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Objectives: Prolonged pleural effusion/chylothorax (PPE/C) is a less investigated complication following paediatric cardiac surgery, and its true incidence, risk factors and impact on postoperative outcomes are not well described. We aim to address these gaps in knowledge using data from a prospective, multicentre study., Methods: Data on 9 post-operative morbidities (unplanned reinterventions, extracorporeal life support, necrotising enterocolitis, PPE/C, renal replacement therapy, major adverse events, acute neurological events, feeding issues and postsurgical infection) were prospectively collected at 5 UK centres between 2015 and 2017, following paediatric cardiac surgery. Incidence of PPE/C, associations with procedure types, and risk factors were described. Mortality (30-day and 6-month) and hospital length of stay (HLoS) were compared between those with isolated PPE/C, single non-PPE/C morbidity, no morbidity, multimorbidity PPE/C and non-PPE/C multimorbidity., Results: A total of 3090 procedures (2861 patients) were included (median age, 228 days). There were 202 PPE/C (incidence of 6.5%), occurring at a median of 6 days postoperatively (interquartile range: 3-10). PPE/C was associated with excess early mortality only when complicating scenarios where at least 2 other post-operative morbidities occurred. On average PPE/C is associated with 8 more HLoS days, but the relative impact is greatest when comparing isolated PPE/C with no morbidity (P < 0.001), whereas in multimorbidity scenarios, PPE/C does not significantly contribute to an increase of HLoS., Conclusions: Addition of PPE/C increases mortality but not HLoS in multimorbidity and HLoS only in single morbidity scenarios. This reinforces the important role of prevention, early detection and management of PPE/C in complex situations., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

