Chylothorax - Modalities of management and outcomes

Abstract

Background: At present, there are no universally accepted protocols for the management of chylothorax. This study aims at reporting the clinical experience and presenting our institutional protocol for managing chylothorax. Materials and Methods: This is a retrospective analysis of chylothorax patients managed at a dedicated thoracic surgical unit over 8 years. A detailed analysis of demography and perioperative variables including complications was carried out. Factors influencing failure of conservative and surgical therapy were analyzed. Results: A total of 26 patients were included with a mean age of 42.4 years (range, 2–72 years). Postsurgical chylothorax was the most common variant (53.8%). Majority (46.1%) of the patients had >1000 ml/24 h intercostal tube drainage at presentation. All patients were initially subjected to conservative management, of which 11 (42.4%) patients were managed successfully with conservative therapy alone. Rest 15 (57.6%) patients required video-assisted thoracoscopic thoracic duct ligation, which was successful in 10/15 (66.7%) patients, whereas additional intervention was required in 5/15 (33.3%) patients. Drain output of >1000 ml/day was an independent predictor of failure of conservative therapy. Nontraumatic bilateral chylothorax was associated with high probability of failure of surgical therapy in the first attempt and may require additional treatment modality. Conclusions: Initial conservative management is recommended for all chylothorax patients, which is unlikely to succeed if daily drainage is >1000 ml/24 h. VATS thoracic duct ligation is recommended in such cases. Nontraumatic bilateral chylothorax has higher surgical failure rates. In such cases, additional procedures in the form of pleurodesis and/or thoracic duct embolization/disruption should be considered.

Non-conservative Management of Chylothorax

“…1 ). Variations have been observed in more than one-third of the population [ 2 , 9 , 11 ]. These anatomic variations are the underlying cause of the diversity of intervention success rates [ 2 , 9 , 11 ].…”

“…Variations have been observed in more than one-third of the population [ 2 , 9 , 11 ]. These anatomic variations are the underlying cause of the diversity of intervention success rates [ 2 , 9 , 11 ]. Moreover, there is a high risk of tearing along the course of the lymphatic pathway during esophagectomy and lymph node dissection due to the proximity of the course of the thoracic duct to other structures [ 1 , 12 , 13 ].…”

“…The appropriate treatment method depends on the etiology and amount of chylothorax. Traditionally, conservative treatment is first administered [ 7 , 9 , 13 - 15 ]. However, in patients with high-volume chylothorax, the timing of appropriate interventions is important.…”

“…Conservative management is considered the first-line modality for all patients with chylothorax [ 7 , 9 , 13 - 15 ].…”

“…Regardless of the cause, the medical and surgical options to reduce lymph leakage for patients with chylothorax are similar to those for patients with high flow chylothorax (>25 mL/kg/day for child, 1,000 mL/day for adult) [ 1 - 8 ]. If even repeated interventions are not effective, surgical treatment might be the last option [ 7 , 9 , 10 ]. In the event that surgical management fails, conservative management may be continued until leakage ceases.…”