Abstract
Introduction
Chylothorax is by definition a collection of lymphatic fluids in the pleural cavity because of leakage from main thoracic duct or its tributaries. It is an uncommon but serious postoperative complication in esophageal cancer patients. There is no standard therapeutic algorithm for chylothorax because no prospective or randomized trials have yet been performed to evaluate the available treatment options. The aim of this study was to evaluate the efficacy of pleurodesis with a combination of platelet-rich plasma (PRP) and fibrin glue to the treatment of chylothorax after trans-hiatal esophagectomy.
Materials and methods
We randomly allocated 52 consecutive esophageal cancer patients with postoperative chylothorax who did not respond to conservative management to either PRP fibrin glue pleurodesis or surgical thoracic duct ligation. 26 patients in each group were treated with PRP fibrin glue pleurodesis or surgical thoracic duct ligation in order to control chylothorax. Perioperative data, including success rate and complications of both interventions, were analyzed.
Results
Two groups were similar in terms of patients’ demographics and tumor characteristics. All 26 patients in pleurodesis group (100%) and 20 patients in surgery group (76.9%) were successfully treated (p = 0.009). Seven patients (26.92%) in pleurodesis group required a second application of PRP fibrin glue after a week. The mean length of hospital stay was 53.50 ± 16.662 days in surgery group and 36.04 ± 8.224 days in pleurodesis group (p < 0.001). Although mortality rate in surgery group was higher than pleurodesis group, it was not statistically significant (p = 0.1621). There was no significant difference in complications between two groups either. No serious side effect occurred with PRP fibrin glue application.
Conclusion
In conclusion, pleurodesis using PRP and fibrin glue for chylothorax after trans-hiatal esophagectomy was associated with significantly increased success rate, decreased ICU stay, decreased overall hospital stay, and decreased mortality compared with surgical thoracic duct ligation. No patient after PRFG required additional intervention including surgery. Thus, given the improved outcomes with PRFG pleurodesis, this technique may be considered in all patients with postoperative chylothorax after or during conservative management and before proceeding to more invasive interventions.
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References
Lagarde SM, Omloo JM, de Jong K, Busch OR, Obertop H, van Lanschot JJ (2005) Incidence and management of chyle leakage after esophagectomy. Ann Thorac Surg 80(2):449–454
Shah RD, Luketich JD, Schuchert MJ, Christie NA, Pennathur A, Landreneau RJ et al (2012) Postesophagectomy chylothorax: incidence, risk factors, and outcomes. Ann Thorac Surg 93(3):897–903 discussion-4
Ferguson MK, Little AG, Skinner DB (1985) Current concepts in the management of postoperative chylothorax. Ann Thorac Surg 40(6):542–545
Terzi A, Furlan G, Magnanelli G, Terrini A, Ivic N (1994) Chylothorax after pleuro-pulmonary surgery: a rare but unavoidable complication. Thorac Cardiovasc Surg 42(2):81–84
Miao L, Zhang Y, Hu H, Ma L, Shun Y, Xiang J et al (2015) Incidence and management of chylothorax after esophagectomy. Thorac Cancer 6(3):354–358
Paes ML, Powell H (1994) Chylothorax: an update. Br J Hosp Med 51(9):482–490