The use of octreotide in managing intrathoracic chyle leak following esophagectomy has gained popularity in the adult population. While the benefits of octreotide have been confirmed in the pediatric population, there remains limited evidence to support its use in the adults post-esophagectomy. Thus, we performed a single-institution cohort study to characterize its efficacy. The study was performed using a prospective, single-center database, from which clinicopathologic characteristics were extracted of patients who had post-esophagectomy chyle leaks. Kaplan-Meier and multivariable Cox regression analyses were performed to investigate the effect of octreotide use on chest tube duration (CTD), hospital length of stay (LOS), and overall survival (OS). In our cohort, 74 patients met inclusion criteria, among whom 27 (36.5%) received octreotide. Kaplan-Meier revealed no significant effect of octreotide on CTD (P = 0.890), LOS (P = 0.740), or OS (P = 0.570). Multivariable Cox regression analyses further corroborated that octreotide had no effect on CTD (HR = 0.62, 95% confidence interval [CI]: 0.32-1.20, P = 0.155), LOS (HR = 0.64, CI: 0.34-1.21, P = 0.168), or OS (1.08, CI: 0.53-2.19, P = 0.833). Octreotide use in adult patients with chyle leak following esophagectomy lacks evidence of association with meaningful clinical outcomes. Level 1 evidence is needed prior to further consideration in this population., (© The Author(s) 2024. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objectives: Effects of aortopulmonary collaterals (APCs) on outcomes after the total cavopulmonary connection (TCPC) are unclear. This study evaluated the incidence of APCs before and after TCPC and analysed the impacts of APCs on adverse outcomes., Methods: A total of 585 patients, who underwent TCPC from 1994 to 2020 and whose preoperative angiographies were available, were included. Pre-TCPC angiograms in all patients were used for the detection of APCs, and post-TCPC angiograms were evaluated in selected patients. Late adverse events included late death, protein-losing enteropathy (PLE) and plastic bronchitis (PB)., Results: The median age at TCPC was 2.3 (1.8-3.4) years with a body weight of 12 (11-14) kg. APCs were found in 210 patients (36%) before TCPC and in 81 (14%) after TCPC. The closure of APCs was performed in 59 patients (10%) before TCPC, in 25 (4.2%) at TCPC and in 59 (10%) after TCPC. The occurrences of APCs before and after TCPC were not associated with short-term or mid-term mortality. The APCs before TCPC were associated with chylothorax (P = 0.025), prolonged chest tube duration (P = 0.021) and PB (P = 0.008). The APCs after TCPC were associated with PLE (P < 0.001) and PB (P < 0.001). With APCs following TCPC, freedom from PLE and PB was lower than without (P < 0.001, P < 0.001)., Conclusions: APCs before TCPC were associated with chylothorax, prolonged chest tube duration and PB. APCs after TCPC were associated with both PLE and PB. The presence of APCs might affect the lymph drainage system and increase the incidence of chylothorax, PLE and PB., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Context: Chylothorax is a well-established acquired complication of thoracic surgery in infants. Current data suggest acquired chylothorax may affect infant growth and nutrition because of a loss of essential nutrients via chylous effusion., Objective: The 3 objectives for this study were: (1) identify nutritional markers affected by the development of acquired chylothorax in infants; (2) highlight the variability in methods used to assess nutritional status and growth in this patient population; and (3) highlight nutritional deficits that can serve as treatment targets during postoperative feeding protocols., Data Sources: A systematic literature search was conducted between May 31, 2021, and June 21, 2022, using the PubMed, Embase, CINAHL, and Web of Science databases. Search terms included, but were not limited to, "chylothorax," "infants," and "nutrition.", Data Extraction: Inclusion criteria required studies that measured quantitative markers of nutrition in ≥10 participants aged <1 year with acquired chylothorax. A total of 575 studies were screened and all but 4 were eliminated. Nutritional markers were categorized into 4 different groups: total serum protein level, triglyceride levels, growth velocity, and weight for length., Data Analysis: The variation in methods, time points, interventional groups, and nutritional markers did not facilitate a meta-analysis. Risk of bias was assessed using the Cochrane Risk of Bias in Nonrandomized Studies assessment tool., Conclusion: This review highlights the need for reliable quantitative markers of nutrition that will enable providers to assess the nutritional needs of infants with chylothorax. Future studies must focus on measuring markers of nutrition at regular intervals in larger study populations., (© The Author(s) 2023. Published by Oxford University Press on behalf of the International Life Sciences Institute. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Chylothorax is an important complication after esophagectomy. Ligation of the injured thoracic duct is the main method to prevent chylothorax after esophagectomy, but may be associated with adverse effects. Whether ligation of the injured tributary alone, keeping the main trunk intact, may suffice to prevent post-operative chylothorax is not well known. Since March 2017, 40 mL of olive oil was administered to patients posted for esophagectomy. We compared patients admitted between March 2017 and December 2019 with patients admitted between July 2014 and February 2017, who had not received pre-operative oil. The outcome measures were the need for thoracic duct main trunk or tributary ligation, development of chylothorax and missed ligation. There were 371 patients in the oil ingestion group and 308 patients in the standard control group. Chylothorax in the oil ingestion group was significantly lower than that in the standard control group (1.3% vs. 4.5%, P = 0.012). Chyle leak from thoracic duct tributaries was diagnosed in a significantly higher percentage (5.7% vs. 0.0%, P < 0.001) and missed ligation of the injured thoracic duct was significantly lower (0.3% vs. 3.9%, P = 0.002) in the oil ingestion group compared with the standard control group. The incidence of post-operative chylothorax was not statistically different (6.3% vs. 10.0%, P = 1.000) between the tributary and the trunk ligation group. Pre-operative oil ingestion can help visualize the thoracic duct trunk and its tributaries during esophagectomy. Thus, non-selected thoracic duct trunk ligation and missed ligation during esophagectomy can be reduced. Precise ligation of the injured tributary while the main trunk is intact can also prevent post-operative chylothorax., (© The Author(s) 2022. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Chylothorax is a serious complication after esophagectomy and there are unmet needs for new intraoperative navigation tools to reduce its incidence. The aim of this study is to explore the feasibility and effectiveness of near-infrared fluorescence imaging (NIR-FI) with indocyanine green (ICG) to identify thoracic ducts (TDs) and chyle leakage during video-assisted thoracoscopic esophagectomy. We recruited 41 patients who underwent thoraco-laparoscopic minimally invasive esophagectomy (MIE) for esophageal cancer in this prospective, open-label, single-arm clinical trial. ICG was injected into the right inguinal region before operations, after which TD anatomy and potential chyle leakage were checked under the near-infrared fluorescence intraoperatively. In 38 of 41 patients (92.7%) using NIR-FI, TDs were visible in high contrast. The mean signal-to-background ratio (SBR) value of all fluorescent TDs was 3.05 ± 1.56. Fluorescence imaging of TDs could be detected 0.5 hours after ICG injection and last up to 3 hours with an acceptable SBR value. The optimal observation time window is from about 1 to 2 hours after ICG injection. Under the guidance of real-time NIR-FI, three patients were found to have chylous leakage and the selective TD ligations were performed intraoperatively. No patient had postoperative chylothorax. NIR-FI with ICG can provide highly sensitive and real-time assessment of TDs as well as determine the source of chyle leakage, which might help reduce TD injury and direct selective TD ligation. It could be a promising navigation tool to reduce the incidence of chylothorax after minimally invasive esophagectomy., (© The Author(s) 2022. