今日の臨床サポート

乳縻胸水

著者: 水守康之 姫路医療センター 呼吸器内科

監修: 杉山幸比古 練馬光が丘病院 呼吸器内科

著者校正/監修レビュー済:2020/07/09
患者向け説明資料

概要・推奨   

  1. 胸水検査の際には乳糜胸水を念頭に置いてTGを測定することが勧められる(推奨度1)。
  1. 外傷歴のない乳糜胸水を認めた際には、悪性腫瘍の検索を行うことが勧められる(推奨度2)。
  1. 乳糜胸水の患者には絶食・完全静脈栄養(TPN)を行うことが勧められる(推奨度2)。
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となりま
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
水守康之 : 特に申告事項無し[2021年]
監修:杉山幸比古 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 定期レビューを行い、一部加筆修正を行った。 

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 乳糜とは胸管を流れる乳白色のリンパ液である。乳糜はカイロミクロンに富む。何らかの原因で胸管が破綻して乳糜が胸腔内に漏出したものが乳糜胸水である。
  1. 原因は、成人では手術に伴う外傷によるものが最も多く、非外傷性では悪性腫瘍によるものが多い[1]。悪性腫瘍としては、悪性リンパ腫や転移性腫瘍、肺癌などが原因となる。
  1. 小児の先天性胸水の原因として最も多い[2]。また小児の先天性心疾患術後に乳糜胸水を合併する頻度は成人の胸部術後よりも高い。ただし本稿では以下、主に成人例について述べる。
  1. 術後に乳糜胸水を合併する率は縦隔リンパ節郭清を伴う肺切除術では2.4%、食道切除術では4%、ただし食道癌手術時に胸管結紮を併用すると0.9%との報告がある[3][4][5]
  1. 非外傷性の乳糜胸水は、悪性腫瘍のほかに上大静脈血栓症、肝硬変、心不全、サルコイドーシス、結核、黄色爪症候群、リンパ脈管筋腫症(LAM)など多くの疾患に合併する。ただし各々の頻度は高くない。
  1. 原因を特定できない、いわゆる特発性の症例もみられる。
  1. 症状は胸水貯留による呼吸困難や倦怠感である。また、ドレナージにより大量の蛋白、脂肪、電解質、脂溶性ビタミン、リンパ球、免疫グロブリンの喪失が継続すると、低栄養と免疫不全を生じる。このため早期に乳糜胸水の流出を止める処置が必要となる。
問診・診察のポイント  
  1. 自覚症状を確認する。症状は呼吸困難感や胸部違和感、倦怠感として現れる。乳糜には刺激性がないため、胸水貯留による症状以外は少ない。通常、乳糜胸水では発熱や疼痛などは認めない。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

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文献 

著者: Clinton H Doerr, Mark S Allen, Francis C Nichols, Jay H Ryu
雑誌名: Mayo Clin Proc. 2005 Jul;80(7):867-70. doi: 10.4065/80.7.867.
Abstract/Text OBJECTIVES: To characterize the etiology of chylothorax in patients encountered at a single tertiary referral center and to compare the findings with those from previous studies.
PATIENTS AND METHODS: The medical records of all patients with chylothorax seen at the Mayo Clinic in Rochester, Minn, over a 21-year period, from January 1, 1980, to December 31, 2000, were retrospectively reviewed to ascertain the underlying cause of their condition.
RESULTS: We identified 203 patients with chylothorax; 92 were females (male-female ratio, 1.21). The median age was 54.5 years (range, 21 weeks' gestation to 93 years). Dyspnea, the most common presenting symptom, occurred in 98 (56.6%) of 173 patients in whom initial symptoms were recorded, whereas 64 (37.0%) had no respiratory symptoms. Median duration of symptoms before diagnosis was 7.5 weeks (range, 1 day to 4.5 years). Causes of chylothorax included surgery or trauma in 101 patients (49.8%), various medical conditions in 89 (43.8%), and unknown in 13 (6.4%). Among surgical procedures, esophagectomy (29 patients) and surgery for congenital heart disease (28 patients) were the most common causes of chylothorax. Among medical conditions, lymphoma (23 patients), lymphatic disorders (19 patients), and chylous ascites (16 patients) were the most common causes.
CONCLUSIONS: Chylothorax has numerous causes. In contrast to previous studies, surgery or trauma was the most common cause of chylothorax at our institution, accounting for nearly 50% of cases. Lymphoma and other malignancies caused chylothorax in only 16.7% of cases. These numbers are possibly related to the high volume of cardiothoracic surgical procedures performed at our tertiary referral center.

PMID 16007891  Mayo Clin Proc. 2005 Jul;80(7):867-70. doi: 10.4065/80.・・・
著者: V Chernick, M H Reed
雑誌名: J Pediatr. 1970 Apr;76(4):624-32.
Abstract/Text
PMID 5420804  J Pediatr. 1970 Apr;76(4):624-32.
著者: Kimihiro Shimizu, Junji Yoshida, Mituyo Nishimura, Kazuya Takamochi, Rie Nakahara, Kanji Nagai
雑誌名: J Thorac Cardiovasc Surg. 2002 Sep;124(3):499-502.
Abstract/Text 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.

PMID 12202866  J Thorac Cardiovasc Surg. 2002 Sep;124(3):499-502.
著者: D Dougenis, W S Walker, E W Cameron, P R Walbaum
雑誌名: Surg Gynecol Obstet. 1992 Jun;174(6):501-6.
Abstract/Text Between January 1983 and May 1987, 255 esophagectomies were performed for carcinoma of the middle (40 patients) or lower (215 patients) esophagus. All patients were operated upon through a left thoracolaparotomy and underwent a radical en bloc resection of the tumor along with all palpable mediastinal nodes. Ten patients had chylothorax develop postoperatively. There were seven men and three women with a mean age of 65.7 years (range of 37.0 to 81.0 years). Parameters that were statistically evaluated for possible correlation to increased incidence of chylous fistula were age, sex, site and size of tumor, histologic type, mediastinal lymphatic involvement and elective prophylactic ligation of the major thoracic duct (MTD) at the conclusion of the procedure. It was found that elective ligation of the MTD was associated with a lower occurrence of chylothorax (2.1 per cent) as compared with those with no routine ligation (9 per cent), p less than 0.05. The leak was successfully treated by repeated thoracotomy and mass ligation of the MTD in eight patients, while one patient underwent closed tube thoracostomy. In one instance, only a pleuroperitoneal shunt was performed. The over-all hospital mortality rate from chylothorax was 10 per cent and there was a late death because of pneumonia. We recommend prophylactic ligation of the MTD in all instances of extensive esophageal resection for the prevention of chylothorax, as well as early thoracotomy for the management of established leaks.