Macfarlane JR, Holman CW (1972) Chylothorax. Am Rev Respir Dis 105(2):287–291
Maldonado F, Cartin-Ceba R, Hawkins FJ, Ryu JH (2010) Medical and surgical management of chylothorax and associated outcomes. Am J Med Sci 339(4):314–318
Doerr CH, Miller DL, Ryu JH (2001) Chylothorax. Semin Respir Crit care Med 22(6):617–626
Maldonado F, Hawkins FJ, Daniels CE, Doerr CH, Decker PA, Ryu JH (2009) Pleural fluid characteristics of chylothorax. Mayo Clin Proc 84(2):129–133
Staats BA, Ellefson RD, Budahn LL, Dines DE, Prakash UB, Offord K (1980) The lipoprotein profile of chylous and nonchylous pleural effusions. Mayo Clin Proc 55(11):700–704
Huggins JT (2010) Chylothorax and cholesterol pleural effusion. Semin Respir Crit Care Med 31(6):743–750
McGrath EE, Blades Z, Anderson PB (2010) Chylothorax: aetiology, diagnosis and therapeutic options. Respir Med 104(1):1–8
Ryu JH, Tomassetti S, Maldonado F (2011) Update on uncommon pleural effusions. Respirology (Carlton, Vic) 16(2):238–243
Park JG, Aubry MC, Godfrey JA, Midthun DE (2006) Mediastinal lymphangioma: Mayo Clinic experience of 25 cases. Mayo Clin Proc 81(9):1197–1203
Mine S, Udagawa H, Kinoshita Y, Makuuchi R (2008) Post-esophagectomy chylous leakage from a duplicated left-sided thoracic duct ligated successfully with left-sided video-assisted thoracoscopic surgery. Interact CardioVasc Thorac Surg 7(6):1186–1188
Takuwa T, Yoshida J, Ono S, Hishida T, Nishimura M, Aokage K et al (2013) Low-fat diet management strategy for chylothorax after pulmonary resection and lymph node dissection for primary lung cancer. J Thorac Cardiovasc Surg 146(3):571–574
Akin H, Olcmen A, Isgorucu O, Denizkiran I, Dincer I (2012) Approach to patients with chylothorax complicating pulmonary resection. Thorac Cardiovasc Surg 60(2):135–139
Cho HJ, Kim DK, Lee GD, Sim HJ, Choi SH, Kim HR et al (2014) Chylothorax complicating pulmonary resection for lung cancer: effective management and pleurodesis. Ann Thorac Surg 97(2):408–413
Zabeck H, Muley T, Dienemann H, Hoffmann H (2011) Management of chylothorax in adults: when is surgery indicated? Thorac Cardiovasc Surg 59(4):243–246
Merrigan BA, Winter DC, O’Sullivan GC (1997) Chylothorax. Br J Surg 84(1):15–20
Browse NL, Allen DR, Wilson NM (1997) Management of chylothorax. Br J Surg 84(12):1711–1716
Fahimi H, Casselman FP, Mariani MA, van Boven WJ, Knaepen PJ, van Swieten HA (2001) Current management of postoperative chylothorax. Ann Thorac Surg 71(2):448–450 discussion50–51
Cerfolio RJ, Allen MS, Deschamps C, Trastek VF, Pairolero PC (1996) Postoperative chylothorax. J Thorac Cardiovasc Surg 112(5):1361–1365 discussion 5–6
Shimizu K, Yoshida J, Nishimura M, Takamochi K, Nakahara R, Nagai K (2002) Treatment strategy for chylothorax after pulmonary resection and lymph node dissection for lung cancer. J Thorac Cardiovasc Surg 124(3):499–502
Sriram K, Meguid RA, Meguid MM (2016) Nutritional support in adults with chyle leaks. Nutrition (Burbank, Los Angeles County, Calif) 32(2):281–286
Vargas FS, Milanez JR, Filomeno LT, Fernandez A, Jatene A, Light RW (1994) Intrapleural talc for the prevention of recurrence in benign or undiagnosed pleural effusions. Chest 106(6):1771–1775
Graham DD, McGahren ED, Tribble CG, Daniel TM, Rodgers BM (1994) Use of video-assisted thoracic surgery in the treatment of chylothorax. Ann Thorac Surg 57(6):1507–1511 discussion 11–12
Mares DC, Mathur PN (1998) Medical thoracoscopic talc pleurodesis for chylothorax due to lymphoma: a case series. Chest 114(3):731–735
