Abstract
Background
Chylothorax after complex abdominal and thoracic procedures remains a challenging complication with a mortality rate reaching 50% if untreated [1]. Iatrogenic trauma accounts for almost 20% of all chyle leaks, and esophagectomy is the most common iatrogenic cause [2]. Consequences of ongoing chyle leak include dehydration, malnutrition, and immunocompromise.
Methods
When nonoperative management techniques fail, prompt ligation of the thoracic duct at the diaphragmatic hiatus should be attempted. The authors present prone thoracoscopic thoracic duct ligation performed for two patients after laparoscopic transthoracic esophagectomy and revision paraesophageal hernia repair.
Results
The prone position for thoracoscopic thoracic duct ligation offers several benefits to the surgeon. Gravity retracts the lung anteriorly, exposing the diaphragmatic hiatus. Single-lumen endotracheal intubation combined with low-pressure carbon dioxide insufflation efficiently collapses the lung to create ample working space. For the two reported patients, only three trocars were necessary to complete suture ligation of the thoracic duct via the right chest. Both patients had complete resolution of their chylothorax and recovered uneventfully. Based on this experience, the authors currently advocate early thoracoscopic treatment for cost and morbidity savings.
Conclusions
The authors believe prone thoracoscopic thoracic duct ligation offers significant advantages to the patient in preventing the dangerous consequences of chyle leak in a timely, minimally invasive fashion. Importantly, the prone technique with carbon dioxide insufflation makes the technical challenges of thoracic duct ligation more facile for the surgeon.
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References
Cerfolio RJ, Allen MS, Deschamps C, Trastek VF, Pairolero PC (1996) Postoperative chylothorax. J Thorac Cardiovasc Surg 112:1361–1366
Merigliano S, Molena D, Ruol A, Zaninotto G, Cagol M, Scappin S, Ancona E (2000) Chylothorax complicating esophagectomy for cancer: a plea for early thoracic duct ligation. J Thorac Cardiovasc Surg 119:453–457
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Denk, P.M., Gatta, P. & Swanström, L.L. Prone thoracoscopic thoracic duct ligation for postsurgical chylothorax. Surg Endosc 22, 2742 (2008). https://doi.org/10.1007/s00464-008-0128-1
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DOI: https://doi.org/10.1007/s00464-008-0128-1