Chylothorax

Der Chylothorax ist ein schwerwiegendes und potenziell lebensbedrohliches Krankheitsbild unterschiedlichster Ätiologie. Dieser Beitrag gibt einen detaillierten Überblick über Anatomie, Physiologie, Ätiologie, Diagnostik und Therapieoptionen im Kontext des Chylothorax.

Abstract

Chylothorax is a serious and potentially life-threatening condition of diverse etiology. This article provides a detailed overview of anatomy, physiology, etiology, diagnosis, and therapeutic options in the context of chylothorax.

Kernaussagen

• Der Chylothorax ist ein seltenes Krankheitsbild, das unbehandelt mit einer hohen Morbidität und Letalität einhergeht.

• Es gibt traumatische und nicht traumatische Ursachen.

• Zur Diagnose gehören die Messung von Cholesterin und Triglyzeriden sowie der Nachweis von Chylomikronen in der Pleuraflüssigkeit.

• Zu den Komplikationen gehören der Verlust von Flüssigkeit, Proteinen und Elektrolyten sowie Unterernährung, Immunsuppression und Atemnot.

• Die Chylusleckage pro Tag entscheidet über die Indikation für ein konservatives oder operatives Vorgehen.

• Die meisten Patient*innen profitieren von einem abgestuften Behandlungsplan, der von den am wenigsten invasiven bis zu den invasiveren Techniken reicht.

Schlüsselwörter

Chylothorax - Pleuraerguss - Ligatur des Ductus thoracicus - Embolisation des Ductus thoracicus - Lymphografie

Keywords

chylothorax - pleural effusion - thoracic duct ligation - thoracic duct embolization - lymphography

