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Eur J Cardiothorac Surg 2008;33:1159. doi:10.1016/j.ejcts.2008.03.029
Copyright © 2008, European Association for Cardio-thoracic Surgery. Published by Elsevier. All rights reserved.
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Letters to the Editor

Chylothorax revisited

Sameh Ibrahim Sersar*

Division of Cardiothoracic Surgery, Department of Cardiovascular Diseases, King Faisal Specialist Hospital and Research Center, MBC-J 16, PO Box 40047, Jeddah 21499, Saudi Arabia

Received 12 March 2008; accepted 23 March 2008.

* Corresponding author. Tel.: +966 2 667 7777x5234; fax: +966 2 6639581. (Email: Sameh001{at}yahoo.com).

Key Words: Chylothorax

We read with interest the article entitled A critical evaluation of a percutaneous diagnostic and treatment strategy for chylothorax after thoracic surgery [1].

We should congratulate the authors for this excellent work. We have a few comments. To explain why lymphangiogram could not demonstrate extravasation in some cases of chylothorax, we should remember that the lymphatic system includes cysterna chyli, thoracic duct, lymph glands, and lymphatic vessels. Significant variations to the lymph pattern can occur. Embryologically, the thoracic duct is a bilateral structure and hence many anatomical variations are possible. The usual pattern is true in only about 65% of the population. The thoracic duct duplicates or triplicates itself in more than 40% of the population. These branches may coalesce to form a plexus in the mid portion of the duct and end independently or as one duct. Infrequently, the upper portion of the thoracic duct divides into two branches that drain separately, one in the usual manner and the other reaching the right subclavian vein. This variation from the normal anatomical pattern explains the incidence of chyle leak despite care and attention the surgeon might have practiced in identifying and protecting the main thoracic duct during an operation such as oesophagectomy [2].

Damage to the thoracic duct is not the only mechanism of chylothorax after cardiothoracic procedures but also disruption of accessory lymphatics and an increased pressure in the systemic vein exceeding that in the thoracic duct have been proposed as possible causes of chylothorax after surgery for congenital heart disease [3].

For us, median chest tube drainage, median duration before and after percutaneous drainage is of minimal value. The e mean (not median) drainage, mean (not median) duration that are significant if the drainage is more than 200 ml/day for 2 weeks after NPo, TPN or median chain fatty diet.

References

  1. Boffa DJ, Sands MJ, Rice TW, Murthy SC, Mason DP, Geisinger MA, Blackstone EH. A critical evaluation of a percutaneous diagnostic and treatment strategy for chylothorax after thoracic surgery. Eur J Cardiothorac Surg 2008;33:435-439.[Abstract/Free Full Text]
  2. Nair SK, Petko M, Hayward MPS. Aetiology and management of chylothorax in adults. Eur J Cardiothorac Surg 2007;32:362-369.[Abstract/Free Full Text]
  3. Chan SY, Lau W, Wong WHS, Cheng, Chau AKT, Cheung YF. Chylothorax in children after congenital heart surgery. Ann Thorac Surg 2006;82:1650-1656.[Abstract/Free Full Text]



This article has been cited by other articles:


Home page
 Eur. J. Cardiothorac. Surg.Home page
T. W. Rice and E. H. Blackstone
Reply to Sersar * Chylothorax revisited and reassessed
Eur. J. Cardiothorac. Surg., June 1, 2008; 33(6): 1159 - 1160.
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