9. 肺切除後乳び胸に対する手術

Reoperation for Chylothorax after Lung Resection

筆者は，はじめて胸管結紮術が奏効し，乳びが止まったときの感激を今も記憶している．前日までの憂うつな回診はなんだったのか，早く手術すればよかったと後悔した．一方で，数を経験するうちに手術無効例にも遭遇し，治療のむずかしさも知った．そもそも，胸管結紮術が元栓を締めて下流の水漏れを防ぐという仕組みなら，その後脂肪は吸収できるのであろうか，乳びも胸管もよく勉強していくと，そう単純ではないことがわかってくる．

Chylothorax is not a rare complication of lung surgery. Diagnosis is easy in most cases, but treatment is sometimes difficult. Dietary restriction is effective in reducing the chyle but does not always cease the lymph and chyle.

Two surgical procedures for postoperative chylothorax are well known：direct closure of the ruptured lymph vessel and ligation of the thoracic duct. Direct closure often fails. It is difficult to detect lymphatic leakage pre- and peri-reoperation. Early reoperation decisions are important for successful direct closure.

Thoracic duct ligation is ordinarily performed using the right thoracoscopic approach because the thoracic duct runs in front of the vertebrae along the azygos vein near the diaphragm in the right pleural cavity. The effect of the ligation should be shown immediately. Unfortunately, even if the thoracic duct is confirmed to have been ligated, it sometimes fails to cease the chyle pleural effusion. This may be due to the existence or formation of lymphatic bypass routes.