Chylothorax: eine Übersicht über aktuelle therapeutische Möglichkeiten

Zusammenfassung

Die Möglichkeiten der Chylothoraxbehandlung sind in den letzten Jahren durch interventionell-radiologische Möglichkeiten erweitert worden. Insbesondere mit der perkutanen Ductus-thoracicus-Embolisation bestehen mittlerweile größere Erfahrungen. Dennoch sind diese Therapieoptionen nur wenig bekannt und werden auch in aktuellen Veröffentlichungen über den Chylothorax nur wenig oder gar nicht dargestellt. Dies war Anlass, die aktuellen Therapieoptionen einmal vergleichend darzulegen. Das Für und Wider der verschiedenen Behandlungsmöglichkeiten wird anhand der aktuellen Literatur diskutiert. Nach derzeitigem Erfahrungsstand ist das interventionell-radiologische Vorgehen mit geringerer Morbidität und Mortalität belastet als operative Maßnahmen. Die interventionelle Behandlung sollte daher heute in die differenzialtherapeutischen Überlegungen einbezogen werden. Unstrittig indiziert ist ein interventionelles Vorgehen bei operativen Therapieversagern, da diese interventionell sehr häufig erfolgreich behandelt werden können, sowie bei nicht operablen Patienten.

Abstract

Therapeutic options in management of chylothorax encompass conservative, surgical and also interventional measures. Despite the fact that interventions have been performed in substantial numbers of patients – particularly thoracic duct embolisations – general knowledge about this therapeutic option is still limited. Therefore, this article gives an overview of the state of the art for therapeutic options, also emphasising radiological/interventional procedures. At present, interventional treatment has lower morbidity and mortality, and is especially indicated after failed surgical therapy, or in inoperable patients.

Schlüsselwörter

Chylothorax - Intervention - postoperative Komplikation - Behandlung - Thoraxchirurgie

