title: Multimedia article. Prone thoracoscopic thoracic duct ligation for postsurgical chylothorax.
abstract: BACKGROUND
  Chylothorax after complex abdominal and thoracic procedures remains a challenging complication with a mortality rate reaching 50% if untreated. Iatrogenic trauma accounts for almost 20% of all chyle leaks, and esophagectomy is the most common iatrogenic cause. Consequences of ongoing chyle leak include dehydration, malnutrition, and immunocompromise.
  
  
  METHODS
  When nonoperative management techniques fail, prompt ligation of the thoracic duct at the diaphragmatic hiatus should be attempted. The authors present prone thoracoscopic thoracic duct ligation performed for two patients after laparoscopic transthoracic esophagectomy and revision paraesophageal hernia repair.
  
  
  RESULTS
  The prone position for thoracoscopic thoracic duct ligation offers several benefits to the surgeon. Gravity retracts the lung anteriorly, exposing the diaphragmatic hiatus. Single-lumen endotracheal intubation combined with low-pressure carbon dioxide insufflation efficiently collapses the lung to create ample working space. For the two reported patients, only three trocars were necessary to complete suture ligation of the thoracic duct via the right chest. Both patients had complete resolution of their chylothorax and recovered uneventfully. Based on this experience, the authors currently advocate early thoracoscopic treatment for cost and morbidity savings.
  
  
  CONCLUSIONS
  The authors believe prone thoracoscopic thoracic duct ligation offers significant advantages to the patient in preventing the dangerous consequences of chyle leak in a timely, minimally invasive fashion. Importantly, the prone technique with carbon dioxide insufflation makes the technical challenges of thoracic duct ligation more facile for the surgeon.
authors.affiliation: Division of Gastrointestinal and Minimally Invasive Surgery, Legacy Health System and The Oregon Clinic, 1040 NW 22nd Avenue, Suite 560, Portland, OR 97210, USA. pmdenk@gmail.com
authors.forename: Peter M
authors.initials: PM
authors.lastname: Denk
authors.forename: Prakash
authors.initials: P
authors.lastname: Gatta
authors.forename: Lee L
authors.initials: LL
authors.lastname: Swanström
mesh_terms: D002245:Carbon Dioxide / Q000008:administration & dosage; D002916:Chylothorax / Q000209:etiology / Q000601:surgery*; D006801:Humans; D007327:Insufflation; D007442:Intubation, Intratracheal; D008026:Ligation / Q000379:methods; D011031:Pneumothorax, Artificial / Q000379:methods; D011183:Postoperative Complications / Q000209:etiology / Q000601:surgery*; D016684:Prone Position; D013536:Suture Techniques; D013897:Thoracic Duct / Q000601:surgery*; D013906:Thoracoscopy / Q000379:methods*
chemical_list: D002245:Carbon Dioxide