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THE

    THE

ChinMedSciJ

    ;December200o

    ;CHINESE

    ;MEDICALSCIENCES

    ;JOURNAL

    ;SHoRTCoUNICAT=oN

    ;Vo1.15,No.4

    ;P.253255

    ;THETREATMENTOFCHYLOTHORAX

    ;LiShanqing(李单青),ZhangZhiyong(张志庸),LiangX~mgA() ;andCuiYushang(崔玉尚)

    ;DepartmentofThoracicSurgery,PUMCHospital,CAMS&PUMC,t~i

    ji.g100730

    ;Keywordschylothorax;iatrogenicchylothorax;spontaneouschylothorax

    ;Obj,~.TounderstandandgraspthediagnosisandtreatmentofcIly10thxcausedbyvariousreasons.

    ;Method.Thetreatmentresultsof31cAt...ae8ofchylothoraxinPUMChospita

    lfrom19631997Welt~rehI舄】)ec

    ;adyzed.

    ;Resu/ts.Among31cAt...ae8,18underwentsurgery,14of18werecured,2died.Inthe13treatedcomerva~vdy,

    ;2werecured,3died.Elevencaseswerecongenital,iatrogenicandtroun~cchylothorax,8ofthemreceivedlIcal

    ;treatmentand6of8Welt~cured.Thespontaneousc~oraxofunknowncausewere10cases.7weIetreatedby

    ;surgeryand6weIecued.

    ;Conc/us/on.SIlIgicalinterventionshouldbeaggressivelyrecommendedforthe把叫c,congenital,andiatro-

    ;gonicchylothorax.TldefiniteIe

    nmustbefoundoutforthespontaneouschylothorax,c0l?

    espcillgmanagement

    ;willbegivenacc0iltotheYea..qou.SI]li

    ;tmtion0fthethoracicductwillcontributesoodresultforthec0o-

    ;raxofunknowncause.butcombinationofmultipletreatmentnlIs_uI

    willbenecessaryforasuccessfulmanagement.

    ;Chylothoraxi8and(1iculttotreatinclinical

    ;practice.It’8etiologyiscomplex.Chylothoraxcallgreatly

    ;affectphysiology,metabolismandimmunity,delayedtreat- ;mentwi11leadto~vereconsequence.Froml9l63t0l99r7.

    ;31case8ofchylothoraxduetovariousreasousweretreatedat ;PUMCHospital,18ofthemunderwentsurgery,while13l1-

    ;ceivedcA)~rvativemanagement.Herewepresenttheclini. ;caldataandresult,chiefdiscussonitsdiagnosisandtreat. ;ReceivedforpublicationApril18.2OOO

    ;Correspondingauthor.

    ;Visitingdoctor.

    ;mentprincipleswillbefollowed.

    ;C.JCALDATA

    ;rn1el1ewere16maleand15femaleinthisseries.age ;rangedfrom15to73yrsththeaverageof40.5yrs.dis- ;easedurationwasldayto9years.-nIemainclinicalc0n

    ;plaintsincludedchesttightriersorshortnessofbreathin24. ;1withdyspnea,2withlowfever.Ieftchylothoraxwas ;foundin5casG:~,rightin7,andbothin19.Sixpatients ;combinedwithchyloperitoneum,threewithchylopericardi. ;um,andonewithchyluria.Etiologyexaminationdisclosed7 ;casesofiatrogenic(post-surgery)chylothorax;2casIesof ;traumaticchylothorax;20casesofspontaneouschylotberax, ;inwhich4duetomalignanttumor,4toTB,ltolymphan. ;

    ;CHINESEMEDICALSCIENCESJOURNAL

    ;gioma,and1toBehcet’sdisease,andtherest10casesof

    ;unknownetiology.Besides,2casesofcongenitallymphatic

    ;vesselmalformationcausingchylothoraxwerefoundinthis ;series.

