Following my last post in Surgical Thoughts - "The challenge of a chylothorax" - my friend and mentor Prof Martin Walz mailed me a 2018 publication from his team from Essen (Germany) about a new approach to surgically ligate the thoracic duct. They used the posterior retroperitoneoscopic approach to ligate the thoracic duct. Impressive. Prof Martin Walz used his extensive experience in adrenal surgery by means of a posterior retroperitoneoscopic approach, to solve a different and life-threatening issue, chylothorax.
Chylothorax is a life-threatening complication that is associated with malnutrition and immunosuppression. Nowadays, it has a mortality rate of less than 10% in experienced hands. Conservative treatment is usually the first line. Some authors advise nill per os plus total parenteral nutrition, but other authors use a low-fat diet or medium-chain fatty acid diet, plus somatostatin. Conservative treatment should be tailored to each case's severity.
Dr. B. Seeliger et al. state in their publication in Surgical Endoscopy that postoperative chylothorax is usually due to an iatrogenic chyle leak. After placing a chest tube a milky liquid will drain. In case of doubt, fluid analysis will show triglyceride greater than 100 mg/dL and the presence of chylomicrons. When conservative treatment fails, surgical treatment or interventional radiology is mandatory to solve the chyle leak (see "The Challenge of a Chylothorax"). The conventional surgical treatment implicates a right thoracic approach (thoracotomy or thoracoscopy), many times exploring the previous surgical field, full of adhesion and inflammatory tissue, which increases the difficulty and the rate of complications and injury to other structures. Supradiaphragmatic transabdominal ligation (laparoscopic or open) by transhiatal access has also been described in a few cases. Dr. B. Seeliger, Dr. P. Alesina, and Prof. Martin Walz (Department of Surgery and Center of Minimally Invasive Surgery, Kliniken Essen-Mitte, Essen, Germany) used the posterior retroperitoneoscopic approach to ligate the thoracic duct through a "virgin" surgical field. In my opinion, this is a major advantage of this new technique.
The authors treated four cancer patients who developed a chylothorax following oncological resection with lymph node dissection (esophagectomy (2), thyroidectomy with lateral neck dissection, ovarian cancer with right-sided supradiaphragmatic lymph node removal). Two patients were previously submitted to thoracoscopy for thoracic duct ligation but failed to solve the chylothorax.
Patients were placed in the same position as for posterior retroperitoneoscopic adrenalectomy (prone position, hips at a near 90º angle, bent and supported knees). Since the thoracic duct emerges from the cisterna chyli, which is located on the anterior surface of the second lumbar vertebra, to the right side of the aorta and behind it, near the right diaphragmatic crus, a right posterior retroperitoneoscopic approach was conducted. In the four patients, a first trocar was placed at the tip of the 12th rib and a second trocar at the tip of the 11th rib. Three patients got a third trocar placed in three different locations. In the last patient, four trocars were used. The thoracic duct was identified transdiafragmatically by splitting diaphragmatic muscle fibers. The thoracic duct and collateral lymphatic vessels were ligated using absorbable clips. The thoracic drain was left in place only in three of the four patients. (Read the article for more technical details) No complications were reported. The mean operative time was 86 min. Resolution of the chylothorax was achieved in all patients. No recurrence was noted. The thyroid cancer patient was sent home three days after retroperitoneoscopic surgery. Impressive, I think.
As the authors highlight, it is important to retain the idea that the retroperitoneoscopic approach avoids the previous surgical field. In the cases of esophagectomy, there was neither manipulation of the gastric conduit nor the anastomosis. In the case of thyroid surgery, this technique avoided a neck re-exploration with the associated increased risk of recurrent laryngeal nerve or vagal nerve injury. Additionally, I think it is very difficult to find and unequivocally see the thoracic duct during a neck re-exploration. Reason why, a muscle flap or a hemostatic sponge is frequently used to cover the suspected location of the chyle leak during a neck re-exploration. For those performing thyroid surgery and neck dissection, remember that chylothorax may complicate 0.5 - 1.4% of thyroidectomies and 2-8% of neck dissections.
According to Dr. B. Seeliger et al, "the retroperitoneoscopic access allowed for a precise identification of the thoracic duct and adjacent collaterals". Due to their long experience in posterior retroperitoneoscopic adrenalectomy, they are now using this approach as a first-line surgical treatment for chylothorax. I believe all surgeons should be aware of this approach since offering a "virgin" access to treat a life-threatening complication such as a chylothorax, is the best way to achieve good outcomes. In conclusion, "retroperitoneoscopic thoracic duct ligation is a safe and effective procedure in postoperative chylothorax management".
This new way of thinking is only possible because of the extraordinary capabilities of Prof. Martin Walz as a true general surgeon, supported by a magnificent team like Dr. Barbara Seeliger and Dr. Pier Alesina. Being able to do different procedures is the key to innovating and bringing extraordinary ideas to the medical practice. Prof Martin Walz is probably one of the best surgeons I have ever worked with, who performs all different procedures of the general surgery's scope in an elegant and perfect way (open or laparoscopically). I must say thank you to Prof Walz for the friendship, and mentorship, and for introducing me to the Posterior Retroperitoneoscopic Adrenalectomy 10 years ago in Essen. I will never forget his statement: "A surgeon can have a hobby but he must know how to do everything."
Link to article:
Dr. Carlos Eduardo Costa Almeida
General Surgeon
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