PMID 1595027  Surg Gynecol Obstet. 1992 Jun;174(6):501-6.
著者: L Bonavina, G Saino, D Bona, M Abraham, A Peracchia
雑誌名: J Laparoendosc Adv Surg Tech A. 2001 Dec;11(6):367-9. doi: 10.1089/10926420152761888.
Abstract/Text BACKGROUND: Chylothorax is a relatively uncommon complication of esophageal surgery that may lead to severe respiratory, nutritional, and immunologic deficiencies.
PATIENTS AND METHODS: Between 1992 and 2000, 3 of 316 patients (0.9%) undergoing transthoracic esophagectomy for carcinoma developed postoperative chylothorax. Two of them had previously been treated with neoadjuvant chemoradiation, and one had been submitted to esophagogastric resection through a left thoracotomy. After a 2-week trial of total parenteral nutrition and drainage, two patients underwent thoracic duct ligation via thoracotomy. In the last patient, the operation was completed by thoracoscopy. The azygos vein and the periaortic tissue above the diaphragm were encircled en bloc by a right-angled clamp, and a roticulating endostapler was applied.
RESULTS: Reoperation was successful in all patients. The postoperative hospital stay was 4 days.
CONCLUSION: Thoracoscopy is a safe and effective procedure for the treatment of chylothorax complicating esophagectomy. Given the minimal trauma to the patient, early thoracoscopic reoperation can be advocated in patients with high-output chyle loss in order to reduce the hospital stay.

PMID 11814127  J Laparoendosc Adv Surg Tech A. 2001 Dec;11(6):367-9. d・・・
著者: H Zabeck, T Muley, H Dienemann, H Hoffmann
雑誌名: Thorac Cardiovasc Surg. 2011 Jun;59(4):243-6. doi: 10.1055/s-0030-1250374. Epub 2011 Mar 21.
Abstract/Text BACKGROUND: The aim of this retrospective study was to analyze the etiology, management and outcome of patients with chylothorax and identify clinical parameters for appropriate treatment decisions.
METHODS: We analyzed 82 cases of chylothorax in 75 patients. In 37 cases (45 %) the cause of chylothorax was surgery, in 45 cases (55 %), the etiology was nonsurgical (malignancy n = 17 [21 %], lymphatic disorders n = 5 [6 %], hepatic cirrhosis, n = 4 [5 %], trauma n = 1 and other causes n = 18 [22 %]).
RESULTS: Conservative treatment was successful in 13 (16 %) cases. In 25 cases (total 31 %, postsurgical n = 19 [51 %], nonsurgical n = 6 [13 %]) a (redo) thoracotomy with ligation of the thoracic duct or repeat surgical procedure was performed. The quantity of chyle drained per 24 hours appeared to be the best indicator to guide management decisions.
CONCLUSION: Chylothoraces that occur postoperatively following thoracic procedures require redo operations in approximately 50 % of cases, whereas nonsurgical causes rarely require surgical intervention. In postoperative chylothoraces with a high flow leak > 900 mL/24 h revision should be performed early on, since conservative management is likely to be unsuccessful.

© Georg Thieme Verlag KG Stuttgart · New York.
PMID 21425049  Thorac Cardiovasc Surg. 2011 Jun;59(4):243-6. doi: 10.1・・・
著者: Fabien Maldonado, Rodrigo Cartin-Ceba, Finn J Hawkins, Jay H Ryu
雑誌名: Am J Med Sci. 2010 Apr;339(4):314-8. doi: 10.1097/MAJ.0b013e3181cdcd6c.
Abstract/Text Chylothorax is an uncommon form of pleural effusion that can be associated with traumatic and nontraumatic causes. Optimal management and outcome for patients with chylothorax remain unclear. This retrospective single-center study assessed the modes of management for chylothorax in 74 adult patients (> or =18 years old) and associated outcomes. The role of lymphangiographic imaging was also evaluated. Initial treatment approach was nonsurgical in 57 patients (77%) but a surgical procedure (pleurodesis, thoracic duct ligation, and/or surgical repair) was eventually performed in 44 patients (59%). The rate of resolution with initial treatment measures was significantly worse for patients with nontraumatic chylothorax compared with those with traumatic causes (27% versus 50%, P = 0.048). Even after additional therapeutic maneuvers including surgery, chylous effusion recurred more commonly in nontraumatic chylothorax when compared with the traumatic group (50% versus 13%, respectively, P < 0.001). Lymphatic imaging did not seem to materially influence management. Nonsurgical approaches may lead to resolution of the chylothorax in nearly one half of patients with traumatic chylothorax but in only a minority of those with nontraumatic chylothorax. The majority of patients with nontraumatic chylothorax will eventually require surgical maneuvers, but one third of such patients still fail to resolve their chylothorax.

PMID 20124878  Am J Med Sci. 2010 Apr;339(4):314-8. doi: 10.1097/MAJ.0・・・
著者: V G Valentine, T A Raffin
雑誌名: Chest. 1992 Aug;102(2):586-91.
Abstract/Text
PMID 1643953  Chest. 1992 Aug;102(2):586-91.
著者: B A Staats, R D Ellefson, L L Budahn, D E Dines, U B Prakash, K Offord
雑誌名: Mayo Clin Proc. 1980 Nov;55(11):700-4.
Abstract/Text The lipoprotein electrophoregrams and the cholesterol and triglyceride levels of the pleural fluid were evaluated for patients with chylous pleural effusions, as defined by the presence of a distinctive band of chylomicrons on the lipoprotein electrophoregram, and in patients with nonchylous effusions of various causes. One hundred forty-one patients were studied during a 3-year period. The chylous effusions had strikingly higher triglyceride levels (median 249, range 49 to 2,270 mg/dl) than the nonchylous group (median 33, range 13 to 107 mg/dl); there were no significant differences in cholesterol or protein between the two groups. The gross description of the fluid was a poor indicator of its origin, being described as consistent with chyle in less than 50% of cases of chylous effusions. The triglyceride values distinguished chylous effusion from nonchylous effusion; values greater than 110 mg/dl are highly suggestive of a chylous effusion. Equivocal cases--triglyceride values between 50 and 110 mg/dl--required lipoprotein analysis. Pleural effusions of undetermined cause, regardless of gross appearance of the fluid, require that a screening triglyceride value be obtained to rule out a chylous effusion.