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Isolated Chylopericardium (without chylothorax) is a rare clinical disorder that may happen idiopathically or secondary to trauma, radiotherapy, lymphatic anomalies, infections or mediastinal neoplasm. We present a case of middle-aged male with no past medical history of note prior to developing heavy sweating, loss of weight and cough. A series of investigations were done including chest computed tomography which showed enlarged mediastinal lymph nodes leading to uncomplicated mediastinoscopy and lymph node biopsy. Six days after being discharged, he developed dyspnoea and chest pain. Echocardiography revealed massive pericardial effusion. Pericardiocentesis was done and surprisingly revealed milky white chylous fluid. The patient was then successfully managed without the need for further intervention., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was how efficacious are Octreotide and Somatostatin in the management of chylothorax in congenital cardiac surgical patients. Altogether >55 papers were found using the reported search, of which 8 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The comparative data on LOS and chylothorax duration are mixed though interpretation is difficult since Octreotide has been instituted belatedly from the onset of chylothorax in multiple instances. There is also preliminary evidence to suggest that responders to Somatostatin and Octreotide are affected by single-ventricle physiology and CVP levels. Meanwhile, non-responders tend to have higher mortality and may merit earlier surgical intervention. The included studies thus far have significant limitations such as low-level evidence study design, selection bias, variability in duration and dosage of therapy and heterogenous comparative arms. Notwithstanding these limitations, Octreotide has shown to be an useful adjunct treatment in reducing chylothorax volume especially in patients with higher output chylothorax (>40 ml/kg/h) after the failure of conservative management., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Both postoperative and spontaneous chylothorax remain therapeutic challenges without recommendations for a standardized treatment approach. Regardless of its aetiology, patients with chylothorax experience prolonged hospitalization and suffer from the associated complications or the invasive therapy administered., Methods: We conducted a retrospective, observational review of adult patients with chylothorax treated between January 2010 and September 2019. The primary end point was successful management with sustained cessation and/or controlled chylous output. Therapy duration, inpatient stay and the incidence of complications were evaluated as secondary end points., Results: Of the 36 patients included (22 men; median age 63 years), 24 patients (67%) suffered from a postoperative accumulation of chylous fluid in the pleural space; in the remaining 12 (33%) patients, chylothoraces occurred spontaneously. Initial conservative treatment was successful in 42% (n = 15); in the other 20 cases (56%) additional invasive therapeutic strategies were followed. A complicated course requiring more than 1 treatment was seen in 54% (n = 13) of the postoperative and in 58% (n = 7) of the spontaneous cases. The median length of hospitalization was significantly longer in the postoperative group (37.5 vs 15.5 days; P = 0.016). Serious complications were observed only in the postoperative group (P = 0.28). There were no in-hospital deaths., Conclusions: Basic treatment of both postoperative and spontaneous chylothorax should include dietary measures in all patients. Additional sclerosing radiotherapy and interventional or surgical therapy are often necessary. The choice of therapeutic approach should be indicated, depending on the aetiology and development of the chylothorax. Early, multimodal treatment is recommended., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Chylothorax is leakage of lymphatic fluid accumulating in the pleural cavity due to the thoracic duct's (TD) trauma or obstructions. It generally occurs as a traumatic complication after general thoracic surgery procedures (0.4%), especially after esophagectomy (4.7-8.6%). Traditionally, surgical intervention is performed if conservative management fails, but reports of high mortality (2.1%) and morbidity (38%) have led to the development of a minimally invasive percutaneous treatment method; TD embolization (TDE). The records of all patients treated for chylothorax with TDE from April 2015 to June 2019 were reviewed. Only patients with iatrogenic chylothorax were included. The outcomes measures are defined as a technical and a clinical success. A technical success, is defined as the ability to perform the embolization procedure, thereby injecting embolizing material Histoacryl with or without coils. A clinical success is defined as a complete cessation of lymphatic leakage into the pleural cavity without surgical intervention and, therefore, a cured patient. Lymphography was performed in all patients, and visualization of cisterna chyli was achieved in 14/17 patients (82.4%). Of the 17 patients included, 15 patients were successfully embolized and cured of chylothorax (88.2%). Successfully embolized patients had a median discharge time of 7 days. Most patients reported postprocedural pain, which was dealt with using conventional pain medication. TDE seems like a safe percutaneous treatment technique with a high clinical success rate in iatrogenic chylothorax patients which can be readily implemented if the clinical experience is available.., (© The Author(s) 2021. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objectives: The postoperative persistence of chylothorax is a fatal complication of paediatric cardiac surgery. There is an urgent need for an effective treatment of chylothorax. This study reports the application of allogenic platelet-rich plasma fibrin glue (PRP-FG) as a conservative therapy before reoperation., Methods: Over a 9-year period, from 2010 to 2019, 27 patients with persistent chylothorax following a cavopulmonary connection, with a mean latency period of 11 days (range 10-15 days), were treated with PRP-FG. These patients were selected because they had not responded positively to initial conservative management plans. The patients were followed up for 9 years., Results: Twenty-five patients (92%) responded positively to treatment with PRP-FG; 2 patients did not respond to the treatment and died after reoperation. All of the successfully treated patients in follow-up continued to live a healthy life without further complications., Conclusions: Recalcitrant chylothorax that persists after paediatric cardiac surgery responded positively to treatment with PRP-FG. This technique precluded the need for another operation and significantly decreased the morbidity and mortality rates., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Ruptured thoracic duct cysts are an extremely rare occurrence that may arise spontaneously or due to trauma. Surgical treatment is needed to provide a definitive diagnosis, drain the chylothorax and ligate the thoracic duct to prevent reoccurrence. We report the case of a woman with a ruptured thoracic duct cyst presenting with abdominal pain and subsequent tension chylothorax. To the best of our knowledge, this is the first such reported case., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Herein, we report the case of a patient with persistent postoperative chylothorax despite right supradiaphragmal ligation of the thoracic duct. Computed tomography lymphangiography after lipiodol injection demonstrated a correctly ligated right thoracic duct but an anatomical variation with patent left-sided thoracic duct, which was successfully ligated afterwards by video-assisted thoracic surgery., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Lymphatic malformations are benign focal proliferations of lymphatic vessels with a congenital origin. We present a case of an 18-year-old patient with post-traumatic chylopericardium and recurrent left-sided chylothorax, who was unresponsive to a variety of therapeutic measures until he was diagnosed with a complicated thoracic lymphatic malformation., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Competing Interests: Competing interests: None declared.