Paul S, Altorki NK, Port JL, Stiles BM, Lee PC (2009) Surgical management of chylothorax. Thorac Cardiovasc Surg 57(4):226–228
Griffo S, De Luca G, Stassano P (2010) Chylothorax after abdominal surgery. Gen Thorac Cardiovasc Surg 58(3):159–162
Cerfolio RJ (2006) Chylothorax after esophagogastrectomy. Thorac Surg Clin 16(1):49–52
Wurnig PN, Hollaus PH, Ohtsuka T, Flege JB, Wolf RK (2000) Thoracoscopic direct clipping of the thoracic duct for chylopericardium and chylothorax. Ann Thorac Surg 70(5):1662–1665
Lyon S, Mott N, Koukounaras J, Shoobridge J, Hudson PV (2013) Role of interventional radiology in the management of chylothorax: a review of the current management of high output chylothorax. Cardiovasc Interv Radiol. 36(3):599–607
Liou DZ, Warren H, Maher DP, Soukiasian HJ, Melo N, Salim A et al (2013) Midodrine: a novel therapeutic for refractory chylothorax. Chest 144(3):1055–1057
Kalomenidis I (2006) Octreotide and chylothorax. Curr Opin Pulm Med 12(4):264–267
Al-Zubairy SA, Al-Jazairi AS (2003) Octreotide as a therapeutic option for management of chylothorax. Ann Pharmacother 37(5):679–682
Kelly RF, Shumway SJ (2000) Conservative management of postoperative chylothorax using somatostatin. Ann Thorac Surg 69(6):1944–1945
Markham KM, Glover JL, Welsh RJ, Lucas RJ, Bendick PJ (2000) Octreotide in the treatment of thoracic duct injuries. Am Surg 66(12):1165–1167
Davis JW, Mackersie RC, Hoyt DB, Garcia J (1994) Randomized study of algorithms for discontinuing tube thoracostomy drainage. J Am Coll Surg 179(5):553–557
Younes RN, Gross JL, Aguiar S, Haddad FJ, Deheinzelin D (2002) When to remove a chest tube? A randomized study with subsequent prospective consecutive validation. J Am Coll Surg 195(5):658–662
Dietrich W, Ebell A, Busley R, Boulesteix AL (2007) Aprotinin and anaphylaxis: analysis of 12,403 exposures to aprotinin in cardiac surgery. Ann Thorac Surg 84(4):1144–1150
Schenk WG 3rd, Burks SG, Gagne PJ, Kagan SA, Lawson JH, Spotnitz WD (2003) Fibrin sealant improves hemostasis in peripheral vascular surgery: a randomized prospective trial. Ann Surg 237(6):871–876 discussion 6
Wenger FA, Szucsik E, Hoinoiu BF, Cimpean AM, Ionac M, Raica M (2015) Circular anastomotic experimental fibrin sealant protection in deep colorectal anastomosis in pigs in a randomized 9-day survival study. Int J Colorectal Dis 30(8):1029–1039
Asadi M, Alamdari DH, Rahimi HR, Aliakbarian M, Jangjoo A, Abdollahi A et al (2014) Treatment of life-threatening wounds with a combination of allogenic platelet-rich plasma, fibrin glue and collagen matrix, and a literature review. Exp Ther Med 8(2):423–429
Akhundov K, Pietramaggiori G, Waselle L, Darwiche S, Guerid S, Scaletta C et al (2012) Development of a cost-effective method for platelet-rich plasma (PRP) preparation for topical wound healing. Ann Burns Fire Disasters 25(4):207–213
Acknowledgements
This study was supported by Grants from Mashhad University of Medical Sciences (MUMS).
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Alamdari, D.H., Asadi, M., Rahim, A.N. et al. Efficacy and Safety of Pleurodesis Using Platelet-Rich Plasma and Fibrin Glue in Management of Postoperative Chylothorax After Esophagectomy. World J Surg 42, 1046–1055 (2018). https://doi.org/10.1007/s00268-017-4242-x
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DOI: https://doi.org/10.1007/s00268-017-4242-x