J Thorac Cardiovasc Surg 2002;124:499-502
© 2002 The American Association for Thoracic Surgery
General Thoracic Surgery (GTS) |
Treatment strategy for chylothorax after pulmonary resection and lymph node dissection for lung cancer
Kimihiro Shimizu, MD,
Junji Yoshida, MD,
Mituyo Nishimura, MD,
Kazuya Takamochi, MD,
Rie Nakahara, MD,
Kanji Nagai, MD
From the Division of Thoracic Surgery, National Cancer Center Hospital East, Kashiwanoha, Kashiwa Chiba, Japan.
Supported in part by a grant-in-aid for cancer research from the Ministry of Health, Labour and Welfare, Japan.
Received for publication Sept 18, 2001. Revisions requested Dec 12, 2001; revisions received Jan 8, 2002. Accepted for publication Feb 21, 2002.
Address for reprints: Kimihiro Shimizu, MD, Division of Thoracic Surgery, National Cancer Center Hospital East, 6-5-1, Kashiwanoha, Kashiwa Chiba, 277-8577, Japan (E-mail: kmshimiza{at}showa.gunmau.ac.jp).
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Abstract
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Objective: We reviewed our experience with iatrogenic chylothorax after pulmonary resections for lung cancer to evaluate our treatment strategy and to identify factors that predict the need for reoperation.
Methods: From July 1992 through February 2000, a total of 1110 patients underwent pulmonary resection (at least lobectomy) and systematic mediastinal lymph node dissection for lung cancer at our division. Twenty-seven patients (2.4%) had postoperative chylothorax develop. We initially treated 26 of these patients conservatively with complete oral intake cessation and total parenteral nutrition, and these patients constituted the subjects in this study.
Results: There were 21 men and 5 women with a median age of 62 years (range 44 to 80 years). The initial procedures were pneumonectomy in 2 cases, bilobectomy in 1 case, and lobectomy in 23 cases. Twenty-one patients (81%) had the condition cured with conservative treatment. These patients resumed a normal diet at a median of 8 days after chylothorax diagnosis (range 4-35 days). The remaining 5 patients (19%) underwent reoperation at a median of 14 days after diagnosis (range 5-35 days). Chest tube drainage of less than 500 mL during the first 24 hours after complete oral intake cessation and total parenteral nutrition predicted a cure with conservative treatment.
Conclusion: Although most cases of chylothorax after pulmonary resection with systematic mediastinal lymph node dissection can be cured with a conservative strategy, early surgical intervention may be indicated if chest tube drainage is more than 500 mL during the first 24 hours after complete oral intake cessation and total parenteral nutrition.
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Introduction
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Postoperative chylothorax is a rare but well-known complication in thoracic surgery.
1 The thoracic duct lies posterior to the aorta and courses to the right of the spine. It usually crosses to the left ventral to the fifth thoracic vertebra, ascends into the neck posterior to the aortic arch, and empties into the left jugulosubclavian junction. Its proximity to the trachea, the presence of collateral channels, and its highly variable anatomic course can lead to an injury to this lymphatic flow during pulmonary resection, especially during mediastinal lymph node dissection. We reviewed our experience with iatrogenic chylothorax after pulmonary resection with systematic mediastinal lymph node dissection for lung cancer, as previously described by Naruke, 2 to evaluate our treatment strategy and to identify factors that predict the need for reoperation.
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Patients and methods
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From July 1992 through February 2000, a total of 1110 patients underwent pulmonary resection (at least lobectomy) and systematic mediastinal lymph node dissection for lung cancer at our division, as described previously elsewhere. 2 Postoperative chylothorax developed in 27 patients (2.4%), and these patients constituted the subjects in this study. Chylothorax was diagnosed on the basis of chylous leakage from the chest tube. The diagnosis was confirmed by presence of triglycerides (>110 mg/dL) and chylomicrons in the drainage fluid. 3 The medical records of these patients were reviewed for age, sex, surgical procedures, pathologic findings, amount of chest tube dainage, and chylothorax treatment methods. Lung cancer was pathologically staged according to the the TMN classification system of the American Joint Committee on Cancer Staging. 4
We initially treated all but one of these patients conservatively with complete oral intake cessation and total parenteral nutrition (TPN); the exception was treated with a medium-chain triglyceride diet and was therefore excluded from the study. If chest tube drainage did not decrease significantly in about 3 days, we performed pleurodesis by injecting a preparation of 10 kE OK-432 plus 20 mL 1% lidocaine plus 20 mL isotonic sodium chloride solution (Picibanil; Chugai Pharmaceutical Co Ltd, Tokyo, Japan) into the thoracic cavity through a chest tube. 5 If chylothorax was not cured in about 2 weeks, the conservative strategy was considered unsuccessful and surgical intervention was indicated.