Thoracic duct ligation is a widely accepted treatment option for chylothorax. This case report describes another treatment approach for recurrent chylothoraxes after thoracic duct ligation. A 40-year-old woman had chylothoraxes after thoracic duct ligation. She underwent a secondary surgery to ligate the thoracic duct. Three days later, the number of chylothoraxes increased compared with presurgery, and we anastomosed the thoracic duct and azygos vein after releasing the thoracic duct ligation. The patient recovered smoothly and was followed up for 2 years. This case shows that anastomosis of the thoracic duct and azygos vein is an alternative surgical approach to treat recurrent chylothoraxes.

Initial conservative therapy is applied to all cases of chylothorax (CTx) with expected excellent outcomes. The indication for aggressive surgical treatment of early CTx remains uncertain and requires rigorous scientific scrutiny. Lymphangiography and lymphoscintigraphy are useful to localize the leak and assess thoracic duct patency as well as to differentiate partial from complete thoracic duct transection. The aetiology of the CTx, flow rate and patient condition dictate the preferred management. Octreotide/somatostatin and etilefrine therapy is highly efficacious in the conservative management of CTx. For patients in whom conservative management fails, those who are good surgical candidates, and those in whom the site of the leak is well identified, surgical repair and/or ligation using minimally invasive techniques is highly successful with limited adverse outcomes. Similarly, if the site of the chylous effusion cannot be well visualized, a thoracic duct ligation via video-assisted thoracic surgery is the gold standard approach. A pleuroperitoneal or less often a pleurovenous shunt is a final option and may be curative in some patients., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Extra-hepatic manifestations have seldom been described with hepatitis A, which usually manifests as mild hepatic dysfunction. We report a 3-year-old boy presenting with 3 days of fever, vomiting, abdominal distention and scleral icterus. On examination, he had tachypnea, hepatosplenomegaly, ascites and right-sided pleural effusion. A diagnostic pleural tap yielded a milky, lymphocyte-predominant exudative aspirate, with pleural fluid triglycerides of 175 mg/dl, suggestive of chylothorax. Serology for anti-HAV IgM was positive in both blood and pleural fluid. The massive effusion causing collapse of the underlying lung was drained by tube thoracostomy, which was followed by complete resolution within 2 weeks. This is the first reported case of chylothorax associated with hepatitis A infection. This report highlights that pleural effusion associated with hepatitis A infection is usually a benign, self-limiting condition which should be considered in the differential diagnosis of pleural effusion or chylothorax in a patient with acute viral hepatitis., (© The Author [2015]. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was 'Is octreotide (a long-acting somatostatin analogue) effective in patients with post-operative or traumatic chylothorax as a part of conservative management to reduce lymphorrhagia?' Altogether 180 papers were found using the reported search, of which 20 represented the best evidence to answer the clinical question. One case was reported twice and therefore was excluded, leaving us with 19 papers. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Although rare, iatrogenic and traumatic chylothorax have been well described in the literature. At present, there have been no randomized controlled clinical trials on the use of octreotide in chylothorax. Sixteen of 19 papers found octreotide to be effective in the treatment of chylothorax. Octreotide was found to have no complementary effect in three reports. Two of the papers were retrospective studies: one a randomized controlled trial in canines, and the remainder were case reports and case series. The two retrospective studies showed a success rate of 87-90% in the use of octreotide as an adjunct to conservative management for the treatment of chylothorax and hence preventing the need for further surgery. Experimental study in canines has shown significant drain reduction and earlier fistula closure, although transferability of this result to human is difficult to interpret. Twelve case reports found octreotide effective in reduction of the volume and arrest of chylothorax. Most reported benefit in 2-3 days of administration of octreotide. The general consensus is for conservative management with octreotide to be instituted for 1 week before consideration of surgery, although some authors have advocated for a large volume chylothorax, especially after oesophageal surgery with no response to conservative management with octreotide, to be operated on sooner. We concluded that octreotide is effective in the management of moderate to large volume chylothorax., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

A best evidence topic in surgery was written according to a structured protocol. The question addressed was whether the initial surgical management of chylothorax after oesophagectomy results in a better outcome. Altogether 357 papers were found as a result of the reported search, of which 4 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers were tabulated. Three studies were retrospective and from single centres with small patient numbers, while one study was a prospective, randomized controlled trial, from which a subgroup analysis was included in our results. We conclude that although all studies to date have had very small patient numbers and some contradictory results, there is some evidence that early surgical intervention of chylothorax following oesophagectomy reduces hospital stay when compared with conservative treatment., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

