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Eur J Cardiothorac Surg 2008;33:1159-1160. doi:10.1016/j.ejcts.2008.03.028
Copyright © 2008, European Association for Cardio-thoracic Surgery. Published by Elsevier. All rights reserved.
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Letters to the Editor

Reply to Sersar

Chylothorax revisited and reassessed

Thomas W. Ricea,*, Eugene H. Blackstonea,b

a Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Avenue/Desk F24, Cleveland, OH 44195, USA
b Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA

Received 20 March 2008; accepted 23 March 2008.

* Corresponding author. Tel.: +1 216 444 1921; fax: +1 216 445 3272. (Email: ricet{at}ccf.org).

Key Words: Chylothorax • Thoracic duct • Lymphatic system

We agree with Sersar [1] that the anatomy of the thoracic duct is highly variable. However, only if there are two parallel, isolated systems will lymphangiography that demonstrates the cisterna chyli fail to identify variable anatomy beyond this lymphatic terminus. Contrast is distributed distally in the lymphatic system flowing from high pressure to low pressure. Thus, intact thoracic lymphatic tributaries (feeder lymphatics) that empty into the thoracic duct will not be demonstrated by lymphangiography. However, retrograde flow in injured feeder lymphatics, driven by the pressure gradient between the thoracic duct and pleural space, will fill these tributaries with contrast. This was demonstrated in our series [2] by the patient with a thymic lymphatic leak, identified at lymphangiography. In its natural state, this thymic feeder lymphatic would not have been seen at lymphangiography; however, once injured, retrograde flow emptying into the pleural space was demonstrated. We believe the variable anatomy of the thoracic duct is probably not an explanation of why clinically suspected leaks were not demonstrated by lymphangiography, but rather resolution of the chylothorax by healing during the period of preparation for lymphangiography.

Injury to the lymphatic system, be it feeder lymphatic, thoracic duct, or one of its many anatomic variants, is the main cause of chylothorax in this surgical series. Yes other factors, such as increased lymph flow, altered lymphatic permeability, distal lymphatic obstruction, and venous occlusion, may complicate or aggravate surgical injury of the thoracic lymphatic system.

For any one patient, day-to-day clinical decisions can be made on total daily chest tube drainage. However, for summary statistics of this highly variable measurement (standard deviation > mean), the median, and not mean value, must be used.

References

  1. Sersar S. Chylothorax revisited. Eur J Cardiothorac Surg 2008;33:1159.[Free Full Text]
  2. 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]




This Article
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Thomas W. Rice
Eugene H. Blackstone
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Right arrow Articles by Blackstone, E. H.
Related Collections
Right arrow Mediastinum
Right arrow Pleura
Right arrow Congenital - cyanotic

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