PMID 7442324  Mayo Clin Proc. 1980 Nov;55(11):700-4.
著者: R L Hughes, R A Mintzer, D F Hidvegi, R K Freinkel, D W Cugell
雑誌名: Chest. 1979 Aug;76(2):212-8.
Abstract/Text
PMID 465132  Chest. 1979 Aug;76(2):212-8.
著者: Fabien Maldonado, Finn J Hawkins, Craig E Daniels, Clinton H Doerr, Paul A Decker, Jay H Ryu
雑誌名: Mayo Clin Proc. 2009 Feb;84(2):129-33. doi: 10.1016/S0025-6196(11)60820-3.
Abstract/Text OBJECTIVE: To determine the biochemical parameters of chylous pleural fluids and better inform current clinical practice in the diagnosis of chylothorax.
PATIENTS AND METHODS: We retrospectively reviewed 74 patients with chylothorax (defined by the presence of chylomicrons) who underwent evaluation during a 10-year period from January 1, 1997, through December 31, 2006. The biochemical parameters and appearance of the fluid assessed during diagnostic evaluation were analyzed.
RESULTS: The study consisted of 37 men (50%) and 37 women (50%), with a median age of 61.5 years (range, 20-93 years). Chylothorax was caused by surgical procedures in 51%. The chylous pleural fluid appeared milky in only 44%. Pleural effusion was exudative in 64 patients (86%) and transudative in 10 patients (14%). However, pleural fluid protein and lactate dehydrogenase levels varied widely. Transudative chylothorax was present in all 4 patients with cirrhosis but was also seen with other causes. The mean +/- SD triglyceride level was 728+/-797 mg/dL, and the mean +/- SD cholesterol value was 66+/-30 mg/dL. The pleural fluid triglyceride value was less than 110 mg/dL in 10 patients (14%) with chylothorax, 2 of whom had a triglyceride value lower than 50 mg/dL.
CONCLUSION: Chylothoraces may present with variable pleural fluid appearance and biochemical characteristics. Nonmilky appearance is common. Chylous effusions can be transudative, most commonly in patients with cirrhosis. Traditional triglyceride cutoff values used in excluding the presence of chylothorax may miss the diagnosis in fasting patients, particularly in the postoperative state.

PMID 19181646  Mayo Clin Proc. 2009 Feb;84(2):129-33. doi: 10.1016/S00・・・
著者: Emmet E McGrath, Zoe Blades, Paul B Anderson
雑誌名: Respir Med. 2010 Jan;104(1):1-8. doi: 10.1016/j.rmed.2009.08.010. Epub 2009 Sep 18.
Abstract/Text Chylothorax is a rare condition that results from thoracic duct damage with chyle leakage from the lymphatic system into the pleural space, usually on the right side. It has multiple aetiologies and is usually discovered after it manifests itself as a pleural effusion. Diagnosis involves cholesterol and triglyceride measurement in the pleural fluid. Complications include malnutrition, immunosuppression and respiratory distress. Treatment may be either conservative or aggressive depending on the clinical scenario. In this review, we discuss the aetiology, diagnosis and treatment of chylothorax. English language publications in MEDLINE and references from relevant articles from January 1, 1980 to February 28, 2008 were reviewed. Keywords searched were chylothorax, aetiology, diagnosis and treatment.

Copyright 2009 Elsevier Ltd. All rights reserved.
PMID 19766473  Respir Med. 2010 Jan;104(1):1-8. doi: 10.1016/j.rmed.20・・・
著者: M A Sarsam, A N Rahman, A K Deiraniya
雑誌名: Ann Thorac Surg. 1994 Mar;57(3):689-90. doi: 10.1016/0003-4975(94)90568-1.
Abstract/Text Over a period of 22 years, chylothorax developed in 9 of 1,800 patients who underwent pneumonectomy. Two groups were identified. In group I (n = 5), accelerated opacification of the pneumonectomy space was noted, but the mediastinum remained shifted to the pneumonectomy site. No hemodynamic problems developed and their course was no different from that of other patients who had undergone pneumonectomy. In the second group (group II; n = 4), rapid opacification of the pneumonectomy space was accompanied by mediastinal shift away from the pneumonectomy site and by major hemodynamic and respiratory embarrassment. All 4 patients required surgical intervention to control the chylous leak.

PMID 8147641  Ann Thorac Surg. 1994 Mar;57(3):689-90. doi: 10.1016/00・・・
著者: J I Ulíbarri, Y Sanz, C Fuentes, A Mancha, M Aramendia, S Sánchez
雑誌名: Lancet. 1990 Jul 28;336(8709):258.
Abstract/Text
PMID 1973814  Lancet. 1990 Jul 28;336(8709):258.
著者: P C Rimensberger, B Müller-Schenker, A Kalangos, M Beghetti
雑誌名: Ann Thorac Surg. 1998 Jul;66(1):253-4.
Abstract/Text Chylothorax is a rare but potentially serious complication of pediatric cardiac operations. We report the case of a 4-month-old boy who underwent a Senning procedure for correction of D-transposition of the great vessels. A persistent postoperative chylothorax developed, necessitating continuous drainage, despite conservative treatment over 3 weeks. Thereafter, continuous somatostatin infusion for 14 days led to the reduction and finally cessation of chyle production. This treatment allowed early enteral feeding and avoided further surgical intervention.

PMID 9692478  Ann Thorac Surg. 1998 Jul;66(1):253-4.
著者: R F Kelly, S J Shumway
雑誌名: Ann Thorac Surg. 2000 Jun;69(6):1944-5.
Abstract/Text Chylothorax is a rare but serious postoperative complication of thoracic surgical procedures. We report the case of a 77-year-old man who underwent a coronary artery bypass procedure using a left internal mammary artery pedicle graft. A permanent pacemaker was required postoperatively. A persistent postoperative chylothorax developed necessitating continuous drainage and conservative management. Somatostatin was instituted when after 1 week this management failed to resolve the chylothorax. This led to rapid cessation of chyle production. Enteral feeding was reinstituted without complication and surgical intervention was avoided.

PMID 10892958  Ann Thorac Surg. 2000 Jun;69(6):1944-5.
著者: Sulaiman A Al-Zubairy, Abdulrazaq S Al-Jazairi
雑誌名: Ann Pharmacother. 2003 May;37(5):679-82.
Abstract/Text OBJECTIVE: To report a case of post-cardiac surgery-induced chylothorax treated with octreotide and review the literature on octreotide efficacy.
CASE SUMMARY: A 5-month-old boy with Down syndrome was admitted for atrioventricular canal repair. On admission, he was taking captopril and furosemide. On postoperative day 4, he exhibited signs of chest wheezing and crackles, but was without cough or fever. Chest X-ray revealed a moderate right-sided pleural effusion. Accordingly, a pleural catheter was inserted and drained an average of 7.14 mL/h of chylous fluid that day. Laboratory analysis of the pleural fluid revealed a triglyceride level of 89 mg/dL, without bacterial growth. Based on those findings, the diagnosis was chylothorax. Because of the continuous extensive tube drainage, octreotide 3.5 micro g/kg/h was begun. The average daily chyle drainage was reduced from 7.14 one day before octreotide initiation to 0.83 mL/h on day 4 of octreotide therapy. After 4 days of therapy (postoperative day 8), octreotide was discontinued because of the satisfactory response and the pleural catheter was removed.
DISCUSSION: In our case and the other few cases reported, octreotide showed acceptable efficacy in the management of chylothorax. The mechanism by which octreotide decreases chyle production includes reducing the intestinal absorption of fats, mainly triglycerides, and increasing fecal fat excretion.
CONCLUSIONS: Octreotide may have reduced chyle production in our patient. Further reports and studies assessing octreotide efficacy in the management of chylothorax are warranted.

