Travmatik olmayan şilotoraksın cerrahi tedavisi ve sonuçları: bir vaka serisi

Öz

Arka Plan ve Amaç: Nontravmatik şilotoraks nadir görülen ancak zorlayıcı bir klinik problem olmaya devam etmektedir. Standart bir tedavi algoritması yoktur ve bu nedenle klinik deneyimlerin aktarılması yol göstericidir. Bu olgu serisinde, dokuz nontravmatik şilotoraks olgusunun; tanı, takip ve tedavi sürecindeki cerrahi deneyimlerimizi paylaşmayı amaçladık. Gereç ve Yöntemler: Nontravmatik şilotoraks kliniği ile başvuran ve daha önce herhangi bir tanısı olmayan dokuz olgunun tanı ve cerrahi tedavi sürecini retrospektif olarak analiz ettik. Bulgular: Ortalama yaşı 52,8 (27-83) olan dokuz hasta çalışmaya dahil edildi. Şilotoraksın etiyolojisinde en sık sebep malignite saptandı (%44,4). Tüm hastalara torasentezle tanı konuldu ve tüp torakostomi uygulandı. Ardından konservatif tedavi uygulanan bu hastalardan ikisinde (%22,2) tek başına konservatif tedavi yaklaşımı yeterli oldu. Geri kalan yedi (%77,8) hastada ise günlük drenaj 500 cc’nin üzerinde devam etti. Bu hastalarda talk plöredez, somatostatin ve video yardımlı torakoskopik girişim gibi ek prosedürlere ihtiyaç duyuldu. Sonuç: Tüm nontravmatik şilotoraks hastalarına başlangıçta tüp torakostomi ve konservatif tedavi yaklaşımı önerilir. Başarılı olunmaması durumunda talk plörodez ve/veya somatostatin tedavisi uygulanabilir. Buna rağmen başarı sağlanamazsa, video yardımlı torakoskopik cerrahi ile duktus torasikus ligasyonu düşünülmelidir.

Anahtar Kelimeler

• şilotoraks
• somatostatin analoğu
• lenfatik sızıntı
• torasentez
• VATS

Surgical management and outcomes of nontraumatic chylothorax: a case series

Abstract

Background and Purpose: Nontraumatic chylothorax remains a rare but challenging clinical problem. There is no standard treatment algorithm and therefore the transfer of clinical experience is instructive. In this case series, nine non-traumatic chylothorax cases; We aimed to share our surgical experiences during the diagnosis, follow-up and treatment process. Material and Methods: We retrospectively analyzed the diagnosis and surgical treatment process of nine cases who presented with non-traumatic chylothorax clinic and had no previous diagnosis. Results: Nine patients with a mean age of 52.8 (27-83) were included in the study. The most common cause of chylothorax was malignancy (44.4%). All patients were diagnosed by thoracentesis and tube thoracostomy was performed. Conservative treatment approach alone was sufficient in two (22.2%) of these patients who subsequently received conservative treatment. In the remaining seven (77.8%) patients, daily drainage continued to exceed 500 cc. These patients required additional procedures such as talc pleurodesis, somatostatin, and video-assisted thoracoscopic intervention. Conclusion: Initially, tube thoracostomy and conservative treatment approach are recommended for all non-traumatic chylothorax patients. If unsuccessful, talc pleurodesis and/or somatostatin therapy can be applied. If success is not achieved, ductus thoracicus ligation with video-assisted thoracoscopic surgery should be considered.

Kaynakça

1. 1- Cholet C, Delalandre C, Monnier-Cholley L, et al.. Nontraumatic chylothorax: nonenhanced MR lymphography. RadioGraphics 2020; 40: 1554–1573. doi: 10.1148/rg.2020200044
2. 2- Majdalany BS, Murrey DA, Kapoor BS, et al.. ACR Appropriateness Criteria® Chylothorax Treatment Planning. J Am Coll Radiol 2017; 14: S118–S126. doi: 10.1016/j.jacr.2017.02.025
3. 3- Rudrappa M, Paul M. Chylothorax. 2023 Feb 21. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan–. PMID: 29083798.
4. 4- McGrath EE, Blades Z, Anderson PB. Chylothorax: aetiology, diagnosis and therapeutic options. Respir Med 2010; 104: 1–8. doi: 10.1016/j.rmed.2009.08.010
5. 5- Pulle MV, Puri HV, Asaf BB, Bishnoi S, Yadav A, Kumar A. Chylothorax - Modalities of management and outcomes: A case series. Lung India. 2021 Mar-Apr;38(2):154-160. doi: 10.4103/lungindia.lungindia_526_20. PMID: 33687010; PMCID: PMC8098887.
6. 6- Huggins JT. Chylothorax and cholesterol pleural effusion. Semin Respir Crit Care Med 2010; 31: 743–750. doi: 10.1055/s-0030-1269834
7. 7- Aşık K, Tuğ T, Konuk S, Ali H, Aydın S. Tümör, Tüberküloz ve Şilotoraks Olgusu. Arch Clin Med Case Rep. 2018;2(3):68-74
8. 8- Cortés-Télles A, Rojas-Serrano J, Torre-Bouscoulet L. Quilotórax: frecuencia, causas y desenlaces. Neumol Cir Torax. 2010; 69(3): 157-162.

