Chylothorax, the accumulation of fatty fluid within the chest cavity, is associated with multiple etiologies including surgical injuries. A rare complication of acupuncture in a 37-year-old woman who developed left pneumothorax and pleural fluid collection after acupuncture was performed on the neck and upper back is described. Chest tube drainage resulted in complete lung expansion, and analysis of the milky fluid revealed chyle leakage. Conservative treatment with a diet low in lipids and rich in medium-chain triacylglycerols allowed extubation. Acupuncture-induced thoracic duct injury, although extremely rare, should be considered as a cause of chylothorax.

BACKGROUND: Chylothorax is a very rare but major complication in thyroid surgery and should be apparent to clinicians in this field. CASE PRESENTATION: We report a case with chylothrax after thyroid surgery in our department that drew our attention. METHODS: Systematic review of the literature to evaluate the incidence and the contributing factors of chylothorax after thyroid surgery. Database (PubMed) and hand searches to identify patients with thyroid surgery and postoperative chylothorax. Keywords included chylothorax, thyroidectomy, thyroid surgery and complications. Two independent reviewers screened studies against inclusion and exclusion criteria. Patient characteristics, risk factors, symptoms, treatments and etiopathogenesis were investigated. RESULTS: We identified 13 articles in the literature describing 19 patients with chylothorax after thyroidectomy and described our own case. Ninety percent of the patients underwent thyroidectomy for thyroid cancer. Sixteen patients (80 %) underwent thyroidectomy with at least a left lateral neck dissection, 2 patients (10 %) underwent thyroidectomy with sternotomy, and in the remaining 2 patients (10 %), thyroidectomy with lateral neck dissection on both sides was performed with partial sternotomy. Our calculated incidence for chylothorax with total thyroidectomy and neck dissection was 1.85 %; for a thoracic approach the calculated incidence was 7.3 %. CONCLUSIONS: There are no reports of chylothorax after thyroidectomy without at least a left lateral neck dissection due to advanced thyroid cancer and/or sternotomy due to the thyroid size. The extension of thyroid surgery seems to be the main risk factor in developing chylothorax either through direct surgical trauma or through increased intraductal pressure after thoracic duct ligation. An early diagnosis of chylothorax may avoid severe metabolic or cardiopulmonary complications.

BACKGROUND: Chylothorax is a rare complication of gastric adenocarcinoma and data on its identification, prevalence and outcomes are scant. OBJECTIVES: To enable identification of gastric carcinoma as a cause of chylothorax. METHODS: A case report and a systematic review were conducted of all reported cases of gastric adenocarcinoma with chylothorax as the presenting complaint in the English literature. RESULTS: Chylothorax is a rare presenting complaint of gastric adenocarcinoma. There are only 18 case reports in the world literature, of which six are in English. Chylothorax occurred variably in gastric adenocarcinoma, either as a presenting feature or as a complication of therapy. Here, we analyze the index case and six patients in whom gastric carcinoma presented with chylothorax as the initial symptom. Respiratory features of cough and dyspnea preempted any abdominal complaint. Bilateral chylothorax (66%) with associated chylous ascites (50%) was common. Four of the six patients had skin lymphedema also as a prominent feature. The chylothoraces have been treated by therapeutic pleurocentesis, intercoastal tube drainage and restriction of oral intake. Gastric adenocarcinoma was associated with high mortality (50%) and morbidity. CONCLUSIONS: Chylothorax can be the presenting feature of gastric adenocarcinoma. A thorough search for this life-threatening disease should be done before labeling the chylothorax as idiopathic.

