Zentralbl Chir 2019; 144(03): 290-297
DOI: 10.1055/a-0733-7268
Übersicht
Georg Thieme Verlag KG Stuttgart · New York

Systematische Übersichtsarbeit: moderne Behandlungsverfahren beim postoperativen Chylothorax

Modern Treatment Options for Postoperative Chylothorax: a Systematic Review
Sebastian Stange
Klinik für Thoraxchirurgie, REGIOMED Kliniken GmbH, Sonneberg/Coburg, Deutschland
,
Zsolt Sziklavari
Klinik für Thoraxchirurgie, REGIOMED Kliniken GmbH, Sonneberg/Coburg, Deutschland
› Author Affiliations
Further Information

Publication History

Publication Date:
15 October 2018 (online)

Zusammenfassung

Hintergrund Der Chylothorax ist i. d. R. eine multifaktorielle Komplikation nach Operationen oder Unfällen, seltener die Folge von Tumoren. Da prospektive, randomisierte Studien fehlen, beruht die evidenzbasierte Behandlung auf persönlichen Erfahrungen, im Idealfall erfolgt sie in Kenntnis retrospektiver Analysen.

Material und Methoden Ziel dieser Übersichtsarbeit ist es, einen umfassenden Überblick über die aktuell zur Verfügung stehenden modernen Behandlungsverfahren beim postoperativen Chylothorax zu geben sowie ihre Vor- und Nachteile aufzuzeigen. Hierzu erfolgte eine Literaturrecherche in der Datenbank „PubMed“ unter Beschränkung auf Publikationen der letzten 10 Jahre. Für die Recherche wurde das Schlüsselwort „Chylothorax“ eingesetzt. Der Schwerpunkt lag auf den Publikationen, die eine vergleichende Bewertung der Behandlungsmöglichkeiten beinhalten. Bei der kritischen Analyse der Therapieansätze und Empfehlungen wurden Reviews der letzten 5 Jahre bevorzugt, des Weiteren stützten sich die Autoren auf eine kumulative langjährige klinische Erfahrung.

Ergebnisse Der Erfolg einer konservativen Behandlung zeigt in Abhängigkeit von der Ätiologie eine große Streuungsbreite (3 – 90%). Die Erfolgsrate der nicht invasiven oder semiinvasiven Verfahren liegt zwischen 50 und 100%, ebenfalls in Abhängigkeit von der Ätiologie. Bei einer erfolglosen konservativen Behandlung operabler Patienten besteht die chirurgische Standardtherapie in der meist thorakoskopisch durchgeführten Ligatur des Ductus thoracicus. Alternativ kann eine Pleurodese oder die Platzierung einer permanenten Thoraxdrainage oder eines pleuroperitonealen Shunts durchgeführt werden. Die Erfolgsrate dieser Eingriffe liegt zwischen 64 und 100%. Die Morbiditäts- und Mortalitätsrate kann hierbei Werte bis zu 25% erreichen.

Schlussfolgerung Die Behandlung eines Chylothorax sollte konservativ begonnen werden. Anschließend kann stufenweise eine aggressivere Therapie empfohlen werden, wobei der Zustand des Patienten und das Drainagevolumen den Entscheidungsprozess steuern. Interventionelle radiologische Verfahren sind sicher in der Anwendung bei gleichzeitig hoher Erfolgsquote und haben somit einen berechtigten Platz neben der konservativen Behandlung bzw. den operativen Verfahren. Sie stehen allerdings aktuell nur in einigen größeren Zentren zur Verfügung.

Abstract

Background Chylothorax is a multifactorial complication, usually caused by surgery or traumatic injury, and more rarely by malignant disease. Because of the lack of prospective, randomised trials, the evidence-based treatment rests upon personal experience, but ideally taking into account retrospective analysis.

Material and Methods The aim of this review is to provide a comprehensive overview of the currently available modern treatment options. Another aspect is to show their advantages and disadvantages. For this purpose, a literature search was performed using the “PubMed” database. Publications older than ten years were excluded from this review. The literature search employed the keyword “chylothorax”. The priority was set on publications including a comparative assessment of treatment approaches. The authors relied on many years of clinical experience to critically analyse and evaluate the treatment options and the given recommendations.