9. 9- Doerr CH, Allen MS, Nichols FC 3rd, Ryu JH. Etiology of chylothorax in 203 patients. Mayo Clin Proc. 2005 Jul;80(7):867-70.
10. 10- Schild HH, Strassburg CP, Welz A, Kalff J.Treatment options in patients with chylothorax. Dtsch Arztebl Int. 2013 Nov 29;110(48):819-26.
11. 11- Ajagopala S, Kancherla R, Ramanathan RP. Tuberculosis-Associated Chylothorax: Case Report and Systematic Review of the Literature. Respiration. 2018;95(4):260-268.
12. 12- Agrawal A, Chaddha U, Kaul V, Desai A, Gillaspie E, Maldonado F. Multidisciplinary Management of Chylothorax. Chest. 2022 Dec;162(6):1402-1412. doi: 10.1016/j.chest.2022.06.012. Epub 2022 Jun 20. PMID: 35738344.
13. 13- Ur Rehman K, Sivakumar P. Non-traumatic chylothorax: diagnostic and therapeutic strategies. Breathe (Sheff). 2022 Jun;18(2):210163. doi: 10.1183/20734735.0163-2021. Epub 2022 Aug 9. PMID: 36337134; PMCID: PMC9584559.
14. 14- Ruiz de Villa A, Spencer S, Sircar S, Bassi R, Charles K, Okonoboh P. An Unusual Case of Non-traumatic Chylothorax. Cureus. 2022 Dec 14;14(12):e32506. doi: 10.7759/cureus.32506. PMID: 36654639; PMCID: PMC9838086.
15. 15- Rajagopala S, Kancherla R, Ramanathan RP. Tuberculosis-Associated Chylothorax: Case Report and Systematic Review of the Literature. Respiration. 2018;95(4):260-268.
16. 16- Gotuzo E. Tuberculosis: ¿quilotórax o seudoquilotórax? Cartas al Director. Anales de Medicina Interna. 2005;22(9): 449-450. | Link
17. 17- Piñeros J, Caicedo V, Camacho L. Quilotórax Traumático: Presentación de un caso. Acta Médica Colombiana. 1977;2(4): 257-262. | Link
18. 18- Maldonado F, Cartin-Ceba R, Hawkins FJ, et al.. Medical and surgical management of chylothorax and associated outcomes. Am J Med Sci 2010; 339: 314–318. doi: 10.1097/MAJ.0b013e3181cdcd6c
19. 19- Gada PB, Sachdev RR, Ansari WA, Jadhav AA. Scourge of tuberculosis: A rare case of simultaneous chylothorax and chylous ascites. Lung India. 2023 May-Jun;40(3):271-274. doi: 10.4103/lungindia.lungindia_494_22. PMID: 37148027; PMCID: PMC10298829.
20. 20- Sun JD, Shum T, Behzadi F, Hammer MM. Imaging Findings of Thoracic Lymphatic Abnormalities. Radiographics. 2022 Sep-Oct;42(5):1265-1282. doi: 10.1148/rg.220040. Epub 2022 Aug 12. PMID: 35960666.
21. 21- Janardhan HP, Jung R, Trivedi CM. Lymphatic System in Organ Development, Function, and Regeneration. Circ Res. 2023 Apr 28;132(9):1181-1184. doi: 10.1161/CIRCRESAHA.123.322867. Epub 2023 Apr 27. PMID: 37104565; PMCID: PMC10155258.
22. 22- Selle J.G, Snyder 3rd, W.H, Schreiber J.T. Chylothorax: indications for surgery. Ann. Surg. 1973; 177: 245-249.
23. 23- Lim KA, Kim SH, Huh J, Kang IS, Lee HJ, Jun TG, et al. Somatostatin for postoperative chylothorax after surgery for children with congenital heart disease. J Korean Med Sci 2005; 20(6): 947-951. 19.
24. 24- Doğan R, Demircin M, Doğan OF, Öç M, Kuzgun E. Effectiveness of somatostatin in the conservative management of chylothorax. Turk J Pediatr 2004; 46(3): 262-264.
25. 25- Nadolski G. Nontraumatic Chylothorax: Diagnostic Algorithm and Treatment Options. Tech Vasc Interv Radiol. 2016 Dec;19(4):286-290.
26. 26- Zabeck H, Muley T, Dienemann H, Hoffmann H. Management of chylothorax in adults: when is surgery indicated? Thorac Cardiovasc Surg 2011; 59(4): 243-246.
27. 27- Cho HJ, Kim DK, Lee GD, Sim HJ, Choi SH, Kim HR, et al. Chylothorax complicating pulmonary resection for lung cancer: effective management and pleurodesis. Ann Thorac Surg 2014; 97(2): 408-413.
28. 28- Akın H, Olcmen A, Isgorucu O, Denizkiran I, Dincer I. Approach to patients with chylothorax complicating pulmonary resection. Thoracic Cardiovasc Surg 2012; 60(2): 135-139.
29. 29- Kutlu CA, Sayar A, Olgac G, et al. Chylothorax: a complication following lung resection in patients with NSCLC—chylothorax following lung resection. Thorac Cardiovasc Surg 2003; 51: 342- 5.
30. 30- Takuwa T, Yoshida J, Ono S, et al. Low-fat diet management strategy for chylothorax after pulmonary resection and lymph node dissection for primary lung cancer. J Thorac Cardiovasc Surg 2013; 14: 571- 4.
31. 31- Dugue L, Sauvanet A, Farges O, Goharin A, Le Mee J, Belghiti J. Output of chyle as an indicator of treatment for chylothorax complicating oesophagectomy. BJS. 1998; 85: 1147-1149.
32. 32- Nadolski GJ, Itkin M. Feasibility of ultrasound-guided intranodal lymphangiogram for thoracic duct embolization. J Vasc Interv Radiol 2012; 23: 613–616. doi: 10.1016/j.jvir.2012.01.078.