OBJECTIVE: Chylothorax is a rare but life-threatening condition in children. To date, there is no commonly accepted treatment protocol. Somatostatin and octreotide have recently been used for treating chylothorax in children. We set out to summarise the evidence on the efficacy and safety of somatostatin and octreotide in treating young children with chylothorax. DESIGN: Systematic review: literature search (Cochrane Library, EMBASE and PubMed databases) and literature hand search of peer reviewed articles on the use of somatostatin and octreotide in childhood chylothorax. PATIENTS: Thirty-five children treated for primary or secondary chylothorax (10/somatostatin, 25/octreotide) were found. RESULTS: Ten of the 35 children had been given somatostatin, as i.v. infusion at a median dose of 204 microg/kg/day, for a median duration of 9.5 days. The remaining 25 children had received octreotide, either as an i.v. infusion at a median dose of 68 microg/kg/day over a median 7 days, or s.c. at a median dose of 40 microg/kg/day and a median duration of 17 days. Side effects such as cutaneous flush, nausea, loose stools, transient hypothyroidism, elevated liver function tests and strangulation-ileus (in a child with asplenia syndrome) were reported for somatostatin; transient abdominal distension, temporary hyperglycaemia and necrotising enterocolitis (in a child with aortic coarctation) for octreotide. CONCLUSIONS: A positive treatment effect was evident for both somatostatin and octreotide in the majority of reports. Minor side effects have been reported, however caution should be exercised in patients with an increased risk of vascular compromise as to avoid serious side effects. Systematic clinical research is needed to establish treatment efficacy and to develop a safe treatment protocol.

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BACKGROUND: Esophagectomy is a challenging operation with considerable potential for postoperative complications, including chylothorax. METHODS: Because no randomized controlled trial or metaanalysis is available to clarify the incidence of chylothorax in esophageal cancer surgery, the authors analyzed their own institutional data for 1,856 patients and performed a systematic review using the MEDLINE database (9,794 patients) to identify risk factors, compare success rates of therapeutic approaches, and investigate long-term outcomes. RESULTS: The overall institutional chylothorax rate was 2 % (n = 39). Reoperation was performed for 69 % of the patients. No significant difference was noted between the transthoracic and transhiatal approaches. Regression analysis showed neoadjuvant treatment (odds ratio [OR], 0.302; p = 0.001) and tumor type (OR, 0.304; p = 0.002) to be independent risk factors. The systematic review included 12 studies. Chylothorax occurred for 2.6 % of the patients. Treatment favored reoperation in five studies (70-100 %) and a conservative approach in four studies (58-72 %), with equal mortality rates. No significant difference was found between the transthoracic and transhiatal approaches. CONCLUSION: Chylothorax rates are low in high-volume centers (2-3 %). No significant difference was noted between the transthoracic and transhiatal approaches. Neoadjuvant treatment and tumor type were shown to be independent risk factors. Treatment concept (reoperation vs conservative treatment) did not affect long-term survival.

A systematic review of English and non-English articles using OVID MEDLINE (1980-2014) was performed to evaluate the potential value of prophylactic ligation of the thoracic duct in preventing chylous leakage after oesophagectomy for cancer. Search terms included [Oesophagectomy OR esophagectomy] AND [chylothorax] AND [thoracic duct ligation]. Only those papers that directly compared the incidence of chylothorax in patients who underwent prophylactic ligation [ligation group (LG)] with that in those who had conservative treatment were selected [preservation group (PG)]; all the articles presenting original data and supplying sufficient information on the chylothorax rate after oesophagectomy were included. Independent extraction of articles was performed by two authors using predefined data fields, including study quality indicators. The PRISMA guidelines were carefully adhered to. A total of 5254 subjects were included in the 7 clinical studies examined into the current meta-analysis. Of these, 2179 patients underwent prophylactic ligature of the thoracic duct (LG group) and 3075 had preservation of the thoracic duct (PG group). A significant difference in terms of chylothorax rate [odd ratios (ORs) 0.47 in favour of LG, 95% confidence interval (CI) 0.27-0.80] was noted between the LG group and the PG group. According to our meta-analysis and taking into account-specific caveats, prophylactic ligation of the thoracic duct could be considered as an effective preventative measure to reduce the incidence of postoperative chylothorax.

We present a case of tuberculosis (TB) paradoxical immune reconstitution inflammatory syndrome (IRIS) complicated by chylous ascites and chylothorax in a HIV-infected child. There are few descriptions of TB IRIS in children. This case extends the clinical spectrum of TB IRIS.