Publication History

Article published online:
05 March 2024

• Literatur

• 1 Langford RJ, Daudia AT, Malins TJ. A morphological study of the thoracic duct at the jugulo-subclavian junction. J Craniomaxillofac Surg 1999; 27: 100-104 DOI: 10.1016/s1010-5182(99)80021-3. (PMID: 10342146)
• 2 Skandalakis JE, Skandalakis LJ, Skandalakis PN. Anatomy of the lymphatics. Surg Oncol Clin N Am 2007; 16: 1-16 DOI: 10.1016/j.soc.2006.10.006. (PMID: 17336233)
• 3 Bessone LN, Ferguson TB, Burford TH. Chylothorax. Ann Thorac Surg 1971; 12: 527-550 DOI: 10.1016/s0003-4975(10)65800-6. (PMID: 4942619)
• 4 Johnstone DW. Anatomy of the thoracic Duct and Chylothorax. In: Shields TW, Locicero III J, Reed CE, Feins RH. General Thoracic Surgery. Philadelphia: Lippincott Williams & Wilkins; 2009: 827-833
• 5 Marchbank A, Ahmed EM. Chylothorax. In: Moorjani N, Viola N, Walker WS. Key Questions in Thoracic Surgery. Shrewsbury: tfm Publishing Limited; 2016: 695-706
• 6 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. (PMID: 19766473)
• 7 Silen ML, Weber TR. Management of thoracic duct injury associated with fracture-dislocation of the spine following blunt trauma. J Trauma 1995; 39: 1185-1187 DOI: 10.1097/00005373-199512000-00033. (PMID: 7500419)
• 8 Cammarata SK, Brush jr RE, Hyzy RC. Chylothorax after childbirth. Chest 1991; 99: 1539-1540 DOI: 10.1378/chest.99.6.1539. (PMID: 2036852)
• 9 Worthington MG, de Groot M, Gunning AJ. et al. Isolated thoracic duct injury after penetrating chest trauma. Ann Thorac Surg 1995; 60: 272-274 DOI: 10.1016/0003-4975(95)00415-h. (PMID: 7646086)
• 10 Attar MA, Donn SM. Congenital chylothorax. Semin Fetal Neonatal Med 2017; 22: 234-239 DOI: 10.1016/j.siny.2017.03.005. (PMID: 28351595)
• 11 Servelle M, Nogues C, Soulie J. et al. Spontaneous, post-operative and traumatic chylothorax. J Cardiovasc Surg (Torino) 1980; 21: 475-486 (PMID: 7419565)
• 12 Brotons ML, Bolca C, Frechette E. et al. Anatomy and physiology of the thoracic lymphatic system. Thorac Surg Clin 2012; 22: 139-153 DOI: 10.1016/j.thorsurg.2011.12.002. (PMID: 22520281)
• 13 Wasmuth-Pietzuch A, Hansmann M, Bartmann P. et al. Congenital chylothorax: lymphopenia and high risk of neonatal infections. Acta Paediatr 2004; 93: 220-224 DOI: 10.1080/08035250310007312. (PMID: 15046278)
• 14 Nair SK, Petko M, Hayward MP. Aetiology and management of chylothorax in adults. Eur J Cardiothorac Surg 2007; 32: 362-369 DOI: 10.1016/j.ejcts.2007.04.024. (PMID: 17580118)
• 15 Lim KG, Rosenow 3rd EC, Staats B. et al. Chyloptysis in adults: presentation, recognition, and differential diagnosis. Chest 2004; 125: 336-340 DOI: 10.1378/chest.125.1.336. (PMID: 14718464)
• 16 Heinrich PC, Löffler G. Lipoproteine – Transportformen der Lipide im Blut. In: Heinrich PC, Müller M, Graeve L, Koch HG. Löffler/Petrides Biochemie und Pathobiochemie. Berlin: Springer; 2022: 389-399 DOI: 10.1007/978-3-662-60266-9_24
• 17 Rahman NM, Chapman SJ, Davies RJ. Pleural effusion: a structured approach to care. Br Med Bull 2004; 72: 31-47 DOI: 10.1093/bmb/ldh040. (PMID: 15767562)
• 18 Sahn SA. Pleural fluid analysis: narrowing the differential diagnosis. Semin Respir Crit Care Med 1987; 9: 22-29
• 19 Romero S, Martin C, Hernandez L. et al. Chylothorax in cirrhosis of the liver: analysis of its frequency and clinical characteristics. Chest 1998; 114: 154-159 DOI: 10.1378/chest.114.1.154. (PMID: 9674463)
• 20 Agrawal A, Chaddha U, Kaul V. et al. Multidisciplinary Management of Chylothorax. Chest 2022; 162: 1402-1412 DOI: 10.1016/j.chest.2022.06.012. (PMID: 35738344)
• 21 Toliyat M, Singh K, Sibley RC. et al. Interventional radiology in the management of thoracic duct injuries: Anatomy, techniques and results. Clin Imaging 2017; 42: 183-192 DOI: 10.1016/j.clinimag.2016.12.012. (PMID: 28103513)
• 22 Stecker MS, Fan CM. Lymphangiography for Thoracic Duct Interventions. Tech Vasc Interv Radiol 2016; 19: 277-285 DOI: 10.1053/j.tvir.2016.10.010. (PMID: 27993323)
• 23 Liao S, von der Weid PY. Lymphatic system: an active pathway for immune protection. Semin Cell Dev Biol 2015; 38: 83-89 DOI: 10.1016/j.semcdb.2014.11.012. (PMID: 25534659)
