Role of pre-operative lymphangiogram and lympangioscintigraphy in the surgical management of spontaneous chylothorax☆

We have read with interest the report from Christodoulou and co-workers [1] regarding the video-assisted thoracic surgery (VATS) treatment of spontaneous (non-traumatic) recurrent chylotorax. As a matter of fact, due to the respiratory, nutritional and immunological implications, surgery is indicated whereas any conservative treatment failed in controlling this clinical condition. On the basis of their experience on a series of six treated patients, the Authors do conclude that recurrent or persistent non-traumatic chylothorax may be successfully treated by video-assisted right supradiaphragmatic thoracic duct ligation. We strongly agree with the Authors on their conclusion since we have observed similar evidences in our own experience (adopting the same surgical approach) on 12 cases (10 right sided, 2 left sided) observed and treated in our Institution in the period between January 2001 and December 2005 (in the same period, two cases were treated by an open thoracotomic approach because they were previously submitted elsewhere to video-assisted thoracic duct ligation). Before surgery, all patients had a pleural drainage for almost 2 weeks with a persisting leak >300 ml/ day. Four patients developed chylothorax as a result of thoracic irradiation and four cancer (three lymphoma, one breast cancer). In particular, we report a mean operating time of 92 14 min with no mortality or major perioperative complications. A single chest drain was left in place after operation connected with a very mild continuous aspiration for the first 24 h. The drain was removed 5 1 days after the operation (mean). Patient controlled anaesthesia (PCA) and physiotherapy were adopted in all cases. A<100 ml/day leak persisted post-operatively in one patient and was conservatively treated (chest drain, parenteral nutrition—no oral intake) up to the complete