistent chylous leakage is an uncommon but serious morbidity associated with aortic surgery [1]. Conservative management of traumatic chylo-leakage is rarely successful, and surgical treatment is therefore necessary in most cases. We have carried out supradiaphragmatic thoracic-duct division in six patients who developed chylothorax after aortic surgery. This communication describes the method employed and discusses the results obtained.
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2. Patients and aortic surgery
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Between January 2000 and June 2004, five adults and one infant were treated at four different institutions. The incidence was 1.25% in all thoracic aortic surgery cases. The adult patients comprised three men and two women, with a mean age of 61.5±19.5 years. Three patients had an aneurysm of the distal arch involving the left subclavian artery, and two had a descending aortic aneurysm. All underwent replacement of the distal arch or descending aorta with a Dacron graft with reconstruction of the left subclavian or intercostal arteries. The infant was a 3-year-old, 13-kg male, who underwent correction of aortic coarctation. Each operation was performed via a left thoracotomy at the fourth or fifth intercostal space. In each patient, immediately after aortic surgery, there was a copious amount of chylous discharge from the left chest drainage tube, and this was aggravated by oral nutrition; the daily volume of discharge exceeded 1500ml in adults, and was about 1000ml in the infant. Oral intake was therefore withdrawn and total parenteral nutrition was implemented in each case.
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3. Supradiaphragmatic thoracic duct division
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Supradiaphragmatic thoracic duct division was carried out by a single surgeon after a mean interval of 4.1±1.8 days (range 2–6 days) following the prior aortic operations. Preoperative lymphangiography was not used in each case.
In the five adult patients, a right thoracoscopic approach was used. In each case, heavy cream was administered via a naso-gastric tube, the patient was placed in left lateral recumbency, and general anesthesia was induced via a double-lumen endotracheal tube. Three ports were created in the lower lateral intercostal spaces (the six or seventh level): the first port for a rigid 5-mm scope, and the second and third ports, posterior to the first one, for working instruments. Under right pulmonary collapse, the thoracic duct was exposed between the azygos vein and the aorta at the diaphragmatic hiatus (Fig. 1), and then it was clip-ligated and divided (Fig. 2). All dissecting and dividing maneuvers were achieved exclusively with an ultrasonic coagulator (Fig. 1) [2]. No new chest tube was placed.
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Fig. 1. Thoracoscopic view of ultrasonic coagulator (arrow) dissecting the thoracic duct near the the azygos vein (arrowheads), which is an important landmark. D; Diaphragm.
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In the infant, the left thoracotomy was re-opened. Despite enhancement of the chylo-discharge with heavy cream, the fistula was not identified. Therefore, the thoracic duct was exposed, ligated, and divided at the right side of the descending aorta.
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4. Results
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There was no mortality and no procedure-related morbidity. The operating time was 22±5.5min (range 18–29min) in the thoracoscopic cases, and 70min in the infant. In all patients, chylous leakage through the left drainage tube ceased immediately. Oral nutrition was therefore restarted, and the drainage tube was removed on the first or second postoperative day in all cases. There was no recurrence of chylothorax in any of the patients during a mean follow-up period of 17±9.7 months.
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5. Comments
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In most operations for aortic disease, the right pleural cavity is untouched. Therefore, in our patient series, right thoracoscopic approach was used safely. In the infant, where the chest cavity was small, the previous left thoracotomy was re-used. Unlike the case in adults, the infant's posterior mediastinal tissue was very thin, allowing the thoracic duct to be easily detected supradiaphragmatically on the right side of the aorta.
To eliminate chylothorax, which is a serious postoperative complication, a 100% success rate is imperative in the relief operation. Although we observed no anomaly in the present patients, and the reported incidence is low, an accessory duct may be present beside the main one [3]. Therefore, we prefer ‘individual exposure and division’ of the duct to a simple mass-ligation technique. In the present cases, the expanded thoracic duct, filled with heavy milk, was easily identified thoracoscopically, and the divided duct was able to be confirmed by observing its tubular appearance (Fig. 2). The thick vagal nerve looks similar and may be cut in error, but it is not tubular. In patients with descending aortic aneurysm, the supradiaphragmatic mediastinal tissue was significantly swollen and shifted to the right side. Despite this pathology, the azygos vein, which is an important landmark close to the duct, was clearly identified (Fig. 1), and this allowed the duct to be located without difficulty.
As chylothorax is rare after cardiovascular surgery (incidence 0.6–0.8%) [1], conservative management for a week or two may be selected in most patients, as noted in textbooks [4]. Talc pleurodesis, percutaneous embolization, and parenteral octreotide in infants [5] are used in the selected patients. Although limited in extent, our experience suggests that the present technique (right thoracoscopy in adults) can be performed safely and quickly for aortic surgery-related traumatic chylo-leakage, and that it is perfectly effective. Thus, more prompt surgical management using the present method may be recommendable [6–8], particularly in elderly or infant patients who are vulnerable and cannot tolerate prolonged chylous leakage.
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References
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- LoCicero J. Benign and malignant disorders of the pleura. In: Baue AE, Geha AS, Hammond GL, Laks H, Nauheim KS, editors. Glenn's thoracic and cardiovascular surgery. Stamford, CT: Appleton and Lange; 1996. pp. 537-555.
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Abstract
1. Introduction