• 24 Kim KW, Song JH. Emerging Roles of Lymphatic Vasculature in Immunity. Immune Netw 2017; 17: 68-76 DOI: 10.4110/in.2017.17.1.68. (PMID: 28261022)
• 25 Sriram K, Meguid RA, Meguid MM. Nutritional support in adults with chyle leaks. Nutrition 2016; 32: 281-286 DOI: 10.1016/j.nut.2015.08.002. (PMID: 26472113)
• 26 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; 146: 571-574 DOI: 10.1016/j.jtcvs.2013.04.015. (PMID: 23764409)
• 27 Jensen GL, Mascioli EA, Meyer LP. et al. Dietary modification of chyle composition in chylothorax. Gastroenterology 1989; 97: 761-765 DOI: 10.1016/0016-5085(89)90650-1. (PMID: 2502466)
• 28 Al-Zubairy SA, Al-Jazairi AS. Octreotide as a therapeutic option for management of chylothorax. Ann Pharmacother 2003; 37: 679-682 DOI: 10.1345/aph.1C265. (PMID: 12708946)
• 29 Kalomenidis I. Octreotide and chylothorax. Curr Opin Pulm Med 2006; 12: 264-267 DOI: 10.1097/01.mcp.0000230629.73139.26. (PMID: 16825878)
• 30 Bryant AS, Minnich DJ, Wei B. et al. The incidence and management of postoperative chylothorax after pulmonary resection and thoracic mediastinal lymph node dissection. Ann Thorac Surg 2014; 98: 232-235 DOI: 10.1016/j.athoracsur.2014.03.003.
• 31 Evans J, Clark MF, Mincher L. et al. Chylous effusions complicating lymphoma: a serious event with octreotide as a treatment option. Hematol Oncol 2003; 21: 77-81 DOI: 10.1002/hon.710.
• 32 Hillerdal G. Yellow nail syndrome: treatment with octreotide. Clin Respir J 2007; 1: 120-121 DOI: 10.1111/j.1752-699X.2007.00022.x. (PMID: 20298292)
• 33 Markham KM, Glover JL, Welsh RJ. et al. Octreotide in the treatment of thoracic duct injuries. Am Surg 2000; 66: 1165-1167 (PMID: 11149591)
• 34 Mincher L, Evans J, Jenner MW. et al. The successful treatment of chylous effusions in malignant disease with octreotide. Clin Oncol (R Coll Radiol) 2005; 17: 118-121 DOI: 10.1016/j.clon.2004.06.016.
• 35 Guillem P, Papachristos I, Peillon C. et al. Etilefrine use in the management of post-operative chyle leaks in thoracic surgery. Interact Cardiovasc Thorac Surg 2004; 3: 156-160 DOI: 10.1016/S1569-9293(03)00263-9. (PMID: 17670203)
• 36 Liou DZ, Warren H, Maher DP. et al. Midodrine: a novel therapeutic for refractory chylothorax. Chest 2013; 144: 1055-1057 DOI: 10.1378/chest.12-3081. (PMID: 24008957)
• 37 Majdalany BS, Murrey DA, Kapoor BS. et al. ACR Appropriateness Criteria® Chylothorax Treatment Planning. J Am Coll Radiol 2017; 14 (Suppl. 05) S118-S126 DOI: 10.1016/j.jacr.2017.02.025. (PMID: 28473067)
• 38 Misthos P, Kanakis MA, Lioulias AG. Chylothorax complicating thoracic surgery: conservative or early surgical management?. Updates Surg 2012; 64: 5-11 DOI: 10.1007/s13304-012-0133-8. (PMID: 22241168)
• 39 Varshney VK, Suman S, Garg PK. et al. Management options for post-esophagectomy chylothorax. Surg Today 2021; 51: 678-685 DOI: 10.1007/s00595-020-02143-y. (PMID: 32944822)
• 40 Huggins JT. Chylothorax and cholesterol pleural effusion. Semin Respir Crit Care Med 2010; 31: 743-750 DOI: 10.1055/s-0030-1269834. (PMID: 21213206)
• 41 Patterson GA, Todd TR, Delarue NC. et al. Supradiaphragmatic ligation of the thoracic duct in intractable chylous fistula. Ann Thorac Surg 1981; 32: 44-49 DOI: 10.1016/s0003-4975(10)61372-0. (PMID: 7247560)
• 42 Pillay TG, Singh B. A review of traumatic chylothorax. Injury 2016; 47: 545-550 DOI: 10.1016/j.injury.2015.12.015. (PMID: 26776461)
• 43 Cerfolio RJ, Allen MS, Deschamps C. et al. Postoperative chylothorax. J Thorac Cardiovasc Surg 1996; 112: 1361-1365 DOI: 10.1016/S0022-5223(96)70152-6. (PMID: 8911335)
• 44 Reisenauer JS, Puig CA, Reisenauer CJ. et al. Treatment of Postsurgical Chylothorax. Ann Thorac Surg 2018; 105: 254-262 DOI: 10.1016/j.athoracsur.2017.07.021. (PMID: 29132697)
• 45 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. (PMID: 20124878)
• 46 Cho HJ, Kim DK, Lee GD. et al. Chylothorax complicating pulmonary resection for lung cancer: effective management and pleurodesis. Ann Thorac Surg 2014; 97: 408-413 DOI: 10.1016/j.athoracsur.2013.10.065. (PMID: 24365215)
• 47 Paul S, Altorki N, Port J. et al. Surgical management of chylothorax. Thorac Cardiovasc Surg 2009; 57: 226-228 DOI: 10.1055/s-0029-1185457. (PMID: 19670117)