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Results
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There were 21 male and 5 female patients. Their ages ranged from 44 to 80 years, with a median age of 62 years. Patient characteristics are shown in Table 1. Pneumonectomy was performed in 2 cases, with the chest tube kept in place until the third postoperative day for unrecorded reasons in 1 case. Bilobectomy was performed in 1 case, and lobectomy was performed in 23 cases. All patients had a single chest tube placed after the initial operation. All chylothoraces developed on the ipsilateral side. Chylothorax was diagnosed at a median of 2 days after operation (range 1-3 days; Table 2). All patients were treated with complete oral intake cessation and TPN. Fifteen patients (58%) received pleurodesis with OK-432 (Table 2), and 13 (87%) of them had the condition cured with the conservative treatment. There were no procedure-related complications, drug-related complications, or deaths related to the thoracic cavity injection of OK-432. The only adverse effects, fever and chest pain, were mild and controllable by medication. In total, 21 patiens (81%) had the chylothorax cured with this conservative strategy. These patients resumed a normal diet at a median of 8 days after chylothorax diagnosis (range 4-35 days). One patient resumed a normal diet at 35 days after chylothorax diagnosis, wheras all the others did so between 4 and 15 days after chylodthorax diagnosis.
The remaining 5 patients (19%) underwent reoperation. The median chest drainage volume during the first 24 hours after complete oral intake cessation and TPN in this group was 706 mL, as opposed to 215 mL for the patients who had the condition cured by the conservative strategy. The chest drainage volume during the first 24 hours after complete oral intake cessation and TPN for the conservative cure group did not exceed 500 mL (Figure 1). Reoperation was performed at a median of 14 days after pulmonary resection (range 5-35 days). Reoperation was successful in all cases.
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Fig. 1. Chest tube drainage during the first 24 hours after complete oral intake cessation and TPN. Statistically significant difference was observed between groups (P < .0001 by t test).
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There were no deaths among the 26 patients. Complications occurred in 4 cases (15%): atrial fibrillation in 1 patient, pneumonia in 2 patients, and a mediastinal chyloma after seemingly successful conservative treatment in 1 patient. 6
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Discussion
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Postoperative chylothorax is an uncommon but well-known complication in thoracic surgery. In our review, we encountered 27 patients (2.4%) with chylothorax among 1110 who underwent pulmonary resection and systematic mediastinal lymph node dissection for lung cancer in our division. Our incidence was much higher than the 0.5% reported by Vallieres and associates 7 or the 0.26% reported by Cerfolio and coworkers. 1 Those reports, however, described few technical details on lymph node dissection or sampling. In our study all patients underwent uniform, systematic mediastinal lymph node dissection, as described previously elsewhere. 2 Bollen and associates 8 reported that 2 patients (3%) who underwent systematic mediastinal lymph node dissection had chylothorax develop. Izbicki and colleagues 9 reported that 1 chylothorax (1.2%) occurred in their systematic mediastinal lymph node dissection group. Their results were comparable to ours.
The basic principle of conservative chylothorax treatment is to inflate the lung to decrease the dead space in the thoracic cavity and to promote adhesion of the lung or pleura to the thoracic duct injury. It is important to reduce chylous leakage to decrease the dead space and to prompt adhesion and accelerate fistula closure. Thoracic duct flow increases after meals, especially when a high-fat meal is ingested. 10 Because starvation reduces the thoracic duct flow, our patients had complete oral intake cessation and TPN after chylothorax diagnosis. Promotion of adhesion of the lung or pleura to the thoracic duct injury by pleurodesis may play an important role. OK-432, a heat- and penicillin-treated lyophilized preparation of the Su strain of Streptococcus pyogenes A3, 11 has been reported to be effective and safe in managing chylothorax. 5 Thoracic cavity injection of OK-432 promotes fibrin clot development, which has been reported to facilitate pleurodesis. 5 Among the 15 patients who underwent pleurodesis with OK-432, 13 (87%) were successfully treated without any major complications. Our study confirmed that OK-432 is effective and safe in managing postoperative chylothorax. However, we previously reported a mediastinal chyloma after seemingly successful conservative treatment with OK-432. 6 Although that patient might have had a chyloma develop even without OK-432 and the causal relationship between OK-432 and mediastinal chyloma was unclear, it should be noted that a chyloma may develop during the clinical course of chylothorax.