Key words

chylothorax - intervention - postoperative complication - treatment

• Literatur

• 1 Schild HH, Strassburg CP, Welz A. et al. Treatment options in patients with chylothorax. Dtsch Arztebl Int 2013; 110: 819-826
• 2 Glatz T, Marjanovic G, Hoeppner J. Prävention und operative Therapie des Chylothorax. Zentralbl Chir 2018; 143: 278-283
• 3 Cope C. Diagnosis and treatment of postoperative chyle leakage via percutaneous transabdominal catheterization of the cisterna chyli: a preliminary study. J Vasc Interv Radiol 1998; 9: 727-734
• 4 Schild H, Hirner A. Perkutan-translymphatische Embolisierung des Ductus thoracicus zur Therapie des Chylothorax. RöFo 2001; 173: 580-582
• 5 Reisenauer JS, Puig CA, Reisenauer CJ. et al. Treatment of postsurgical chylothorax. Ann Thorac Surg 2018; 105: 254-262
• 6 OʼCallaghan AM, Mead GM. Chylothorax in lymphoma: mechanisms and management. Ann Oncol 1995; 6: 603-607
• 7 Talwar A, Lee HJ. A contemporary review of chylothorax. Indian J Chest Dis Allied Sci 2008; 50: 343-351
• 8 Staats BA, Ellefson RD, Budahn LL. et al. The lipoprotein profile of chylous and nonchylous pleural effusions. Mayo Clin Proc 1980; 55: 700-704
• 9 Ramos W, Faintuch J. Nutritional management of thoracic duct fistulas. A comparative study of parenteral versus enteral nutrition. J Parenter Enteral Nutr 1986; 10: 519-521
• 10 Aljazairi AS, Bhuiyan TA, Alwadai AH. et al. Octreotide use in post-cardiac surgery chylothorax: a 12-year perspective. Asian Cardiovasc Thorac Ann 2017; 25: 6-12
• 11 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
• 12 McGrath EE, Blades Z, Anderson PB. Chylothorax: Aetiology, diagnosis and therapeutic options. Respir Med 2010; 105: 1-8
• 13 Schirren M, Sponholz S, Schirren J. Therapie des Chylothorax. Chirurg 2018; 89: 563-574
• 14 Zabeck H, Muley T, Dienemann H. et al. Management of chylothorax in adults: when is surgery indicated?. Thorac Cardiovasc Surg 2011; 59: 243-246
• 15 Gupta D, Ross K, Piacentino V. et al. Use of LeVeen pleuroperitoneal shunt for refractory high-volume chylothorax. Ann Thorac Surg 2004; 78: e9-e12
• 16 Tanaka E, Matsumoto K, Shindo T. et al. Implantation of a pleurovenous shunt for massive chylothorax in a patient with yellow nail syndrome. Thorax 2005; 60: 254-255
• 17 Tang H, Bai Y, Shen W. et al. Anastomosis of the thoracic duct and the azygos vein for the treatment of recurrent chylothoraxes. Eur J Cardiothorac Surg 2018; 53: 1093-1094
• 18 Pillay TG, Singh B. A review of traumatic chylothorax. Injury 2016; 47: 545-550
• 19 Hsu MC, Itkin M. Lymphatic anatomy. Tech Vasc Interv Radiol 2016; 19: 247-254
• 20 Mares DC, Mathur PN. Medical thoracoscopic talc pleurodesis for chylothorax due to lymphoma – a case series. Chest 1998; 114: 731-735
• 21 Alamdari DH, Asadi M, Rahim AN. et al. Efficacy and safety of pleurodesis using platelet-rich plasma and fibrin glue in management of postoperative chylothorax after esophagectomy. World J Surg 2018; 42: 1046-1055
• 22 Alejandre-Lafont E, Krompiec C, Rau WS. et al. Effectiveness of therapeutic lymphography on lymphatic leakage. Acta Radiol 2011; 52: 305-311
• 23 Hara H, Mihara M, Yamamoto M. Therapeutic lymphangiography for traumatic chylothorax. J Vasc Surg Venous Lymphat Disord 2018; 6: 237-240
• 24 Gruber-Rouh T, Naguib NN, Lehnert T. et al. Direct lymphangiography as treatment option of lymphatic leakage: indications, outcomes and role in patientʼs management. Eur J Radiol 2014; 83: 2167-2171
• 25 Pieper CC, Schild HH. Interstitial transpedal MR-lymphangiography of central lymphatics using a standard MR contrast agent: feasibility and initial results in patients with chylous effusions. RoFo 2018; 190: 938-945
• 26 Itkin M, Kucharczuk JC, Kwak A. et al. Nonoperative thoracic duct embolization for traumatic thoracic duct leak: experience in 109 patients. J Thorac Cardiovasc Surg 2010; 139: 584-589
• 27 Pamarthi V, Stecker MS, Schenker MP. et al. Thoracic duct embolization and disruption for treatment of chylous effusions: experience with 105 patients. J Vasc Interv Radiol 2014; 25: 1398-1404