PMID 12708946  Ann Pharmacother. 2003 May;37(5):679-82.
著者: Ioannis Kalomenidis
雑誌名: Curr Opin Pulm Med. 2006 Jul;12(4):264-7. doi: 10.1097/01.mcp.0000230629.73139.26.
Abstract/Text PURPOSE OF REVIEW: This article reviews the current literature concerning the role of somatostatin and its synthetic analogue, octreotide, in the treatment of chylothorax.
RECENT FINDINGS: Management of chylothorax includes evacuation of the pleural cavity through a chest tube to alleviate dyspnoea, and dietary fat restriction aimed at reducing lymph flow. When these measures fail to control lymph flow, surgical interventions are employed to achieve definite closure of the thoracic duct leak. Several case reports and series have shown that octreotide is safe and probably effective in both children and adults with chylothorax of different origins. The property of somatostatin and octreotide to induce leak closure is attributed to a decelerating effect on lymph flow, although their exact mechanism of action is not well defined. In successful cases, a substantial reduction of lymph drainage through the chest tube is evident within the first few days of commencing the drug, and treatment lasts for 1-2 weeks. Treatment failure has been also reported, however.
SUMMARY: Accumulating evidence suggests that octreotide is a putative novel therapeutic intervention for chylothorax. It is imperative that randomized controlled studies are conducted in order to fully elucidate the efficacy and safety of this treatment.

PMID 16825878  Curr Opin Pulm Med. 2006 Jul;12(4):264-7. doi: 10.1097/・・・
著者: Charles C Roehr, Andreas Jung, Hans Proquitté, Oliver Blankenstein, Hannes Hammer, Kokila Lakhoo, Roland R Wauer
雑誌名: Intensive Care Med. 2006 May;32(5):650-7. doi: 10.1007/s00134-006-0114-9. Epub 2006 Mar 11.
Abstract/Text OBJECTIVE: Chylothorax is a rare but life-threatening condition in children. To date, there is no commonly accepted treatment protocol. Somatostatin and octreotide have recently been used for treating chylothorax in children. We set out to summarise the evidence on the efficacy and safety of somatostatin and octreotide in treating young children with chylothorax.
DESIGN: Systematic review: literature search (Cochrane Library, EMBASE and PubMed databases) and literature hand search of peer reviewed articles on the use of somatostatin and octreotide in childhood chylothorax.
PATIENTS: Thirty-five children treated for primary or secondary chylothorax (10/somatostatin, 25/octreotide) were found.
RESULTS: Ten of the 35 children had been given somatostatin, as i.v. infusion at a median dose of 204 microg/kg/day, for a median duration of 9.5 days. The remaining 25 children had received octreotide, either as an i.v. infusion at a median dose of 68 microg/kg/day over a median 7 days, or s.c. at a median dose of 40 microg/kg/day and a median duration of 17 days. Side effects such as cutaneous flush, nausea, loose stools, transient hypothyroidism, elevated liver function tests and strangulation-ileus (in a child with asplenia syndrome) were reported for somatostatin; transient abdominal distension, temporary hyperglycaemia and necrotising enterocolitis (in a child with aortic coarctation) for octreotide.
CONCLUSIONS: A positive treatment effect was evident for both somatostatin and octreotide in the majority of reports. Minor side effects have been reported, however caution should be exercised in patients with an increased risk of vascular compromise as to avoid serious side effects. Systematic clinical research is needed to establish treatment efficacy and to develop a safe treatment protocol.

PMID 16532329  Intensive Care Med. 2006 May;32(5):650-7. doi: 10.1007/・・・
著者: M C Murphy, B M Newman, B M Rodgers
雑誌名: Ann Thorac Surg. 1989 Aug;48(2):195-200.
Abstract/Text Between June 1981 and June 1988, we placed pleuroperitoneal shunts in 16 patients for the management of refractory chylothorax on the Pediatric Surgical Service, University of Virginia. The cause of the chylothorax was caval thrombosis from central venous catheters in 5 patients, idiopathic in 3, and mediastinal lymphangioma in 2, and in 6, it developed after a cardiac procedure. Chylothorax in each patient was unresponsive to thoracentesis, tube thoracostomy, and dietary manipulations. A Denver double-valved shunt system is currently employed and is implanted using general anesthesia. Manual pumping is required postoperatively for several months. Twelve (75%) of the 16 patients had excellent results with complete elimination of the chylothorax and resolution of symptoms. In 10 of these 12, the shunt has been removed. Four had an unsatisfactory result: 3 had inferior vena cava hypertension, and 3 were low-birth-weight premature infants. Four patients seen early in this series required revision of the position of the pleural catheter, with successful drainage in each instance. Pleuroperitoneal shunting is a safe, simple, and effective treatment of chylothorax in infants and children. In view of our success in treating chylothorax with these shunts, we recommend early shunting before the development of nutritional or immunological depletion.

PMID 2764611  Ann Thorac Surg. 1989 Aug;48(2):195-200.
著者: T Yamagami, T Masunami, T Kato, O Tanaka, T Hirota, T Nomoto, K Mikami, T Miki, T Nishimura
雑誌名: Br J Radiol. 2005 Sep;78(933):854-7. doi: 10.1259/bjr/61177542.
Abstract/Text We report a 34-year-old man with the complication of chylous ascites after retroperitoneal lymphadenectomy that was refractory to various conservative therapies. Because surgical treatment for chylous ascites was considered, lymphangiography was performed to identify the area of leakage of chyle, after which the chylous ascites spontaneously healed.

PMID 16110112  Br J Radiol. 2005 Sep;78(933):854-7. doi: 10.1259/bjr/6・・・
著者: T Matsumoto, T Yamagami, T Kato, T Hirota, R Yoshimatsu, T Masunami, T Nishimura
雑誌名: Br J Radiol. 2009 Apr;82(976):286-90. doi: 10.1259/bjr/64849421. Epub 2008 Nov 24.
Abstract/Text The purpose of this study was to assess the effectiveness of lymphangiography as a treatment for various chyle leakages. Pedal lymphangiography was performed in 9 patients (6 men and 3 women; mean age, 59 years) who were unlikely to be cured only by conservative treatment - a low-fat medium-chain triglyceride diet, total parenteral nutrition and insertion of a drainage tube - and in whom chylothorax (n = 5), chylous ascites (n = 2) and lymphatic fistulae (n = 2) were refractory to conservative treatment. In 7 of these 9 patients (78%), we could detect the chyle leakage sites. In 8 of the 9 patients (89%), lymphatic leakage was stopped after lymphangiography, and surgical re-intervention was avoided. No cases had a recurrence of chyle leakage during follow-up (range, 1-54 months). Lymphangiography is effective not only for diagnosis but also as treatment for various chyle leakages. Early lymphangiography is therefore recommended for patients with chyle leakages who are unlikely to be cured by conservative treatment only.