Results The success rate of the conservative treatment methods ranges widely, depending on the underlying cause of the disease (3 – 90%). Non-invasive or semi-invasive procedures are successful in 50 to 100% of the cases, also depending on the aetiology. After unsuccessful conservative treatment of operable patients, the standard surgical therapy consists of thoracic duct ligature, which is usually performed thoracoscopically. Alternatively, pleurodesis or the placement of a permanent chest drain (PleurX) or a pleuroperitoneal shunt may be performed. The success rate of these procedures is between 64 and 100%. The morbidity and mortality rate can reach values up to 25%.

Conclusion Treatment of a chylothorax should be started conservatively. Subsequently, a more aggressive therapy may be gradually considered, based on the patientʼs health and the amount of the secretion. Interventional radiological procedures are safe, successful, and have a legitimate place alongside conservative or surgical treatment. However, they are currently only available in some larger centres.

 
  • Literatur

  • 1 McGrath EE, Blades Z, Anderson PB. Chylothorax: aetiology, diagnosis and therapeutic options. Respir Med 2010; 104: 1-8
  • 2 Doerr CH, Allen MS. et al. Nichols FC3rd et al. Etiology of chylothorax in 203 patients. Mayo Clin Proc 2005; 80: 867-870
  • 3 Narayan P, Rahaman N, Molnar TF. et al. Chylothorax following cardiac surgery caused by unusual lymphatic anatomy. Asian Cardiovasc Thorac Ann 2007; 15: e58
  • 4 Sziklavari Z, Allgäuer M, Hübner G. et al. Radiotherapy in the treatment of postoperative chylothorax. J Cardiothorac Surg 2013; 8: 72
  • 5 Chalret du Rieu M, Baulieux J, Rode A. et al. Management of postoperative chylothorax. J Visc Surg 2011; 148: e346-e352
  • 6 Schild HH, Strassburg CP, Welz A. et al. Therapieoptionen beim Chylothorax. Dtsch Arztebl Int 2013; 110: 819-826
  • 7 Glatz T, Marjanovic G, Hoeppner J. [Prevention and surgical therapy of chylothorax]. Zentralbl Chir 2018; 143: 278-283
  • 8 Kaul TK, Bain WH, Turner MA. et al. Chylothorax: report of a case complicating ductus ligation through a median sternotomy, and review. Thorax 1976; 31: 610-616
  • 9 Pillay TG, Singh B. A review of traumatic chylothorax. Injury 2016; 47: 545-550
  • 10 Hölscher AH, Fetzner UK, Bludau M. et al. [Complications and management of complications in oesophageal surgery]. Zentralbl Chir 2011; 136: 213-223
  • 11 Bryant AS, Minnich DJ, Wei B. et al. The incidence and management of postoperative chylothorax after pulmonary resection and thoracic mediastinal lymph node dissection. Ann Thorac Surg 2014; 98: 232-235
  • 12 Kunitoh H, Kato H, Tsuboi M. et al. Phase II trial of preoperative chemoradiotherapy followed by surgical resection in patients with superior sulcus non-small-cell lung cancers: report of Japan Clinical Oncology Group trial 9806. J Clin Oncol 2008; 26: 644-649
  • 13 Rudrappa M, Paul M. Chylothorax. StatPearls [Internet]. Treasure Island: StatPearls Publishing; 2017
  • 14 Miller JI. Anatomy of the thoracic Duct and Chylothorax. In: Shields TW, Locicero J, Ponn RB, Rusch VW. eds. General thoracic Surgery. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2005: 887-889
  • 15 Skouras V, Kalomenidis I. Chylothorax: diagnostic approach. Curr Opin Pulm Med 2010; 16: 387-393
  • 16 Wasmuth-Pietzuch A, Hansmann M, Bartmann P. et al. Congenital chylothorax: lymphopenia and high risk of neonatal infections. Acta Paediatr 2004; 93: 220-224