• 28 Schild HH, Naehle CP, Wilhelm KE. et al. Lymphatic interventions for treatment of chylothorax. RoFo 2015; 187: 584-588
• 29 Boffa DJ, Sands MJ, Rice TW. et al. A critical evaluation of a percutaneous diagnostic and treatment strategy for chylothorax after thoracic surgery. Eur J Cardiothorac Surg 2008; 33: 435-439
• 30 Litherland B, Given M, Lyon S. Percutaenous radiological management of high output chylothorax with CT-guided needle disruption. J Med Imaging Radiat Oncol 2008; 52: 164-167
• 31 Binkert CA, Yucel K, Davison BD. et al. Percutaneous treatment of high-output chylothorax with embolization or needle disruption technique. J Vasc Interv Radiol 2005; 16: 1257-1262
• 32 Laumen K, Schild HH, Pieper CC. Interventionell-radiologische Behandlung einer postoperativen rechts zervikalen Chylusfistel bei anatomisch variantem Verlauf des Ductus thoracicus. RöFo 2018; 190: 361-363
• 33 Pieper CC, Schild HH. Direct cervical puncture for retrograde thoracic duct embolization in a postoperative cervical lymphatic fistula. J Vasc Interv Radiol 2015; 26: 1405-1408
• 34 Guevara CJ, Rialon KL, Ramaswamy RS. et al. US-guided, direct puncture retrograde thoracic duct access, lymphangiography, and embolization: feasibility and efficacy. J Vasc Interv Radiol 2016; 27: 1890-1896
• 35 Kariya S, Nakatani M, Ueno Y. et al. Transvenous retrograde thoracic ductography: initial experience with 13 consecutive cases. Cardiovasc Intervent Radiol 2018; 41: 406-414
• 36 Srinivasa RN, Chick JFB, Hage AN. et al. Endolymphatic thoracic duct stent-graft reconstruction for chylothorax: approach, technical success, safety, and short-term outcomes. Ann Vasc Surg 2018; 48: 97-103
• 37 Laba JM, Nguyen TK, Boldt RG. et al. Spontaneous resolution of chylothorax-associated lymphoma treated with external beam radiotherapy: a case report and comprehensive review of the literature. Cureus 2016; 8: e761
• 38 Van De Voorde L, Vanneste B, Borger J. et al. Rapid decline of follicular lymphoma-associated chylothorax after low dose radiotherapy to retroperitoneal lymphoma localization. Case Rep Hematol 2014; 2014: 684689
• 39 Gerstein J, Kofahl-Krause D, Frühauf J. et al. Complete remission of a lymphoma-associated chylothorax by radiotherapy of the celiac trunk and thoracic duct. Strahlenther Onkol 2008; 184: 484-487
• 40 Sziklavari Z, Allgäuer M, Hübner G. et al. Radiotherapy in the treatment of postoperative chylothorax. J Cardiothorac Surg 2013; 8: 72
• 41 Thomson AH, Sivalingham S, Rajesh PB. et al. Chylothorax after radiotherapy in oesophageal carcinoma. Lancet Oncol 2003; 4: 703-704
• 42 Cerfolio RJ, Allen MS, Deschamps C. et al. Postoperative chylothorax. J Thorac Cardiovasc Surg 1996; 112: 1361-1365
• 43 Paul S, Altorki NK, Port JL. et al. Surgical management of chylothorax. Thorac Cardiovasc Surg 2009; 57: 226-228
• 44 Akin H, Olcmen A, Isgorucu O. et al. Approach to patients with chylothorax complicating pulmonary resection. Thorac Cardiovasc Surg 2012; 60: 135-139
• 45 Nadolski GJ, Itkin M. Thoracic duct embolization for nontraumatic chylous effusion: Experience in 34 Patients. Chest 2013; 143: 158-163
• 46 Kariya S, Nakatani M, Yoshida R. et al. Embolization for thoracic duct collateral leakage in high-output chylothorax after thoracic surgery. Cardiovasc Intervent Radiol 2017; 40: 55-60
• 47 Milson JW, Kron IL, Rheuban KS. et al. Chylothorax: an assessment of current surgical management. J Thorac Cardiovasc Surg 1985; 89: 221-227
• 48 Lam KH, Lim ST, Wong J. et al. Chylothorax following resection of the oesophagus. Br J Surg 1979; 66: 105-109
• 49 Laslett D, Trerotola SC, Itkin M. Delayed complications following technically successful thoracic duct embolization. J Vasc Interv Radiol 2012; 23: 76-79
• 50 Nadolski GJ, Itkin M. Lymphangiography and thoracic duct embolization following unsuccessful thoracic duct ligation: imaging findings and outcomes. J Thorac Cardiovasc Surg 2018; 156: 838-843