An 82-year-old male was hospitalised for dyspnoea, hypoxaemia and general fatigue; a predominant left chylothorax was revealed. Previously, he had been diagnosed with Waldenström's macroglobulinaemia (WM). Chylothorax complications in patients with WM are rare events and only six such cases have so far been reported. The most common malignant causes of chylothorax are through mediastinal adenopathy. Direct infiltration of the pleura by tumour cells is the most likely cause with this patient, and for this reason, we believe that this case is an instructive one. Chemotherapy induced rapid and persistent improvement after 10-month follow-up., (© The Author 2014. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Objectives: Although video-assisted thoracoscopic surgery (VATS) is widely used for the resection of a mediastinal mass, it is converted to an open resection in some patients with a mature teratoma because of dense adhesions. We reviewed cases with a mature teratoma removed by VATS and investigated the indications for that procedure for this tumour., Methods: We retrospectively investigated 15 patients with a benign mediastinal mature teratoma who underwent a thoracoscopic procedure., Results: The mean tumour diameter was 5.3 cm (range 3.2-8.5). The mean operative time was 188 min (78-430), and intraoperative blood loss was 138 ml (10-450). Thoracoscopic resection was completed in all except 3 patients with larger tumours, which presented the most difficult problems with dissection. Each of those 3 had severe preoperative chest pain and a tumour larger than 5.5 cm. No mortality or postoperative complications were recorded, except for postoperative chylothorax. Tumour recurrence did not develop in any patient during the mean follow-up period of 4.6 years., Conclusions: For selected patients with a mediastinal teratoma, VATS may be considered standard care, as most are benign. In contrast, an open approach may be more appropriate for patients with a large tumour or preoperative symptoms.

No conservative treatments for chylothorax have yet been established, and surgical ligation of the thoracic duct is required in many cases. In the present study, we investigated the management of body fluid in a canine chylothorax model. Twelve beagle dogs were divided evenly into three groups: A, B, and C. Under general anesthesia, the thoracic duct was cut and opened, and the amount of lymph fluid leakage was measured. Intravenous extracellular fluid infusion was started at 5mL/kg/h for the first 2h, and then between 2 and 4h, the infusion rate was increased to 10 mL/kg/h in group A and to 20mL/kg/h in group B. During the first 2h after cutting the thoracic duct, the mean lymph fluid leakage rates in groups A, B, and C were 0.466, 0.635, and 0.575 mL/kg/h, respectively. The rates of leakage did not differ significantly among the groups. Between 2 and 4h, the mean rates of leakage were 0.750, 1.43, and 0.544mL/kg/h, respectively, being significantly higher in groups A and B than in group C. The amount of lymph fluid ascending the thoracic duct correlates with the amount of intravenous fluid infusion. For the management of chylothorax, it is important to avoid fluid overload., (© 2011 Copyright the Authors. Journal compilation © 2011, Wiley Periodicals, Inc. and the International Society for Diseases of the Esophagus.)

Thoracic duct cysts of the mediastinum are extremely rare. The etiology is related to a congenital or degenerative weakness in the wall of the thoracic duct. Symptoms may arise from compression of adjacent structures. Surgical resection is recommended and allows a definitive histological diagnosis. Postoperative chylothorax is the most frequent complication. We describe a 30-year-old female who presented to us with a history of dry cough and hiccups within the last four months.

This retrospective study was carried out to evaluate the indications for and outcomes of the hemiclamshell (HCS) approach (longitudinal partial sternotomy with antero-lateral thoracotomy) in patients undergoing mass resection in thoracic surgery. All patients (50) who underwent a HCS procedure in our department, between July 1996 and July 2005, were studied retrospectively, analyzing the indications, morbidity and outcome (pain, neurological or shoulder defects, mortality) at one month and one year. The main indications were apical tumours (38%), tumours of the cervicothoracic junction (46%) and chest wall (10%), and 'bulky' tumours (6%). One-month mortality was 6%. Two patients suffered from a chylothorax and one from phrenic paralysis. The postoperative analgesic requirements were similar to those after other thoracic surgery approaches. Twelve percent of patients suffered pain at one month and 6% at one year. Shoulder dysfunction was observed in 10% of patients at one month and 6% at one year. In conclusion, the HCS surgical approach was associated with an uncomplicated postoperative course. This anterior approach is suitable for apical tumours, tumours of the cervicothoracic junction and 'bulky' lung tumours, providing good access for control of the large vessels and radical mediastinal clearance.

Three months after esophagectomy for esophageal cancer, a 58-year-old man presented with fluid trapped in his upper mediastinum due to chylous leakage from a duplicated left-sided thoracic duct that remained after excision of the main thoracic duct. Classical lymphangiography using lipiodol confirmed the presence of duplicated thoracic ducts. Conservative treatments were not effective, and then we performed ligation of the left-sided thoracic duct with left-sided video-assisted thoracoscopic surgery. Anatomic variations of the thoracic duct can result in chylous leakage after thoracic surgery. Even if the patient has anomaly of the thoracic duct, classical lymphangiography is useful for detecting locations of the thoracic duct precisely, allowing for certain ligation of the duct with video-assisted thoracoscopic surgery.

Lymphangioleiomyomatosis (LAM) is a rare, idiopathic disease affecting young women often complicated by refractory and difficult to manage chylothorax. We report one case of a patient who received a bilateral lung transplantation for LAM presenting a refractory chylothorax. The instillation of povidone iodine in the pleural space was effective in inducing pleurodesis.