  • 17 Breaux J, Marks C. Chylothorax causing reversible T-cell depletion. J Trauma 1988; 28: 705-707
  • 18 Staats BA, Ellefson RD, Budahn LL. et al. The lipoprotein profile of chylous and nonchylous pleural effusions. Mayo Clin Proc 1980; 55: 700-704
  • 19 Maldonado F, Hawkins FJ, Daniels CE. et al. Pleural fluid characteristics of chylothorax. Mayo Clin Proc 2009; 84: 129-133
  • 20 Sassoon CS, Light RW. Chylothorax and pseudochylothorax. Clin Chest Med 1985; 6: 163-171
  • 21 Huggins JT. Chylothorax and cholesterol pleural effusion. Semin Respir Crit Care Med 2010; 31: 743-750
  • 22 Guo W, Zhao YP, Jiang YG. et al. Prevention of postoperative chylothorax with thoracic duct ligation during videoassisted thoracoscopic esophagectomy for cancer. Surg Endosc 2012; 26: 1332-1336
  • 23 Bessone LN, Ferguson TB, Burford TH. Chylothorax. Ann Thorac Surg 1971; 12: 527-550
  • 24 Nair SK, Petko M, Hayward MP. Aetiology and management of chylothorax in adults. Eur J Cardiothorac Surg 2007; 32: 362-369
  • 25 Lv S, Wang Q, Zhao W. et al. A review of the postoperative lymphatic leakage. Oncotarget 2017; 8: 69062-69075
  • 26 Benedix F, Lippert H, Meyer F. Etiology, diagnosis and treatment of lymphocutaneous fistulas, chylascites and chylothorax as infrequent but serious complications following surgical procedures. Zentralbl Chir 2012; 137: 580-586
  • 27 Dietl B, Pfister K, Aufschläger C. et al. [Radiotherapy of inguinal lymphorrhea after vascular surgery. A retrospective analysis]. Strahlenther Onkol 2005; 181: 396-400
  • 28 Das A, Shah PS. Octreotide for the treatment of chylothorax in neonates. Cochrane Database Syst Rev 2010; (09) CD006388
  • 29 Bello SO, Rahamim J. High-Dose intravenous octreotide is safe and may be superior to surgery in managing severe postesophagectomy chylothorax in high-risk patients. Ann Thorac Surg 2015; 100: 297-299
  • 30 Roehr CC, Jung A, Proquitté H. et al. Somatostatin or octreotide as treatment options for chylothorax in young children: a systematic review. Intensive Care Med 2006; 32: 650-657
  • 31 Lim KA, Kim SH, Huh J. et al. Somatostatin for postoperative chylothorax after surgery for children with congenital heart disease. J Korean Med Sci 2005; 20: 947-951
  • 32 Zabeck H, Muley T, Dienemann H. et al. Management of chylothorax in adults: when is surgery indicated?. Thorac Cardiovasc Surg 2011; 59: 243-246
  • 33 Alejandre-Lafont E, Krompiec C, Rau WS. et al. Effectiveness of therapeutic lymphography on lymphatic leakage. Acta Radiol 2011; 52: 305-311
  • 34 Nadolski GJ, Itkin M. Thoracic duct embolization for nontraumatic chylous effusion: experience in 34 Patients. Chest 2013; 143: 158-163
  • 35 Pui MH, Yueh TC. Lymphoscintigraphy in chyluria, chyloperitoneum and chylothorax. J Nucl Med 1998; 39: 1292-1296
  • 36 Yu DX, Ma XX, Wang Q. et al. Morphological changes of the thoracic duct and accessory lymphatic channels in patients with chylothorax: detection with unenhanced magnetic resonance imaging. Eur Radiol 2013; 23: 702-711
  • 37 Collard JM, Laterre PF, Boemer F. et al. Conservative treatment of postsurgical lymphatic leaks with somatostatin-14. Chest 2000; 117: 902-905
  • 38 Lee EW, Shin JH, Ko HK. et al. Lymphangiography to treat postoperative lymphatic leakage: a technical review. Korean J Radiol 2014; 15: 724-732
  • 39 Schild HH, Naehle CP, Wilhelm KE. et al. Lymphatic interventions for treatment of chylothorax. Rofo 2015; 187: 584-588
  • 40 Gaba RC, Owens CA, Bui JT. et al. Chylous ascites: a rare complication of thoracic duct embolization for chylothorax. Cardiovasc Intervent Radiol 2011; 34 (Suppl. 02) S245-S249
