| Popis: |
Chylothorax may be a rare problem in thoracic and cardiovascular surgery, but it is one which is often difficult to handle. The therapeutic procedure required in each individual case is determined by the anatomy and physiology of the ductus thoracicus and the individual etiology of the chylothorax. The ductus thoracicus runs from the cysterna chilii through the right hemithorax in a dorsolateral position relative to the hiatus aortae, crossing over to the left at the height of the fourth thoracic vertebra and passing to the left supraclavicular venous angle. Major pathogenetic features of the duct are its variability, the large number of collaterals, and the variety of lymphaticovenous anastomoses found. Lymph flow at peak pressures up to 25 cm H2O is tolerated; at higher pressures the duct or its collaterals rupture. In terms of etiology, two groups may be distinguished: (a) traumatic or iatrogenic causes, i.e., direct punctual lesions, and (b) chylothorax of neoplastic origin, caused either by direct destruction by the tumor or by ruptures of the collaterals or intrathoracic lymphaticovenous anastomoses due to increased intraductal pressure. The absolute incidence of chylothorax remains at a constant low level. Over a period of 20 years the Mayo Clinic reports only 53 cases; at our clinic we have treated a total of 9 cases in the past 10 years. Our therapeutic approach, which is based on pathophysiological and anatomical considerations, is as follows: (a) Primary attempt at conservative treatment: parenteral feeding with a fat-free diet using a gastric tube (!) to relieve the stomach combined with Buelau drainage with a low suction. (b) In the case of traumatic or operative/iatrogenic chylothorax, the direct suture or supradiaphragmal ligature (Lampson) may be used; the possibility of the complication of chyloperitoneum must, however, be considered if there is a lack of collaterals. (c) In the case of severe localized obstruction due to tumor growth, relapse due to increased pressure in the collaterals is very probable. In such cases it is better to cover the rupture directly with autologous or xenogenic material and to seal it with fibrin glue. Fibrin glue appears helpful in providing an absolutely tight seal against fatty fluids in the area of the leakage for 1–2 days until the area is further sealed by cicatrization due to incipient healing and conversion processes. We see our concept as a promising additive to surgery, which can reduce the complication rate in the case of chylothorax caused by tumors with high secretion rates. |
