MINIMALLY INVASIVE TREATMENT OF CHYLOTHORAX

Ameet Singh
University of Guelph
Department of Clinical Studies
Guelph, Ontario
Canada

Idiopathic chylothorax (IC) in dogs is a complex and incompletely understood disorder that results in the
accumulation of chyle within the pleural space resulting in respiratory distress and in some cases, restrictive
pleuritis. Many treatment modalities, both medical and surgical, have been proposed for management of
IC. Medical therapy with benzopyrones, low fat diets and medium chain triglycerides with or without
intermittent pleural drainage are often discussed but have generally not been highly successful and no large
studies exist reporting encouraging results with non-surgical management.1 It is now generally accepted
that IC represents a surgical disease in most cases.

Early reports of surgical management of IC in dogs were not always highly encouraging and generally
focused on the outcomes of thoracic duct ligation (TDL). In dogs, early statistics suggested that resolution
could be expected in only 59% of cases after TDL.2 In cats the outcomes of TDL were even poorer with
studies reporting resolution in only 20-53% of cases.3,4

Research into improving outcomes of this challenging condition has always been hampered by its
infrequent occurrence. However, in recent years despite this challenge, a much better understanding of the
natural variation of the lymphatic drainage patterns in cats and dogs has occurred and improvements in
diagnostic imaging techniques have enhanced our ability to accurately identify the lymphatic anatomy in an
individual patient.5-8 This in turn has improved pre- and intraoperative decision-making for existing
techniques as well as spurring the development of new techniques. Intraoperative use of contrast agents
such as methylene blue6 as well as lymphangiographic techniques using intraoperative fluoroscopy or pre-
operative percutaneous computed tomographic (CT) lymphangiography have been described.7,8 These
modalities have enhanced surgeon’s ability to make sure that all branches of the thoracic duct are ligated.
The most recent advance in this area is the use of near-infrared fluorescence imaging for detection of
lymphatic channels in the medistinum. A recent report described its use in 15 dogs with idiopathic
chylothorax.9

The surgical procedure that has received the most coverage in the literature for management of IC is the
combination of thoracic duct ligation (TDL) and subphrenic pericardectomy (SPP). When performed in
dogs and cats through one or two intercostal thoracotomies resolution rates between 80-100% have been
reported with the TDL/SPP combination.10,11 A general trend towards more minimally invasive procedures
has occurred in veterinary medicine in recent years and minimally invasive options for IC have been
documented. Currently the only procedures where the results from clinical cases of IC have been
documented include thoracoscopic TDL and pericardectomy12-14 and thoracic duct embolization.15 In one
study of 7 dogs with IC resolution of clinical signs was seen in 6/7 dogs.12 The authors group in collaboration
with investigators from Washington State University and the Ontario Veterinary Collage recently reported
results from 39 dogs operated thoracoscopically14 (the first 6 of which were already reported in the
literature13). In this study resolution of pleural effusion was seen in 95% of dogs with 6% suffering late
recurrence. From this data we believe that the results of thoracoscopic management of IC appear to be at
least as effective as when the procedure is performed through one or two thoracotomies as is often required
for the open approach.

When TDL and pericardectomy are performed thoracoscopically the patient can be positioned in either
lateral13,14 or sternal12 recumbency. It has been hypothesized that sternal recumbency may provide
improved visualization of the caudal mediastinal area during TDL. For TDL thoracic ports are established
in the proximal third of the right 8th, 9th and 10th intercostal spaces in dogs. In cats classically the ports would
be placed at the same locations but on the contralateral (left) side although the side used in cats is usually
decided upon after a CT lymphangiogram has been obtained as the author has seen several cats with right-
sided thoracic duct branches. Dissection through the mediastinal root dorsal to the aorta is initiated being
careful not to rupture the vertebral branches from the aorta. Sterile methylene blue dye (diluted 1:1 with
sterile saline and administered at no more than 1.5mg/kg into the lymph node) OR indocyanine green (ICG)
is then slowly infused either into a mesenteric lymph node (after a small paracostal incision has been made
into the abdomen). Within 1-2 minutes the methylene blue dye or ICG will usually be visualized passing
through the thoracic duct(s) in the caudal mediastinum. Further dissection is performed to isolate all the
ducts that are visualized prior to their ligation with laparoscopic hemoclips or intracorporeal suturing. Further
injection of methylene blue into the lymph node will then often produce a visual bulging of the duct caudal
to the ligation site if complete ductal occlusion has been achieved. After the TDL has been completed the
thoracic cannulae are removed and the incisions are closed prior to the patient being repositioned in dorsal
recumbency. A subtotal pericardectomy (SPP) is then performed by placement of a subxiphoid telescope
portal and two instrument portals at the 4-6th intercostal spaces on the right and left side. This technique
has been described in both research dogs15 and clinical patients13 in order to remove all the pericardium
ventral to the phrenic nerves. Other authors have advocated a “banana skin” approach to the
pericardectomy where cuts are simply made that go down to the pericardium but no attempt is made to
remove all of the pericardial tissue ventral to the nerves.17 It is not known whether any one of these
techniques is superior to the other.

A minimally invasive approach to the cisterna chyli has also been recently documented in research dogs18
and has been reported in a cohort of clinical patients with good results.19,20 The authors of the research dog
study attempted to approach the cisterna chyli through both a transdiaphragmatic approach as well as a
trans-abdominal approach both in sternal recumbency from the left side.18 Some complications including
tension pneumothorax, aortic laceration and inability to locate the cisterna chyli were reported but overall a
successful CCA was performed in 12 of 14 dogs in which it was attempted.18

Thoracic duct embolization was described some time ago but results of clinical cases have not been
available until recently.15 One of two dogs that had been treatment failures of surgical management showed
resolution of IC. The authors of this report suggest that embolization might be a good salvage technique
for cases that have not resolved after surgical management but further work to refine the technique in the
future might allow this to be a useful first-line minimally invasive therapy for IC as well.

The more recent results of minimally invasive therapy for idiopathic chylothorax are very encouraging with
consistent results from multiple papers and multiple techniques suggesting that resolution rates >90% can
be achieved with these techniques. The challenge of the future is to personalize the surgical approach to
each patient as current multiple technique approaches (TDL+CCA+Pericardectomy) are often very time
consuming and can be associated with morbidity.

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