Prävention und operative Therapie des Chylothorax

Zusammenfassung

Hintergrund Der Chylothorax ist eine seltene Komplikation nach Thoraxtrauma oder chirurgischen Eingriffen, insbesondere der Ösophagusresektion, die unbehandelt in ein potenziell lebensbedrohliches Krankheitsbild übergeht.

Methoden Dieser Artikel bietet einen Überblick über die bestehende Literatur zur Prävention und chirurgischen Therapie des Chylothorax.

Ergebnisse Das Risiko für eine Chylusleckage steigt mit der Schwierigkeit der mediastinalen Präparation. Es ist mit etwa 3% am höchsten bei radikalen Ösophagusresektionen und kardiochirurgischen Eingriffen bei Kindern. Bei diesem Risiko besteht die Möglichkeit einer prophylaktischen intraoperativen Ligatur des Ductus thoracicus entweder als selektive Ligatur oder als Massenligatur. Metaanalysen bestätigen die Effektivität dieser Maßnahme mit einer Senkung des Risikos bis auf unter 1% bei der Ösophagusresektion. Bei Vorliegen eines postoperativen Chylothorax kann ein konservativer Therapieversuch bei Drainagenfördermenge bis zu 1000 ml täglich unternommen werden. Bei Anzeichen für eine persistierende Leckage scheint eine zügige chirurgische Re-Intervention angezeigt. Diese kann entweder transthorakal oder transhiatal als selektive Ligatur oder Massenligatur erfolgen und hat eine Erfolgswahrscheinlichkeit von über 90%.

Schlussfolgerung Die prophylaktische primäre oder therapeutische sekundäre Ligatur des Ductus thoracicus ist ein effektives Mittel zur Prävention und Therapie einer postoperativen Chylusleckage.

Abstract

Background Chylothorax is a rare complication after thoracic trauma or surgery, especially oesophagectomy, which, if left untreated, can be potentially life-threatening.

Methods This article provides an overview of the existing literature on the prevention and surgical therapy of chylothorax.

Results The risk of chyle leakage after oesophagectomy increases with the difficulty of mediastinal dissection and is reported to be around 3% for oesophagectomy. With this risk, there is the possibility of a prophylactic intraoperative ligature of the thoracic duct, either as a selective or mass ligation. Meta-analyses confirm the effectiveness of this measure, with a reduction in the risk to less than 1%. In the case of postoperative chylothorax, a conservative therapeutic trial may be undertaken with drainage of up to 1000 ml per day for up to one week. If there is any indication of persistent leakage, rapid surgical reintervention appears appropriate. This can be either transthoracic or transhiatal as a selective or mass ligation and has a probability of success of over 90%.

Conclusion The prophylactic primary or therapeutic secondary ligature of the thoracic duct is an effective surgical preventive measure and therapy of postoperative chyle leakage.

Schlüsselwörter

Ösophagusresektion - Chylothorax - Ductus thoracicus - Massenligatur

Key words

esopahgectomy - chylothorax - thoracic duct - mass ligation

• Literatur

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