Chylothorax

Chilothorax - accumulation of lymphatic fluid in the chest cavity. This is a serious and often life-threatening condition, often causing cardiac-pulmonary insufficiency. Metabolic, electrolyte and immunological disorders.

Classification of chylothorax:

• congenital chylothorax;
• traumatic chylothorax;
• nontraumatic chylothorax.

Chiliotic pleural effusion in newborns can appear spontaneously, with congenital anomalies of the thoracic duct or birth trauma. The causes of congenital chylothorax may be anomalies in the development of the duct: anomalies of the branching of the branches of the duct in embryogenesis, congenital duct duct fistulas, congenital intracardial obstruction.

Traumatic chylothorax can occur after trauma and surgical interventions on the thoracic organs: operations on the heart, aorta, esophagus, lungs, structures of the sympathetic system. Damage to the thoracic duct during surgery is facilitated to some extent by its abnormal course. Noted in more than 50% of patients. Damage to the duct on the neck can occur with a biopsy of lymph nodes and novocain blockades.

The cause of non-traumatic chylothorax may be tumors. In particular, lymphomas and neuroblastomas sometimes lead to obstruction of the thoracic duct, and with lymphangiomatosis, the chyliform effusion appears at times in both the pleural and abdominal cavities. Also, the development of nontraumatic chylothorax is possible with thrombosis of the superior vena cava and subclavian veins, aortic aneurysm, filariasis. Right ventricular failure, etc.

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How is the chylothorax manifested?

Manifesting symptoms may be acute respiratory failure, especially tachypnea and cyanosis. In a physical examination, the symptoms of fluid accumulation in the pleural cavity are revealed - some bulging of the chest wall on the side of the lesion, a shortening of the percussion sound and a weakening of the breathing, a displacement of the heart beat in the opposite direction. Sequestration of the lymphatic fluid in the pleural cavities can lead to metabolic disorders: hypoproteinemia, meta-ololic acidosis, water, electrolyte and immune disorders. Sometimes with traumatic chylotorax, from the time of the damage to the duct to the moment of manifestation of the symptoms, several weeks pass. This is due to the development of chyloma under the mediastinal pleura, which subsequently breaks through the pleural cavity.

How to recognize chylothorax?

In this case, pleural effusion is detected in the pleural cavities, determined on the chest X-ray or ultrasound. Volumetric chylothorax, diagnosed antenatal with ultrasound. Can cause a severe respiratory distress syndrome immediately after birth and, accordingly, require an emergency pleural puncture. When aspirations of effusion in newborns usually receive a transparent straw-yellow liquid (if the child is not fed). The effusion acquires a milky color in children previously fed. Examination of the effusion usually reveals an increased lipid content (more than 4-6 g / l) and protein (above 30 g / L - its plasma content), the triglyceride level exceeds 13 mmol / l. With microscopy, lymphocytes predominate to 80-90%. These data confirm that the effusion obtained in puncture is lymph. The increase in body temperature is not typical.

Hiloenic fluid can also infiltrate the mediastinum and accumulate in the pericardial cavity (chylopericard). At the same time on the roentgenogram of the chest there is a symptom of widening of the mediastinum or enlargement of the shadow of the heart. With increasing chilopericarde, hemodynamic signs may develop - cardiac compression (tamponade) - heart failure. Puncture of the pericardium allows you to make an accurate diagnosis.

A combination of chylothorax and chyloperitoneum is also possible. These conditions can change each other during the treatment period.

How is chylothorax treated?

Treatment of children with chilothorax should begin with total parenteral nutrition and pleural punctures (puncture of the pericardium in the case of chylopericard). If repeated pleural punctures are not effective, drain the pleural cavity. The transfer of a child to total parenteral nutrition leads in fact to the cessation of lymphatic formation, which can contribute to recovery. An alternative to transferring a child to total parenteral nutrition is the appointment of special mixtures in the form of triglycerides with short and medium chains (TCS).

Congenital chylothorax in neonates is usually amenable to treatment with pleural punctures or drainage of the chest. Non-traumatic chylothorax in more adult children is an excuse for eliminating intercurrent diseases or malignant neoplasms. With traumatic chylothorax conservative treatment is also usually effective.

Long-standing chylothorax leads to the formation of clots, adhesions and limitations in the pleural cavity, making it difficult to remove this content.

In the event that the positive dynamics are absent for more than 14 days or if the developed metabolic disorders develop, surgical intervention is indicated. The operation of choice is the ligation of the thoracic duct at the site of the defect or over the diaphragm. The operation is effective in 96% of cases. A good alternative to the standard surgery from thoracotomy is thoracoscopic ligation or clipping of the thoracic duct. To improve the visualization of the duct, pre-operative administration through the probe of fatty foods: cream, sour cream, cream or olive oil is used. In those cases when visualization of the thoracic duct fails, stitch muscle mass and fiber between the aorta and the unpaired vein over the diaphragm. In severe cases, temporary pleuroperitoneal shunting can be performed.