PMID 19029221  Br J Radiol. 2009 Apr;82(976):286-90. doi: 10.1259/bjr/・・・
著者: J G Selle, W H Snyder, J T Schreiber
雑誌名: Ann Surg. 1973 Feb;177(2):245-9.
Abstract/Text
PMID 4698540  Ann Surg. 1973 Feb;177(2):245-9.
著者: J Shimizu, Y Hayashi, M Oda, K Morita, Y Arano, S Nagao, S Murakami, H Urayama, Y Watanabe
雑誌名: Thorac Cardiovasc Surg. 1994 Aug;42(4):233-6. doi: 10.1055/s-2007-1016494.
Abstract/Text Of the 2877 patients who underwent chest surgery at our department during the 20-year period between 1973 and 1992, 9 (0.3%) developed postoperative chylothorax. The underlying disease included primary lung cancer in 5 patients, pulmonary metastasis in 1, invasive thymoma in 2, and neuroblastoma of the posterior mediastinum in 1. For the treatment of chylothorax, the thoracic duct was ligated in 2 patients with a high volume of chylous leakage. In 6 patients treated conservatively, early pleurodesis was attained by injecting 1 to 5 doses (mean: 2.2 doses) of the streptoccal preparation OK-432 intrathoracically; favorable results were achieved. In 1 patient, the diagnosis of chylothorax was delayed because of postoperative pyothorax. This patient developed nutritional deficiency, compromised immunity, and disseminated intravascular coagulation (DIC), which led to death before the chylothorax could be treated. In principle, postoperative chylothorax should be treated conservatively. Favorable results can be expected with the intrathoracic injection of OK-432 beginning at the early postoperative period to achieve pleurodesis, combined with the prevention of nutritional deficiency, electrolyte imbalance, and infection.

PMID 7825162  Thorac Cardiovasc Surg. 1994 Aug;42(4):233-6. doi: 10.1・・・
著者: Gregory J Nadolski, Maxim Itkin
雑誌名: J Vasc Interv Radiol. 2012 May;23(5):613-6. doi: 10.1016/j.jvir.2012.01.078. Epub 2012 Mar 21.
Abstract/Text PURPOSE: To show the feasibility of opacifying the thoracic duct using ultrasound-guided intranodal lymphangiogram (IL) for thoracic duct embolization (TDE).
MATERIALS AND METHODS: Six patients (two women and four men, mean age, 59.2 y [range, 43-74 y]) underwent IL and TDE for chylothorax. Under ultrasound guidance, a needle was positioned in a groin lymph node, and lipiodol was injected. The thoracic duct was catheterized, and embolization was performed as indicated. Cumulative times from start of the procedure until initiation of the lymphangiogram, until identification of target lymphatic, until catheterization of the thoracic duct, and until completion of the procedure were collected. Times were compared with times of a control group of six patients (two women and four men, mean age, 66.7 y [range, 49-82 y]) who had undergone TDE using pedal lymphangiography (PL).
RESULTS: The procedure of opacification, catheterization, and embolization of the thoracic duct was successful in all cases. Cumulative times (mean ± standard deviation) in the IL and PL groups from start of the procedure until (i) initial lymphangiogram were 20.5 minutes ± 8.6 and 46.5 minutes ± 22.6, (ii) identification of a target lymphatic for catheterization were 60.5 minutes ± 18.2 and 110.5 minutes ± 31.6, (iii) catheterization of the thoracic duct were 79.0 minutes ± 28.9 and 128.2 minutes ± 37.0, and (iv) completion of procedure were 125.8 minutes ± 49.0 and 152.8 minutes ± 36.4.
CONCLUSIONS: IL is a feasible technique to visualize the thoracic duct for embolization. Using IL, the thoracic duct may be more quickly visualized and catheterized for TDE than with PL.

Copyright © 2012 SIR. Published by Elsevier Inc. All rights reserved.
PMID 22440590  J Vasc Interv Radiol. 2012 May;23(5):613-6. doi: 10.101・・・
著者: Mohammad Toliyat, Kanwar Singh, Robert C Sibley, Murthy Chamarthy, Sanjeeva P Kalva, Anil K Pillai
雑誌名: Clin Imaging. 2017 Mar - Apr;42:183-192. doi: 10.1016/j.clinimag.2016.12.012. Epub 2017 Jan 3.
Abstract/Text Disruption of the thoracic duct can have devastating consequences and be associated with a high morbidity and mortality. Conservative therapies have been attempted to treat chylothorax without much success. Surgical management has traditionally been necessary to provide definitive treatment at the expense of increased morbidity. Lymphatic interventions have recently emerged as a new frontier for interventional radiologists to add value and provide minimally invasive therapies for debilitating conditions. The goal of this manuscript is to review the anatomy of the thoracic duct, describe various percutaneous techniques for accessing the duct, and briefly discuss outcomes as reported in the literature.

Published by Elsevier Inc.
PMID 28103513  Clin Imaging. 2017 Mar - Apr;42:183-192. doi: 10.1016/j・・・
著者: Bradley Bender, Vijayashree Murthy, Ronald S Chamberlain
雑誌名: Eur J Cardiothorac Surg. 2016 Jan;49(1):18-24. doi: 10.1093/ejcts/ezv041. Epub 2015 Mar 1.
Abstract/Text Initial conservative therapy is applied to all cases of chylothorax (CTx) with expected excellent outcomes. The indication for aggressive surgical treatment of early CTx remains uncertain and requires rigorous scientific scrutiny. Lymphangiography and lymphoscintigraphy are useful to localize the leak and assess thoracic duct patency as well as to differentiate partial from complete thoracic duct transection. The aetiology of the CTx, flow rate and patient condition dictate the preferred management. Octreotide/somatostatin and etilefrine therapy is highly efficacious in the conservative management of CTx. For patients in whom conservative management fails, those who are good surgical candidates, and those in whom the site of the leak is well identified, surgical repair and/or ligation using minimally invasive techniques is highly successful with limited adverse outcomes. Similarly, if the site of the chylous effusion cannot be well visualized, a thoracic duct ligation via video-assisted thoracic surgery is the gold standard approach. A pleuroperitoneal or less often a pleurovenous shunt is a final option and may be curative in some patients.

© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
PMID 25732972  Eur J Cardiothorac Surg. 2016 Jan;49(1):18-24. doi: 10.・・・
著者: Douglas Z Liou, Heather Warren, Dermot P Maher, Harmik J Soukiasian, Nicolas Melo, Ali Salim, Eric J Ley
雑誌名: Chest. 2013 Sep;144(3):1055-1057. doi: 10.1378/chest.12-3081.
Abstract/Text Thoracic duct injury is a rare but serious complication following surgery of the neck or chest that leads to uncontrolled chyle leak. Conventional management includes drainage, nutritional modification, or aggressive surgical interventions such as thoracic duct ligation, flap coverage, fibrin glue, or talc pleurodesis; few successful medical therapeutics are available. We report a case of a high-output chylothorax refractory to aggressive medical and surgical interventions. Chyle output decreased substantially after initiating midodrine, an α1-adrenergic agonist that causes vasoconstriction of the lymph system, reducing chyle flow. This case report suggests that midodrine may be a novel therapeutic for refractory chyle leaks.

PMID 24008957  Chest. 2013 Sep;144(3):1055-1057. doi: 10.1378/chest.12・・・
著者: Parthipan Sivakumar, Liju Ahmed
雑誌名: Chest. 2018 Jul;154(1):e1-e4. doi: 10.1016/j.chest.2018.02.005.
Abstract/Text A 70-year-old woman presents with recurrent idiopathic chylothorax refractory to both medical and surgical treatment. To our knowledge, this is the first reported case where midodrine, an alpha-1 receptor agonist, was used as an adjunctive therapy for idiopathic chylothorax resulting in both a radiographic and clinical response.

Copyright © 2018 American College of Chest Physicians. All rights reserved.
PMID 30044748  Chest. 2018 Jul;154(1):e1-e4. doi: 10.1016/j.chest.2018・・・
著者: D C Mares, P N Mathur
雑誌名: Chest. 1998 Sep;114(3):731-5.
Abstract/Text STUDY OBJECTIVES: Recurrent chylothorax as a complication of lymphoma has had unsatisfactory outcomes. Serial thoracentesis, tube thoracostomy, and pleurodesis via chest tube have been ineffective and compromise the nutritional and immune status of the patient. Medical thoracoscopic talc pleurodesis has been safe and effective in the treatment of some other varieties of recurrent pleural effusions. Our objective was to investigate the safety and efficacy of medical thoracoscopic talc pleurodesis in the palliation of chylothorax related to lymphoma.
DESIGN: This is a report of 24 hemithoraces treated in 19 consecutive patients with lymphoma-related chylothorax, failing chemotherapy or radiation therapy. The average patient age was 55 years.
INTERVENTIONS: Medical thoracoscopy was performed under local anesthesia and conscious sedation in a bronchoscopy suite. Sedation included midazolam (mean dose, 6 mg; range, 2-14 mg) with either meperidine (mean dose, 94 mg; range 25-140 mg), or morphine (mean dose, 18 mg; range 4-40 mg). Pleurodesis was performed with insufflation of sterile asbestos-free talc, (4-8 g). After pleurodesis, chest tubes were placed, with the mean duration of chest tube placement being 4 days, range 3 to 10 days.
RESULTS: One patient died a few days after the procedure due to causes related to the primary disease process. Follow-up was for at least 90 days following the procedure. Patients were assessed at 30, 60, and 90 days following the procedure. At each of these endpoints, all patients remaining alive were without recurrence of pleural effusions, which was confirmed by chest radiography. Eight patients in the series died of the effects of their malignancy during the 90-day evaluation interval. Complications included medication reactions in two patients (8.3%) and ARDS in one patient (4.1%).
CONCLUSION: Many patients with lymphoma-related chylothorax are refractory to chemotherapy and/or radiation therapy. In this group, medical thoracoscopic talc pleurodesis has an acceptable complication rate and a 100% success rate in the prevention of recurrence of pleural effusions at 30, 60, and 90 days following the procedure.

PMID 9743158  Chest. 1998 Sep;114(3):731-5.
著者: Enrique Alejandre-Lafont, Christoph Krompiec, Wigbert S Rau, Gabriele A Krombach
雑誌名: Acta Radiol. 2011 Apr 1;52(3):305-11. doi: 10.1258/ar.2010.090356.
Abstract/Text BACKGROUND: The number of conventional lymphographies has declined markedly since the introduction of cross-sectional imaging techniques. Nevertheless, lymphography has a high potential as a reliable method to visualize and directly occlude lymphatic leaks. When used as a distinct radiological procedure with the intention to treat, this application can be described as therapeutic lymphography.
PURPOSE: To investigate if therapeutic lymphography is a reliable method to treat lymphatic leakage when conservative treatment fails and to investigate which parameters influence the success rate.
MATERIAL AND METHODS: Between August 1995 and January 2008, 50 patients with lymphatic leakage in form of chylothorax, chylous ascites, lymphocele, and lymphatic fistulas underwent conventional therapeutic lymphography after failure of conservative therapy. Of these 50 patients, seven could not be statistically evaluated in our retrospective study: one patient died of cancer 1 day after lymphography, and six were excluded due to various technical problems. The remaining 43 patients were evaluated. Therapeutic success was evaluated and correlated to the volume of lymphatic leakage (more or less than 500 mL/day), as assessed by drainage.
RESULTS: In nearly 79% of patients, the location of the leak could be detected, and surgical intervention could be planned when therapeutic lymphography failed. Due to the irrigating effect of the contrast medium (lipiodol), the lymphatic leak could be completely occluded in 70% of patients when the lymphatic drainage volume was less than 500 mL/day. Even when lymphatic drainage was higher than 500 mL/day, therapeutic lymphography was still successful in 35% of the patients. The overall success rate in patients with failed conservative treatment was 51%. Success did not depend on other factors such as age and sex, cause of lymph duct damage, or time elapsed between lymphatic injury and intervention.
CONCLUSION: Therapeutic lymphography is an effective method in the treatment of lymphatic leakage when conservative therapy fails. The volume of lymphatic drainage per day is a significant predictor of the therapeutical success rate.