  • 41 Cope C, Kaiser L. Management of unremitting chylothorax by percutaneous embolization and blockage of retroperitoneal lymphatic vessels in 42 patients. J Vasc Interv Radiol 2002; 13: 1139-1148
  • 42 Itkin M, Kucharczuk JC, Kwak A. et al. Nonoperative thoracic duct embolization for traumatic thoracic duct leak: experience in 109 patients. J Thorac Cardiovasc Surg 2010; 139: 584-589
  • 43 Binkert CA, Yucel K, Davison BD. et al. Percutaneous treatment of high-output chylothorax with embolization or needle disruption technique. J Vasc Interv Radiol 2005; 16: 1257-1262
  • 44 Lutz P, Strunk H, Schild HH. et al. Transjugular intrahepatic portosystemic shunt in refractory chylothorax due to liver cirrhosis. World J Gastroenterol 2013; 19: 1140-1142
  • 45 Bölükbas S, Kudelin N, Dönges T. et al. [Therapy management of chylothorax]. Chirurg 2010; 81: 255-263
  • 46 Orringer MB, Bluett M, Deeb GM. Aggressive management of chylothorax complicating transhiatal esophagectomy without thoracotomy. Surgery 1988; 104: 720-726
  • 47 Fujita T, Daiko H. Efficacy and predictor of octreotide treatment for postoperative chylothorax after thoracic esophagectomy. World J Surg 2014; 38: 2039-2045
  • 48 Mares DC, Mathur PN. Medical thoracoscopic talc pleurodesis for chylothorax due to lymphoma: a case series. Chest 1998; 114: 731-735
  • 49 Alexiou C, Watson M, Beggs D. et al. Chylothorax following oesophagogastrectomy for malignant disease. Eur J Cardiothorac Surg 1998; 14: 460-466
  • 50 Cerfolio RJ, Allen MS, Deschamps C. et al. Postoperative chylothorax. J Thorac Cardiovasc Surg 1996; 112: 1361-1365
  • 51 Ryu JH, Tomassetti S, Maldonado F. Update on uncommon pleural effusions. Respirology 2011; 16: 238-243
  • 52 Paul S, Altorki NK, Port JL. et al. Surgical management of chylothorax. Thorac Cardiovasc Surg 2009; 57: 226-228
  • 53 Akin H, Olcmen A, Isgorucu O. et al. Approach to patients with chylothorax complicating pulmonary resection. Thorac Cardiovasc Surg 2012; 60: 135-139
  • 54 Sahn SA. Management of malignant pleural effusions. Monaldi Arch Chest Dis 2001; 56: 394-399
  • 55 Gupta D, Ross K, Piacentino V. et al. Use of LeVeen pleuroperitoneal shunt for refractory high-volume chylothorax. Ann Thorac Surg 2004; 78: e9
  • 56 Shimizu K, Yoshida J, Nishimura M. et al. Treatment strategy for chylothorax after pulmonary resection and lymph node dissection for lung cancer. J Thorac Cardiovasc Surg 2002; 124: 499-502
  • 57 Cho HJ, Kim DK, Lee GD. et al. Chylothorax complicating pulmonary resection for lung cancer: effective management and pleurodesis. Ann Thorac Surg 2014; 97: 408-413
  • 58 Schoellnast H, Maybody M, Getrajdman GI. et al. Computed tomography-guided access to the cisterna chyli: introduction of a technique for direct lymphangiography to evaluate and treat chylothorax. Cardiovasc Intervent Radiol 2011; 34 (Suppl. 02) S240-S244
  • 59 Takuwa T, Yoshida J, Ono S. et al. Low-fat diet management strategy for chylothorax after pulmonary resection and lymph node dissection for primary lung cancer. J Thorac Cardiovasc Surg 2013; 146: 571-574
  • 60 Boffa DJ, Sands MJ, Rice TW. et al. A critical evaluation of a percutaneous diagnostic and treatment strategy for chylothorax after thoracic surgery. Eur J Cardiothorac Surg 2008; 33: 435-439
  • 61 Cope C, Salem R, Kaiser LR. Management of chylothorax by percutaneous catheterization and embolization of the thoracic duct: prospective trial. J Vasc Interv Radiol 1999; 10: 1248-1254