Objective: Because chylothorax complicating thoracic surgery is difficult to diagnose and failure of nonoperative management necessitates further surgery, we critically evaluated an evolving percutaneous strategy for diagnosing and treating chylothorax., Methods: After thoracic surgery, 37 patients with a clinical diagnosis of chylothorax were referred for lymphangiography for definitive diagnosis and percutaneous treatment. Successful localization of the cisterna chyli by lymphangiogram facilitated percutaneous cannulation of the thoracic duct and its embolization. In patients in whom cannulation was not possible, the thoracic duct was percutaneously disrupted., Diagnosis: Lymphangiography was successful in 36 of the 37 patients (97%). Contrast extravasation, confirming clinical diagnosis, was present in 21 of the 36 (58%)., Management: Twenty-one of 36 patients underwent 22 lymphangiographically directed percutaneous interventions: 12 embolizations and 10 disruptions. Mortality was zero, with two manageable complications. Patients without percutaneous intervention were discharged a median of 7 days (range 4-58) after first lymphangiography, 8 days (range 2-19) after percutaneous embolization, and 19 days (range 6-48) after first disruption. Eight patients had nine subsequent reoperations for chylothorax, two with negative lymphangiograms; no embolization patient required reoperation., Conclusions: There is a discrepancy between the clinical diagnosis of chylothorax after thoracic surgery and the presumed gold standard of diagnosis, contrast extravasation at lymphangiogram. Percutaneous treatment by thoracic duct embolization or disruption is safe and may obviate reoperation, but embolization of the thoracic duct is preferable to its disruption.

Though rare in incidence, chylothorax can lead to significant morbidity and mortality. Its occurrence corresponds to increased mortality following esophagectomy. Leakage of chyle and lymph leads to significant loss of essential proteins, immunoglobulins, fat, vitamins, electrolytes and water. The presence of chylomicrons and a triglyceride level >110 mg/dl in the aspirated pleural fluid confirms the diagnosis of chylothorax. Identifying the aetiology using different diagnostic tests is important in planning treatment. While therapeutic thoracentesis provides relief from respiratory symptoms, the nutritional deficiency will continue to persist or deteriorate unless definitive therapeutic measures are instituted to stop leakage of chyle into the pleural space. Definitive therapy consists of obliteration and prevention of recurrence of chylothorax. Aggressive surgical therapy is recommended for post-traumatic or post-surgical chylothorax.

Chylothorax is a life-threatening clinical entity. Traditional surgical management for cases refractory to conservative treatment is thoracic duct ligation through a right open thoracotomy or closure of the site of duct laceration through an open thoracotomy. We report herein two patients with left chylothorax successfully treated by supradiaphragmatic thoracic duct (STD) ligation through left-sided video-assisted thoracoscopic surgery (VATS). This approach offers optimal exposure for the thoracic duct ligation and is useful for treatment of left chylothorax after left-sided thoracic surgery and idiopathic left chylothorax.

Chyle leak is an unwelcome complication of esophagectomy that is associated with a high mortality. The diagnosis of this condition may be difficult or delayed and requires a high index of suspicion. Management varies from conservative treatment with drainage, intravenous nutrition, treatment and prevention of septic complications, to re-operation, either by thoracotomy or laparotomy to control the fistula. To reduce the mortality, early surgical intervention is advised and a minimally invasive approach has recently been reported in several cases. From June 2002 through August 2005 we have used video-assisted thoracoscopic surgery to diagnose and treat chyle fistulas from 6/129 (5%) patients who underwent esophagectomy for resectable carcinoma of the esophagus or high-grade dysplasia. The fistula was successfully controlled in 5/6 cases by direct thoracoscopic application of a suture, clips or fibrin glue. One patient required a laparotomy and ligation of the cysterna chyli after thoracoscopy failed to identify an intrathoracic source of the leak. An early minimally invasive approach can be safely and effectively applied to the diagnosis and management of post-esophagectomy chylous fistula in the majority of cases. Open surgery may be appropriate where minimally invasive approaches fail or where the availability of such skills is limited.

Objective: To analyze the success rate of somatostatin in children with persistent chylothorax who failed dietary treatment options (fat-free nutrition, total parenteral nutrition) and to work out predictive factors for a successful therapy with somatostatin., Methods: Retrospective cohort study over a 5-year period (2000-2004) in a neonatal and pediatric intensive care unit of a tertiary university hospital. We analyzed the data of 85 neonatal and pediatric patients. Treatment of chylothorax occurred according to a multistage protocol with progressing invasiveness: (1) fat-free enteral nutrition, (2) total parenteral nutrition, (3) somatostatin infusion, (4) surgery. The percentages of patients successfully treated at the progressing steps were recorded. The somatostatin group was analyzed regarding to physiologic, diagnostic, treatment and outcome parameters. Somatostatin-responders were compared with non-responders., Results: Seventy-six of the 85 patients had chylothorax after cardiac surgery. Sixty-six percent could be treated with fat-free nutrition alone, 19% needed treatment with total parenteral nutrition and in 15% somatostatin was added. Of the whole sample, 4.7% required a surgical intervention. Of the 13 patients treated with somatostatin, all had bilateral chylothorax. Six patients (46%) responded to somatostatin. Responders and non-responders did not differ significantly regarding age, day of postoperative diagnosis of chylothorax, amount of chylous effusion before somatostatin infusion, triglyceride concentration and lymphocyte percentage in chylous, and central venous pressure (p=0.066)., Conclusions: Somatostatin, integrated in a treatment algorithm, was successful in resolving persistent chylothorax in around 50% of patients. With this strategy, some children may be prevented from undergoing an operation. However, factors predicting successful therapy with somatostatin could not be elicited.