Surgical treatment generally involves ligation of the thoracic duct. The criteria for surgical intervention described by Selle and coworkers 12 are most frequently used in clinical practice. Selle and coworkers 12 recommend reoperation to ligate the thoracic duct when chylous leakage persists for at least 5 days at the rate of 1500 mL/day or more in adults and when the drainage of chyle does not decrease within 2 weeks or the patient's nutrition or metabolic status becomes measurably more impaired during the same period. Cerfolio and coworkers 1 and Patterson and colleagues 13 have reported similar strategies. They recommend observation for 7 days; if drainage is still greater than 1000 mL/day, reoperation to ligate the thoracic duct is necessary. If drainage is higher or chylothorax occurs after an esophageal operation, early reoperation should be strongly considered. These strategies were derived from retrospective analyses of heterogeneous patients who underwent general thoracic surgical procedures, including cardiovascular surgery and esophageal resection with mediastinal lymphadenectomy. Our study, in contrast, retrospectively analyzed a homogeneous series of consecutive patients who underwent pulmonary resection and systematic mediastinal lymph node dissection. This study showed that chest tube drainage less than 500 mL during the first 24 hours after complete oral intake cessation and TPN predicted a cure with conservative treatment. On the basis of our experience, we recommend the treatment flow chart shown in Figure 2.
Chylothorax is an infrequent postoperative complication. However, pulmonary resection for lung cancer with systematic mediastinal lymph node dissection may lead to a higher incidence of postoperative chylothorax than is seen with other general thoracic surgical procedures, except for esophageal resection with mediastinal lymphadenectomy. 1 Although most chylothoraces after pulmonary resection with systematic mediastinal lymph node dissection can be cured with a conservative strategy, immediate reoperation may be indicated to expedite recovery and minimize hospital stay if chest tube drainage is more than 500 mL during the first 24 hours after complete oral intake cessation and TPN.
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Acknowledgments
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We thank Professor J. Patrick Barron (International Medical Communication Center, Tokyo Medical University) for reviewing the English manuscript.
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References
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- Cerfolio RJ, Allen MS, Deschamps C, Trastek VF, Pairolero PC. Postoperative chylothorax. J Thorac Cardiovasc Surg. 1996;112:1361-5.[Abstract/Free Full Text]
- Naruke T. Mediastinal lymph node dissection. In: Shields TW, editor. General thoracic surgery. Philadelphia: Lea & Febiger; 1995. p. 469-80.
- Staats BA, Ellefson RD, Budahn LL, Dines DE, Prakash UB, Offord K. The lipoprotein profile of chylous and nonchylous pleural effusions. Mayo Clin Proc. 1980;55:700-4.[Medline]
- Mountain CF. Revisions in the International System for Staging Lung Cancer. Chest. 1997;111:1710-7.[Abstract/Free Full Text]
- Shimizu J, Hayashi Y, Oda M, Morita K, Arano Y, Nagao S, et al. Treatment of postoperative chylothorax by pleurodesis with the streptococcal preparation OK-432. Thorac Cardiovasc Surg. 1994;42:233-6.[Medline]
- Suzuki K, Yoshida J, Nishimura M, Takahashi K, Nagai K. Postoperative mediastinal chyloma. Ann Thorac Surg. 1999;68:1857-8.[Abstract/Free Full Text]
- Vallieres E, Shamji FM, Todd TR. Postpneumonectomy chylothorax. Ann Thorac Surg. 1993;55:1006-8.[Abstract]
- Bollen EC, van Duin CJ, Theunissen PH, vt Hof-Grootenboer BE, Blijham GH. Mediastinal lymph node dissection in resected lung cancer: morbidity and accuracy of staging. Ann Thorac Surg. 1993;55:961-6.[Abstract]
- Izbicki JR, Thetter O, Habekost M, Karg O, Passlick B, Kubuschok B, et al. Radical systematic mediastinal lymphadenectomy in non-small cell lung cancer: a randomized controlled trial. Br J Surg. 1994;81:229-35.[Medline]
- Paes ML, Powell H. Chylothorax: an update. Br J Hosp Med. 1994;51:482-90.[Medline]
- Okamoto H, Shoin S, Koshimura S, Shimizu R. Studies on anticancer and streptolysin S-forming abilities of hemolytic streptococci. Jpn J Microbiol. 1967;11:323-36.[Medline]
- Selle JG, Snyder WH 3rd, Schreiber JT. Chylothorax: indications for surgery. Ann Surg. 1973;177:245-9.[Medline]
- Patterson GA, Todd TR, Delarue NC, Ilves R, Pearson FG, Cooper JD. Supradiaphragmatic ligation of the thoracic duct in intractable chylous fistula. Ann Thorac Surg. 1981;32:44-9.[Abstract]
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Abstract
Introduction
