Management of Chylothorax in Adults: When is Surgery Indicated?

Abstract

Background: The aim of this retrospective study was to analyze the etiology, management and outcome of patients with chylothorax and identify clinical parameters for appropriate treatment decisions. Methods: We analyzed 82 cases of chylothorax in 75 patients. In 37 cases (45 %) the cause of chylothorax was surgery, in 45 cases (55 %), the etiology was nonsurgical (malignancy n = 17 [21 %], lymphatic disorders n = 5 [6 %], hepatic cirrhosis, n = 4 [5 %], trauma n = 1 and other causes n = 18 [22 %]). Results: Conservative treatment was successful in 13 (16 %) cases. In 25 cases (total 31 %, postsurgical n = 19 [51 %], nonsurgical n = 6 [13 %]) a (redo) thoracotomy with ligation of the thoracic duct or repeat surgical procedure was performed. The quantity of chyle drained per 24 hours appeared to be the best indicator to guide management decisions. Conclusion: Chylothoraces that occur postoperatively following thoracic procedures require redo operations in approximately 50 % of cases, whereas nonsurgical causes rarely require surgical intervention. In postoperative chylothoraces with a high flow leak > 900 mL/24 h revision should be performed early on, since conservative management is likely to be unsuccessful.

Key words

chylothorax - conservative management - VATS - thoracotomy

References

• 1 Doerr C H, Allen M S, Nichols 3rd F C, Ryu J H. Etiology of chylothorax in 203 patients.  Mayo Clin Proc. 2005;  80 867-870
• 2 Benedix F, Lippert H, Meyer F. [Post-surgical lymphocutaneous fistula, chylous ascites and chylothorax–infrequent but serious complications: etiology, diagnosis and therapeutic options].  Zentralbl Chir. 2007;  132 529-538
• 3 Smoke A, Delegge M H. Chyle leaks: consensus on management?.  Nutr Clin Pract. 2008;  23 529-532
• 4 McGrath E E, Blades Z, Anderson P B. Chylothorax: aetiology, diagnosis and therapeutic options.  Respir Med. 2010;  104 (1) 1-8
• 5 Le Pimpec-Barthes F, D'Attellis N, Dujon A, Legman P, Riquet M. Chylothorax complicating pulmonary resection.  Ann Thorac Surg. 2002;  73 1714-1719
• 6 Malthaner R, Inculet R. The thoracic duct and chylothorax.. In: Pearson F G C, Cooper J D, Deslauriers J, Ginsberg R J, Hiebert C A, Patterson G A, Urschel Jr H C, eds. Thoracic Surgery.. 2nd ed. New York, Edinburgh, London, Philadelphia: Churchill Livingstone; 2002: 1228-1240
• 7 Gerstein J, Kofahl-Krause D, Fruhauf J, Bremer M. Complete remission of a lymphoma-associated chylothorax by radiotherapy of the celiac trunk and thoracic duct.  Strahlenther Onkol. 2008;  184 484-487
• 8 Cigarral C, Montero A, Salas C, Rodriguez G, de la Torre A. Chylothorax due to metastatic prostate carcinoma: an unusual complication.  Clin Transl Oncol. 2009;  11 767-769
• 9 Shimizu K, Yoshida J, Nishimura M et al. Treatment strategy for chylothorax after pulmonary resection and lymph node dissection for lung cancer.  J Thorac Cardiovasc Surg. 2002;  124 499-502
• 10 Hongjing Jiang C W. Treatment strategy for chylothorax after resection for lung cancer – 16 case report.  Chinese Journal of Clinical Oncology. 2006;  3 158-161
• 11 Fahimi H, Casselman F P, Mariani M A et al. Current management of postoperative chylothorax.  Ann Thorac Surg. 2001;  71 448-450 discussion 450-451
• 12 Nair S K, Petko M, Hayward M P. Aetiology and management of chylothorax in adults.  Eur J Cardiothorac Surg. 2007;  32 362-369
• 13 Choo J C, Foley P T, Lyon S M. Percutaneous management of high-output chylothorax: case reviews.  Cardiovasc Intervent Radiol. 2009;  32 828-832