Objective: To characterize surgical invasiveness and morbidity and to verify therapeutic efficacy, we reviewed perioperative and postoperative courses and therapeutic outcomes of patients who underwent retroperitoneal lymph node dissection (RPLND) for testicular germ cell cancers., Methods: The study included 31 patients who underwent retroperitoneal lymph node dissection. A modified template was used if retroperitoneal metastasis was limited to the areas below the level of the renal hilus and above the level of the inferior mesenteric artery (IMA). Perioperative and postoperative courses and complications were reviewed as well as therapeutic outcomes., Results: Overall, 27 perioperative and postoperative complications were observed in 15 patients (48.4%). Superficial surgical site infection and paralytic ileus were seen most frequently. All of them were resolved without special additional treatments; however, patients who underwent retrocrural dissection had a tendency to have severe symptomatic complications such as chylothorax, phrenic nerve palsy and orthostatic hypotension. Antegrade ejaculation was preserved in 94.1% of patients with modified template dissection, whereas no patients with additional dissection below the level of the IMA had the function preserved. One patient (3.2%) developed a postoperative recurrent disease in the retroperitoneum, which was outside the dissection field, as well as in the mediastinum., Conclusions: Although RLND had high morbidity, most peri- and postoperative complications were manageable conservatively. Modified template dissection enabled patients to preserve antegrade ejaculation without compromising its therapeutic efficacy, if the disease extension allowed us to use the template.

Background: Chylothorax is an uncommon disorder with respiratory, nutritional and immunological manifestations. Surgical management is indicated in case of recurrence or failure after conservative treatment. We report our experience with video-assisted right-sided supradiaphragmatic thoracic duct ligation for non-traumatic, non-postoperative persistent or recurrent chylothorax., Patients and Methods: The medical records of six patients operated at our institution between 1999 and 2004 were retrospectively reviewed. A right-sided chylothorax was found in four patients, a left-sided in one, and a bilateral in one. Three patients developed chylothorax after chemotherapy and chest irradiation for malignant diseases (lymphoma in two patients and breast cancer in one), one in the context of lymphangioleiomyomatosis, one due to a non-diagnosed lymphoma, and one after heart transplantation., Results: The mean operative time was 102 min, with an average length of hospital stay of 14 days. Persistent cessation of chylous effusion within 7 days after surgery was observed in 5/6 patients without recurrence during a mean follow-up time of 41 months. One patient with undiagnosed mediastinal lymphoma required re-operation and thoracic duct ligation on day 8 by right-sided thoracotomy due to persistent chylothorax. No 30-day mortality was recorded. Two patients presented postoperative complications including respiratory insufficiency requiring mechanical ventilation in one, and chylous ascites development requiring peritoneo-venous LeVeen shunting in one patient., Conclusions: Recurrent or persistent non-traumatic chylothorax may be successfully treated by video-assisted right supradiaphragmatic thoracic duct ligation.

Objective: To determine whether increased antithrombin loss is present in children with chylothorax after cardiac surgery., Methods: Plasma and pleural effusion samples of children with chylous and non-chylous pleural effusion were assayed for antithrombin activity., Results: Ten children with chylothorax and five children with non-chylous pleural effusion were investigated. There was statistically significant increase in mean antithrombin activity in chylous samples (32.2+/-11.4%) compared to non-chylous samples (14.4+/-13.9%), and significant decrease in plasma of children with chylothorax (44.6+/-15.4%) compared to children with non-chylous pleural effusion (69.9+/-22.4%). Seven of 10 children with chylous and none of the children without chylous developed thrombosis (p<0.007)., Conclusions: Increased loss of antithrombin is present in children with chylothorax, potentially predisposing these children to an increased risk of thrombosis. Repeated antithrombin substitution should be considered in critically ill children with chylothorax.

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+/-5.5 min for the thoracoscopy cases, and 70 min 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.

Thoracic duct injury is an uncommon complication of esophagectomy. Experience in managing these cases is limited to large centers performing esophagectomies in good numbers. We analyzed the prospectively maintained esophageal diseases database of patients presenting to a surgical unit between 1982 and 2002. Among 552 esophagectomies during this period we had encountered 14 cases of chylothorax (2.54%). We analyzed the type and site of lesion and the impact of neoadjuvant therapy on the incidence of thoracic duct injury. Among 459 patients of transhiatal esophagectomy, 11 developed postoperative chylothorax (2.40%). In 93 transthoracic resections, there were three cases of chylothorax (3.23%; (P = 0.9185)). The incidence following preoperative radiotherapy was 2.17%. None of the 31 patients, who had undergone esophagectomy for benign diseases had developed chylothorax. In the carcinoma group the incidence in middle third lesions was 5.85% and in lower third lesions was 0.80% (P = 0.0018). Seven patients were managed conservatively. Two of these patients, for whom surgery had been planned, died before they could be taken up for surgery. In the remaining seven patients transthoracic ligation of the thoracic duct was performed. Two patients in this group died. The average hospital stay was 20 days in the conservative group and 12 days in the surgery group. Among the factors studied, patients with middle third lesions were at increased risk of developing postoperative chylothorax, when compared to upper or lower third lesions.