ANTECEDENTES: La atención habitual del quilotórax en los recién nacidos incluye enfoques conservadores o quirúrgicos. La octreotida, un análogo de la somatostatina, se utiliza para el tratamiento de los pacientes con quilotórax refractario que no responden al tratamiento conservador. OBJETIVOS: Evaluar la eficacia y seguridad de la octreotida para el tratamiento del quilotórax en los recién nacidos. ESTRATEGIA DE BÚSQUEDA: Se hicieron búsquedas en el Registro Cochrane Central de Ensayos Controlados (Cochrane Central Register of Controlled Trials) (CENTRAL) (The Cochrane Library), MEDLINE y en EMBASE (hasta el 7 de marzo, 2010). Se evaluaron las listas de referencias de los ensayos y los resúmenes identificados de las Pediatric Academic Societies publicadas en Pediatric Research (2002 a 2009), sin restricciones de idioma. CRITERIOS DE SELECCIÓN: Se incluyeron ensayos controlados aleatorios o cuasialeatorios sobre la octreotida para el tratamiento del quilotórax congénito o adquirido en recién nacidos a término o prematuros, con cualquier dosis, duración o vía de administración. OBTENCIÓN Y ANÁLISIS DE LOS DATOS: Los datos sobre los resultados primarios (cantidad de líquido drenado, asistencia respiratoria, mortalidad) y secundarios (efectos secundarios) se obtuvieron y analizaron mediante la diferencia de medias, el riesgo relativo y la diferencia de riesgo con intervalos de confianza del 95%. RESULTADOS PRINCIPALES: No se identificaron ensayos controlados aleatorios. Se identificaron diecinueve informes de casos de 20 recién nacidos con quilotórax que recibieron octreotida por vía subcutánea o intravenosa. Catorce informes de casos describieron el uso exitoso (resolución del quilotórax), cuatro informaron fracaso (sin resolución) y uno presentó resultados equívocos luego de utilizar octreotida. El momento del inicio, la dosis, la duración y la frecuencia de las dosis variaron de manera significativa entre los estudios. LOS EFECTOS SECUNDARIOS INFORMADOS FUERON: la intolerancia gastrointestinal, los cuadros clínicos indicadores de enterocolitis necrosante y el hipotiroidismo transitorio. CONCLUSIONES DE LOS AUTORES: No es posible realizar recomendaciones sobre la base de las pruebas identificadas en esta revisión. Se requiere un registro prospectivo de pacientes con quilotórax y un ensayo controlado aleatorio multicéntrico posterior para evaluar la seguridad y eficacia de la octreotida para el tratamiento del quilotórax en los recién nacidos.

AIM: To assess the effects of 3-field lymphadenectomy for esophageal carcinoma. METHODS: We conducted a computerized literature search of the PubMed, Cochrane Controlled Trials Register, and EMBASE databases from their inception to present. Randomized controlled trials (RCTs) or observational epidemiological studies (cohort studies) that compared the survival rates and/or postoperative complications between 2-field lymphadenectomy (2FL) and 3-field lymphadenectomy (3FL) for esophageal carcinoma with R0 resection were included. Meta-analysis was conducted using published data on 3FL vs 2FL in esophageal carcinoma patients. End points were 1-, 3-, and 5-year overall survival rates and postoperative complications, including recurrent nerve palsy, anastomosis leak, pulmonary complications, and chylothorax. Subgroup analysis was performed on the involvement of recurrent laryngeal lymph nodes. RESULTS: Two RCTs and 18 observational studies with over 7000 patients were included. There was a clear benefit for 3FL in the 1- (RR = 1.16; 95%CI: 1.09-1.24; P < 0.01), 3- (RR = 1.44; 95%CI: 1.19-1.75; P < 0.01), and 5-year overall survival rates (RR = 1.37; 95%CI: 1.18-1.59; P < 0.01). For postoperative complications, 3FL was associated with significantly more recurrent nerve palsy (RR = 1.43; 95%CI: 1.28-1.60; P = 0.02) and anastomosis leak (RR = 1.26; 95%CI: 1.05-1.52; P = 0.09). In contrast, there was no significant difference for pulmonary complications (RR = 0.93; 95%CI: 0.75-1.16, random-effects model; P = 0.27) or chylothorax (RR = 0.77; 95%CI: 0.32-1.85; P = 0.69). CONCLUSION: This meta-analysis shows that 3FL improves overall survival rate but has more complications. Because of the high heterogeneity among outcomes, definite conclusions are difficult to draw.