    ;ChestX_myrevealedpleuraleffusionandpositiveSu

    ;daniUstainorethertestconfirmedthediagnosisinallc8$

    ;es.Otherexaminationmethodssearchingetiologyincluded ;lymphoscintigraphyin14,10ofthemwerepositiveand4 ;falsenegative;lymphangiographyin7,6ofthemshowing ;escapeofcontrastmediumfromthoracicduct,and1nor-

    surgerynutritionalstatus ;rea1.111eevaluationofthepre

    ;demonstratedhypoalbuminemiainhalfofallpatients. ;Amongourcases.18underwentsurgeryand13re

    ;ceivedconservativetreatment.1f1latterincludedlow.fatdi

    ;etortotalparenteralnutrition(TPN);repeatedthoracentesis ;orclosedthoracicdrainage;pleurodesisandetiologicaltreat

    ;ment.suchasantiTBandantitumortreatment.Among22

    ;patientswithcompletedatarecord,preoperativethorocente

    ;sisfrom1to17times.withanaverageof5times.111e ;chylevolumebythorocentesisrangedfrom1000mlto ;35000?I1.withanaverageof8783m1.Conservativetreat

    ;mentwaslastedforfivedaystosixmonths.Surgeryproce

    ;dure,i.e.thoracicductligationwasperformed,alsopleu

    ;rodesisandresectionofpleuraeviarightorleftthoracotomy.

;Intmthoracicdrainageandparenteralnutritionwaskeptpost

    ;operativelyaccordingtothepatientstatusaswellasthe ;drainagevolume,generallylastedfor4daysto4weekswith ;anaverage10days.

    ;ThetreatmentoutcomewasshowninTable1.Insurgi

    ;calinterventiongroup,14of18caseswerecured,2died, ;and2gaveupbecauseofthefinancialreason.Inconserva

    ;tivemanagementgroup,3of13wererecovered,4im

    ;proved,3nochange(2gaveup),and3died.Besides,7 ;casesofiatrogenicchylothorax,5ofthemhadthoracicduct ;ligation,3haduneventfulpostoperativecouIse,exceptone ;diedbecauseoftoolatesuIcalmanagement,anotherwith ;thymomaresectionunimprovedevenaggressivetreatment. ;Twocaseshavingconservativetreatments,onewasCUl’ed

    ;andtheotheronegaveupwithunimpmved.Inthe10cases ;ofspontaneouschylothoraxofunknownetiology,7were ;treatedbysurgery,6ofthemwerecured,1died,theother ;3receivedconservativetreatment,2ofthemweredied,1 ;wasrecovered.

    ;n

    ;Iatm~nic

    ;Congeni~

;,Bm?Ilac

    ;Spontaneous ;malignanttill/lOt

    ;benigntumor ;tubewulosis ;unknown

    ;olleIs

    ;surgery5

    ;conservative2 ;surgery2

    ;smgery1

    ;conservative1 ;surgery1

    ;conservative3 ;conservative1 ;surgery1

    ;conservative3 ;surgery7

    ;conservative3 ;surgery1

    ;1.Lymphangiographyandlymphoscintigraphyhavebeen

    ;appliedforclinicaldiagnosisofchylothoraxforseveral

    ;decades.Theoretically,lymphoscintigraphycanassessthe ;couIseofthelymphaticvessel,velocationandqualitative ;diagnosis.Lymphangiographycandemonstratetheexistence ;ofthestricture,stenosisandleakageoflymphaticvessel(1). ;Fortraumaticandiatrogenicchylothorax,lymphangiography ;andlymphoscintigraphycanidentifythelocationofthefistu

    ;la.Butforspontaneouschylothorax,thesetwomeasurements ;I

    ;1

    ;2

    ;1

    ;2

    ;cannotvesatisfactoryanswer,becausethelocationand ;etiologicdiagnosisofspontaneouschylothoraxareverydiffi

    ;cult.Inthisseries,lymphoscintigraphyonlyrevealedthe ;rupturelocationin4casesamong14o~1sesofexamined. ;Sometimes,itofferedthefalsenegativeresults,therewere4 ;casesinthisseries.Lymphangiographycouldnotvemore ;detailsaboutthelocationandoriginofthefistula,except ;chyleescape.Itisveryimportantfortheclinicaldoctorsto ;paYmoreattentiontoinquiringhistoryandcompletephysical ;examinationinsteadofonlyrelyingonthemodemtechniques

;ofexamination,suchaslympl1al1雩卿Ilyandlympho~inti

    ;414m1

    ;

    ;CHINI~EMEDICALSCIENCESJOURNAL

    ;graphy.Itismoleimportantforthoracicsurgeonstocompm

    ;hensiveanalysisandcorrectexplanationoftheclinicalmani

    ;festationsandresultsofobjectiveexamination,sotheycan ;obtainreasonableconclusionandresolvetheclinicalpmb

    ;lems.