A 65-year-old retired professional boxer presented with progressively worsening shortness of breath, peripheral oedema and mild abdominal swelling over a period of 6 months. His only past medical history was hypertension. Subsequent investigations revealed chylous ascites, pericardial constriction and bilateral chylothorax. He had uneventful pericardectomy, and post-operatively the chylothorax resolved only after administration of octreotide for 10 days. The histopathological features of fibrosis, haemosiderin deposition in the pericardium and abundant haemosiderin-laden macrophages are consistent with chronic resolving haemopericardium. These findings suggested that the cause of pericardial constriction was repeated chest trauma from boxing.

Thymectomy has been shown to be effective in the treatment of myasthenia gravis patients. Rarely, bilateral chylothorax, was noted as a complication of thymectomy via median sternotomy. Probably unseen division of mediastinal lymphatics, remote from thoracic duct, can explain this phenomenon. We report the case of a patient, female, who developed bilateral chylothorax after the former surgical approach, and our initial conservative policy to treat it (unilateral chest tube, total parenteral nutrition and subcutaneous administration of octreotide, a long-acting somatostatin analog), with good results.

We describe the case of tension chylothorax in a 29-year-old man following blunt chest trauma sustained in a road traffic accident. This presented with respiratory and haemodynamic compromise. Conservative treatment was attempted but definitive surgical intervention was required.

Objective: To define the incidence, causes, management and impact of Chylothorax after oesophagogastrectomy for malignant disease in Nottingham Thoracic Surgery unit., Patients and Methods: Retrospective analysis of 523 patients with cancer of the oesophagus or the gastro-oesophageal junction who underwent oesophageal resection between January 1987 and November 1997 in a single unit using similar techniques and uniform routine perioperative management., Results: Chylothorax occurred in 21 patients (4.0%). There were 12 males and 9 females with a mean age of 64.7 years (SD 7.5). Age, sex, tumour site, length, histological type, depth of wall penetration, nodal status and type of operative approach were not significant predisposing factors on univariate and multivariate analysis. Seventeen patients were treated conservatively (four deaths, 23.5%) and four surgically (one death, 25.0%), effective control of the chylous leak being achieved in all four cases. Eleven patients with a chylous drainage of up to 2.2 l/day, diminishing within 1 week of conservative treatment had an uneventful recovery. However, a chylous drainage of more than 2.5 l/day in the remaining ten patients was associated with increased morbidity, hospital stay, operative mortality and the need for surgical intervention. In comparison with the remaining patients (n = 502), those who developed chylothorax (n = 21) had more respiratory complications (42.8%, P = 0.008), longer mean hospital stay (23.8 days, P = 0.004), higher operative mortality (23.1%, P = 0.004) and, unexpectedly, reduced 5 year survival rate (P < 0.0001)., Conclusions: There appeared to be no clear predisposing factor in the development of a chylous leak other than the routine extensive dissection. Although definitive conclusions can not be drawn, where there is early reduction of the initial amount (in this series up to 2.2 l/day) of drainage, there may be a place for successful non-surgical management; in cases of high output chylothorax, persisting after a few days of conservative treatment, however, early re-operation and ligation of the thoracic duct, seems to be advisable.

Background: The management of chylothorax complicating oesophagectomy remains controversial. Even if medical management alone can be successful, some authors advocate early reoperation. The aim of this retrospective study was to identify the clinical variables associated with a high probability of full recovery with medical treatment., Methods: Among 850 Lewis procedures performed for oesophageal carcinoma, 23 patients (2.7 per cent) developed postoperative chylothorax despite systematic preventive ligation of the main thoracic duct. Patients who responded to conservative management were compared with those requiring reoperation for preoperative radiotherapy, unilateral versus bilateral pleural effusion, delay of occurrence of the chylothorax, and ratio of mean chylous output to body-weight 1 and 5 days after its onset., Results: Conservative management was successful in 14 patients with a mean(s.d.) delay of 12(5) (range 7-21) days and there were no hospital deaths. Reoperation was necessary in nine patients; there were two postoperative deaths and no recurrence of the chylothorax. The only significant difference between reoperated and medically treated patients was the mean(s.d.) chylous output at day 5: 23.5(16.6) versus 6.7(5.5) ml per kg body-weight (P< 0.001). At this time, the output was less than 10 ml/kg in 12 of 14 patients in whom medical treatment was successful (sensitivity 86 per cent), and equal to or greater than this cut-off value in all the patients who underwent reoperation (specificity 100 per cent)., Conclusion: The ratio of chylous output to body-weight on the fifth day after the onset of a chylothorax complicating oesophagectomy seems to reliably predict the success of continuing medical treatment.