Retroaortic closure of thoracic duct in the management of persistent chylothorax: a case report
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(2019) 14:100
CASE REPORT
Open Access
Retroaortic closure of thoracic duct in the management of persistent chylothorax: a case report Francesco Paolo Caronia1, Giuseppe Di Miceli1, Andrea Macaluso1, Damiano Librizzi1, Francesco Sgalambro2 and Alfonso Fiorelli3*
Abstract Background: Chylothorax is a life-threatening pathological condition associated with significant morbidity and mortality. If chyle leakage does not close spontaneously with medical therapy, surgical treatment is inevitable. Herein, we reported a case of spontaneous persistent chylothorax from mediastinal seminoma that was successfully closed between the descending thoracic aorta, and the vertebral column through a left mini-thoracotomy. Case presentation: A 24-year old man with mediastinal seminoma was referred to our attention for management of high output persistent chylothorax (> 800 ml/24 h for 30 days) that did not close with conservative treatment. As the leak was isolated within left upper chest cavity, we planned to close the thoracic duct via Poirier’s triangle by uniportal thoracoscopy. However, the long conservative treatment favoured the formation of multiple, tenacious, and bleeding adhesions that made unfeasible thoracoscopy. A conversion to mini-thoracotomy was performed; by the incision of the posterior parietal pleura, the thoracic duct was isolated and ligated behind the thoracic aorta, in an anatomical space delimited by the 4th and the 5th posterior intercostal arteries and the vertebral column. Conclusions: Complete resolution of chylothorax was obtained the day after. Patient was discharged on postoperative day 5, and no recurrence was observed during the follow-up. Keywords: Thoracic duct, Chylothorax, Surgical closure
Introduction Chylothorax is a pathological condition characterized by accumulation of lymphatic fluid into the pleural cavity from injury of TD and lymphatic tributaries. It is associated with a significant morbidity and mortality rate as chylothorax leads to malnutrition and immunosuppression through loss of lymphocytes, proteins, fat and respiratory distress [1]. The treatment ranging from conservative to surgery, but the best strategy is still debate as no comparative studies exist. Generally, low output chylothorax (< 1000 mL/24 h) is treated conservatively by low-fat diet, TPN, and chest drainage while surgery is indicated in case of failure. Conversely, patients with high output chylothorax
(> 1000 mL/24 h) are candidates for early surgical closure to avoid the deleterious effects of malnutrition and immunosuppression [2]. Mortality rate after early TD surgical closure was reported to be 10%, but it raised to 50% after conservative treatment [3]. TD embolization is a minimally invasive treatment, alternative to surgery, to avoid major trauma in already debilitated patients. Several authors [4, 5] reported a successful rate up to 70%, but these results are difficult to reproduce as TD catheterization and lymphangiography require specific skills available only in selected centres. Herein, we reported a
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