    ;2.Itiseasytoconfirmadiagnosisofchylothorax.but ;difficulttofindouttheetiology,especiallyspontaneouschy

    ;lothorax.Thecausesoftraumaticandiatmgenicchylothorax ;areusuallyclear;however,thecauseofspontaneouschy

    ;lothoraxisquitecomplex.Insomecasesthecauseswereun

    ;knownorequivocalafterseriesofno-endedexaminations. ;Suchcasesareregardedastheindeterminablechylothorax ;(accotmtforabout10%ofallchylothorax)(2).Therewere ;10casesinthisseries.whichcomprisedof1/3ofal1.Soan ;imperativechallengebeforethoracicsurgeonswasnotonlyto ;catchtheetiologybutalsotodealwiththechylothorax.Six ;casesofunknownspontaneouschylothoraxinthisseriesre

    ;ceivedthoracicductligafionandobtaineddefinitecurative

;effects.Therefore,thoracicsurgeonsshouldCalTyoutOpera

    ;tionforthosepatientswithunknownchylothoraxafterlong- ;termmultiexaminationsandconservativetreatmentsoasto ;relievethepatients’symptoms.

    ;3.TheroleofpreoperativeoralintakeofcrlP~amorintra

    ;gastricinjectionofmethylenebluetohelprecognizethetho

    ;racicduct.Inpreviousarticlesortextbooks,preoperativein

    ;takeofcnxImorinjectionofmethylenebluewereemphasized ;ontohelptoshowthethoracicductleakageduringopera

    ;tion.Inreviewofnearly20casesoperated.wefounditis ;notaseffectiveasabovementioned.Thelacerationsoftho

    ;racicductinsomecaseswerenotasl~gularorclearlyde. ;finedasdescribedorimagination.Infact,thepleuraeof ;chylothoraxwereadhesive,thickening,paleandedematous. ;Thus.itwasdculttofindoutthebrokenendofthetho

    ;racicduct.Sometimes.thethoracicducthadbrancheswith ;notypicalmute.Wehadonlyfoundonethoracicductwith ;typicalbrokenendduringsurgeryandsawtheclearwhite ;liquidsflowingoutfromtheproximalendofthethoracicduct ;atintervals.Therefore.itwouldincreasethedimcultyto ;recognizethethoracicductifintakeofcreamorinjectionof ;methylenebluebeforeoperation.

    ;4.Comprehensivesurgicalmanagementofchylothorax: ;255

    ;comprehensivesurgicalmanagementincludedpreoperative ;nutritionsupplement;thoracicductligation;andpleurodesis; ;postoperativenutritionsupport;thoracicdrain;adhesive印一

    ;plication;andcausetreatment.Itwasadilemmahow1orig

    ;conservativetreatmentshouldbecontinued?Seele,eta1. ;(3)suggestedsurgeryshouldbeconsideredwhenthe ;drainagevolumewasmorethan15O0ml/dinadultormore ;than100ml/dinchildfor5consecutivedoys.OuroDinion ;wasthatfortraumaticoriatrogenicchylothorax,surgery ;shouldbeaggressivelyintervened.Otherauthorshadthe ;sameopinion(2,4,5).Inthisseries,onepatientwithtrau

    ;mariechylothoraxdiedbeforeoperationbeP~lllseofdelayed ;surgicaloperation.Congenitalchylothoraxshouldbesui

    ;callymanagedasearlyaspossible.Forthepatientsofspon

    ;taneouschylothorax,conservativetreatmentshouldbecontin

    ;uedforaperiod.butdefinitecausesshouldbelookedforat ;thesalnetime.

    ;Nutritionsupport,nodoubt,wasnecessaryforanychy

    ;lothoraxpatientbeforeoperation.Inourexperience,itshould ;bekeptforaboutoneweek.Surgeryshouldbedoneasstated

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