The patient is a sixty-two-year-old man who was in a motor vehicle collision that caused a thoracic spinal fracture and a refractory thoracic duct leak. The patient was initially managed conservatively with NPO, TPN, and octreotide. However, despite optimal medical treatment, the patient was still draining 1 to 3 liters of chylous fluid daily from his chest tube. Thus, the patient was taken for operative repair.
He first underwent an esophagogastroduodenoscopy (EGD) with instillation of cream into the duodenum. Afterwards, a right-sided robot-assisted thoracoscopic thoracic duct ligation was performed. The dissection was challenging due to the inflamed tissue secondary to lung adherence to the spinal fracture and persistent chylous effusion. Multiple clips and two figure-of-eight sutures were used to successfully ligate the thoracic duct and control the chyle leak. A complete decortication of the lung was performed after ligation followed by talc pleurodesis.
Additional surgical steps demonstrated in the video include evacuation of the chylous pleural fluid, decortication of the adhesed lung from the spine, dissection and identification the thoracic duct, clipping of the thoracic duct, and additional circumferential thoracic duct dissection.
Postoperatively, the patient recovered very well. On postoperative day one, the patient was breathing comfortably on room air. On postoperative day four, the patient’s chest tubes had minimal output and were water sealed. By postoperative day eight, both chest tubes were removed and the patient was transferred out of the ICU. On postoperative day 14, the patient was discharged to rehab.
References
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- Squitieri RP, DiMeo AC. Left-sided robotic thoracic duct clipping for chylothorax. J Thorac Cardiovasc Surg. 2013 Jan;145(1):299-300. doi: 10.1016/j.jtcvs.2012.08.052. Epub 2012 Oct 3. PMID: 23040324.
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- Van Natta TL, Nguyen AT, Benharash P, French SW. Thoracoscopic thoracic duct ligation for persistent cervical chyle leak: utility of immediate pathologic confirmation. JSLS. 2009 Jul-Sep;13(3):430-2. PMID: 19793489; PMCID: PMC3015971.
- Devulapalli, Chris et al. Thoracic Duct Ligation: Right Video-assisted Thoracoscopic Surgery Approach. Operative Techniques in Thoracic and Cardiovascular Surgery. 2016 Jun;21(2): 152-159. ISSN 1522-2942.
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