PMID 21498367  Acta Radiol. 2011 Apr 1;52(3):305-11. doi: 10.1258/ar.2・・・
著者: Sebastian Kos, Harald Haueisen, Ulrich Lachmund, Thomas Roeren
雑誌名: Cardiovasc Intervent Radiol. 2007 Sep-Oct;30(5):968-73. doi: 10.1007/s00270-007-9026-5.
Abstract/Text Since the advent of computed tomography, numbers and expertise in Lymphangiography (LAG) have markedly dropped. The intention of our study was to demonstrate the persisting diagnostic and therapeutic impact of LAG on the postoperative patient with known or suspected lymphatic vessel leakage. Between May 1, 1999, and April 30, 2006, we investigated pedal lipiodol-LAGs (18 monopedal, 2 bipedal) on 22 patients (16 male, 6 female) with known or suspected postoperative chylothorax, chylaskos, lymphocele, or lymphatic fistula. Ages varied from 26 to 81 years. The spectrum of operative procedures was broad: 6 thoracic, 5 abdominal, and 11 peripheral operations were performed. In 20 patients who underwent mono- or bipedal LAG for lymphatic vessel injury, we were able to demonstrate the specific site of leakage in 15 cases (75%) and found signs of extravasation in 5 patients (25%). Furthermore, in 11 patients (55%) we were able to avoid surgery because of closure of the leak after LAG. As the conservative therapeutic approach usually takes 2-3 weeks to reveal its therapeutic effects, 73.3% (11/15) of the patients who were not reoperated before this hallmark was passed did not need any further operation. Our study clearly demonstrates that even in the decades of modern cross-sectional imaging, classic LAG is a powerful and highly reliable tool to visualize and even assist occlusion of the postoperatively damaged lymphatic vessel and may thereby avoid the need for reoperation.

PMID 17508245  Cardiovasc Intervent Radiol. 2007 Sep-Oct;30(5):968-73.・・・
著者: Mitsuhiro Momose, Satoshi Kawakami, Tomonobu Koizumi, Kazuo Yoshida, Shintaro Kanda, Ryoichi Kondo, Masumi Kadoya
雑誌名: Radiat Med. 2008 Oct;26(8):508-11. doi: 10.1007/s11604-008-0265-4. Epub 2008 Oct 31.
Abstract/Text Technetium-99m human serum albumin diethylene-triaminepentaacetic acid (HSA-DTPA) lymphoscintigraphy with single photon emission computed tomography combined with integrated low-dose computed tomography (SPECT/CT) is useful for evaluating chylothorax. We report a case of chylothorax that occurred 2 months after childbirth in a 24-year-old woman. Lymphoscintigraphy with SPECT/CT showed abnormal tracer accumulation in the right plural effusion, and chylothorax was diagnosed. Collateral branches of the thoracic duct were found to be ruptured during video-assisted thoracoscopic surgery performed for ligation.

PMID 18975054  Radiat Med. 2008 Oct;26(8):508-11. doi: 10.1007/s11604-・・・
著者: A Qureshy, K Kubota, S Ono, T Sato, H Fukuda
雑誌名: Clin Nucl Med. 2001 Oct;26(10):847-55.
Abstract/Text PURPOSE: To investigate the use of orally administered iodine-123-labeled 15-(4-iodophenyl)-3(R,S)-methyl-pentadecanoic acid (I-123 BMIPP) for thoracic duct imaging in normal and pathologic states and to study the tracer distribution and dynamics in healthy participants.
METHODS: The radiotracer was administered with solid (in three healthy persons and one patient) or liquid meals (in three other healthy persons). Solid meals contained relatively more fat content than did the liquid meal. Images were acquired to trace the passage of radiotracer from the intestine to the systemic venous circulation via the lymphatic route. Multiple static planar images were acquired in the anterior and posterior views. Blood samples were analyzed for radioactivity and serum triglyceride levels.
RESULTS: In the healthy participants, I-123 BMIPP was absorbed from the intestine and reached the venous circulation through the thoracic duct. The thoracic part of the duct was visualized successfully in all healthy persons within 80 minutes. The radiotracer dynamics varied according to the type of meal administered. The patient had chylomediastinum and right chylothorax and underwent thoracic duct ligation. In the patient, marked stasis in the collateral lymphatic channels was seen, as was chylous leakage into the mediastinal space and right pleural cavity. Passage of tracer to the general venous circulation was delayed. A normal thoracic duct was not seen in this patient.
CONCLUSIONS: Scintigraphy by orally administered I-123 BMIPP is a simple method to image the thoracic duct and to monitor its lesions. Meals with a higher fat content result in better BMIPP absorption and may be used as a standard method.

PMID 11564922  Clin Nucl Med. 2001 Oct;26(10):847-55.
著者: Kimihiko Sugiura, Yoshio Tanabe, Toshihide Ogawa, Takeshi Tokushima
雑誌名: Ann Nucl Med. 2005 Oct;19(7):597-601.
Abstract/Text The authors present a 71-year-old woman who had a right chylothorax after right upper lobectomy for lung cancer. As the chylothorax was considered to be due to thoracic duct injury at the time of operation, lymphoscintigraphy was performed by oral administration of I-123 beta-methyl-iodophenyl pentadecanoic acid (BMIPP). After visualization of the stomach and intestine, abnormal accumulation of the radiotracer was found initially around the right pulmonary hilum and then spread laterally in the upper pleural cavity, indicating chyle leakage in the region of the right pulmonary hilum. Scintigraphic finding was well correlated with the subsequent thoracoscopic observation, showing chyle leakage from a lymphatic tributary near its confluence to the thoracic duct at the level of the azygos continuation. The disruption site was ligated by video-assisted-thoracoscopic-surgery procedure with successful termination of the chyle leakage. Lymphoscintigraphy by oral administration of I-123 BMIPP is thought to be a useful method for localization of chyle leakage in patients with chylothorax induced by thoracic surgery.

PMID 16363625  Ann Nucl Med. 2005 Oct;19(7):597-601.
著者: Constantin Cope, Larry R Kaiser
雑誌名: J Vasc Interv Radiol. 2002 Nov;13(11):1139-48.
Abstract/Text PURPOSE: To demonstrate the applicability, technique, and efficacy of percutaneous transabdominal catheter embolization or needle disruption of retroperitoneal lymphatic vessels in the treatment of high-output or unremitting chylothorax.
MATERIALS AND METHODS: Forty-two patients (21 men, 21 women; mean age, 56 y; range, 19-80 y) who had chylothorax with various etiologies were referred from the thoracic surgery department for treatment as soon as chylothorax was documented. The thoracic duct was punctured and catheterized via a peritoneal cannula to facilitate embolization with use of microcoils, particles, or glue; if there were no lymph trunks that could be catheterized, attempts were made to disrupt lymph collaterals with use of needles.
RESULTS: The thoracic duct was catheterized in 29 patients and embolized in 26 patients. In patients with lymph trunks that could be catheterized, treatment resulted in cure within 7 days in 16 patients and partial response with cure within 3 weeks in six patients. In the patients with lymph trunks that could not be catheterized (n = 16), disruption with use of needles resulted in cure in five patients and partial response in two patients. Cure and partial response rates after thoracic duct embolization and needle disruption were 73.8%, with no morbidity. Surgical thoracic duct ligation was performed in seven patients. The nonprocedural mortality rate was 19%. Follow-up was 3 months or longer.
CONCLUSIONS: Effective percutaneous treatment of high-output or medically uncontrollable chylothorax was performed promptly and safely in more than 70% of referred cases. This procedure should be attempted, especially if patients are very ill, before riskier surgical thoracic duct ligation is considered.

PMID 12427814  J Vasc Interv Radiol. 2002 Nov;13(11):1139-48.
著者: Maxim Itkin, John C Kucharczuk, Andrew Kwak, Scott O Trerotola, Larry R Kaiser
雑誌名: J Thorac Cardiovasc Surg. 2010 Mar;139(3):584-89; discussion 589-90. doi: 10.1016/j.jtcvs.2009.11.025. Epub 2009 Dec 29.
Abstract/Text OBJECTIVE: To demonstrate the efficacy of a minimally invasive, nonoperative, catheter-based approach to the treatment of traumatic chyle leak.
METHODS: A retrospective review of 109 patients was conducted to assess the efficacy of thoracic duct embolization or interruption for the treatment of high-output chyle leak caused by injury to the thoracic duct.
RESULTS: A total of 106 patients presented with chylothorax, 1 patient presented with chylopericardium, and 2 patients presented with cervical lymphocele. Twenty patients (18%) had previous failed thoracic duct ligation. In 108 of 109 patients, a lymphangiogram was successful. Catheterization of the thoracic duct was achieved in 73 patients (67%). In 71 of these 73 patients, embolization of the thoracic duct was performed. Endovascular coils or liquid embolic agent was used to occlude the thoracic duct. In 18 of 33 cases of unsuccessful catheterization, thoracic duct needle interruption was attempted below the diaphragm. Resolution of the chyle leak was observed in 64 of 71 patients (90%) post-embolization. Needle interruption of the thoracic duct was successful in 13 of 18 patients (72%). In 17 of the 20 patients who had previous attempts at thoracic duct ligation, embolization or interruption was attempted and successful in 15 (88%). The overall success rate for the entire series was 71% (77/109). There were 3 (3%) minor complications.
CONCLUSION: Catheter embolization or needle interruption of the thoracic duct is safe, feasible, and successful in eliminating a high-output chyle leak in the majority (71%) of patients. This minimally invasive, although technically challenging, procedure should be the initial approach for the treatment of a traumatic chylothorax.

Published by Mosby, Inc.
PMID 20042200  J Thorac Cardiovasc Surg. 2010 Mar;139(3):584-89; discu・・・
著者: Stuart Lyon, Nigel Mott, Jim Koukounaras, Jen Shoobridge, Patricio Vargas Hudson
雑誌名: Cardiovasc Intervent Radiol. 2013 Jun;36(3):599-607. doi: 10.1007/s00270-013-0605-3. Epub 2013 Apr 12.
Abstract/Text Chylothorax is an uncommon type of pleural effusion whose etiology may be classified as traumatic or nontraumatic. Low-output chylothoraces usually respond well to conservative management, whereas high-output chylothoraces are more likely to require surgical or interventional treatment. Conservative management focuses on alleviation of symptoms, replacement of fluid and nutrient losses, and reduction of chyle output to facilitate spontaneous healing. Surgical management can be technically difficult due to the high incidence of variant anatomy and the high-risk patient population. Percutaneous treatments have rapidly developed and evolved during the past 14 years to represent a minimally invasive treatment compared with the more invasive nature of surgery. Percutaneous therapies provide a range of treatment options despite difficult or variant anatomy, with a reported high success rate coupled with low morbidity and mortality. This article is a review of etiology, diagnosis, and treatment of chylothorax, with a focus on interventional management techniques.

PMID 23580112  Cardiovasc Intervent Radiol. 2013 Jun;36(3):599-607. do・・・
著者: David Laslett, Scott O Trerotola, Maxim Itkin
雑誌名: J Vasc Interv Radiol. 2012 Jan;23(1):76-9. doi: 10.1016/j.jvir.2011.10.008. Epub 2011 Nov 23.
Abstract/Text PURPOSE: Thoracic duct (TD) embolization (TDE) has become a universally accepted treatment of chylous pleural effusion. However, the long-term sequelae of occlusion of the TD are unknown. The objective of the present study was to determine the rate of delayed complications after technically successful TDE.
MATERIALS AND METHODS: A total of 169 patients underwent TDE for symptomatic chylous effusion between January 1, 1994, and June 11, 2010. In 106 of 169 cases (63%), TDE embolization was technically successful. Retrospective review of these charts was performed, and patients were interviewed to determine the development of lower-extremity edema, diarrhea, abdominal swelling, and other symptoms.
RESULTS: Follow-up information was available in 78 of 106 patients (73.6%). Mean length of follow-up was 34 months. During follow-up, 32 patients (41%) died of causes unrelated to TDE, and 46 (59%) were alive at the end of follow-up. The families of three deceased patients were available for interview. Four of 49 patients (8%) had chronic leg swelling that was probably related to the procedure, three (6%) had abdominal swelling, and six (12%) had chronic diarrhea. In four of these six cases, diarrhea was considered "probably related" to the procedure. Overall, a 14.3% rate of probably-related long-term complications after TDE was recorded.
CONCLUSIONS: Chronic diarrhea and lower-extremity swelling may be related to TDE and should be part of informed consent before the procedure. A prospective follow-up study is needed to further establish these relationships.

Copyright © 2012 SIR. Published by Elsevier Inc. All rights reserved.
PMID 22115569  J Vasc Interv Radiol. 2012 Jan;23(1):76-9. doi: 10.1016・・・
著者: Philippe Guillem, Ioannis Papachristos, Christophe Peillon, Jean-Pierre Triboulet
雑誌名: Interact Cardiovasc Thorac Surg. 2004 Mar;3(1):156-60. doi: 10.1016/S1569-9293(03)00263-9.
Abstract/Text Etilefrine, a sympathomimetic drug, was used 11 times in 10 patients with thoracic (n=8) or abdominal (n=2) chyle leak occurring after thoracic surgical procedures. It was given as a 4.2-5 mg/h intravenous infusion. During the 11 etilefrine administrations, three patients had total parenteral nutrition, three had enteral nutrition, three had oral fat-free diet and medium-chain triglyceride supplementation, and two were fed orally without restriction. Daily chyle flow output decreased in all but one patient who was reoperated. Chyle flow output did not decrease relevantly in one patient who was reoperated. Chylothorax recurred after reoperation and etilefrine then induced significant output decrease. In another patient, etilefrine was stopped despite significant output reduction because of interactions with other sympathomimetic drugs used for heart failure. The mean etilefrine treatment duration was 6.4 days (range 4-7). The mean daily output was from 740 ml before etilefrine infusion to 183 ml on the seventh day of etilefrine use. By inducing contraction of the smooth muscle fibres present in the wall of the main thoracic chyle ducts, etilefrine can be considered as a useful adjunct in the management of post-operative chyle leak.

PMID 17670203  Interact Cardiovasc Thorac Surg. 2004 Mar;3(1):156-60. ・・・

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