eMedicine Specialties > Gastroenterology > Systemic Disease

Chylothorax: Treatment & Medication

Author: Rosemary Kozar, MD, PhD, Assistant Professor, Department of Surgery, Division of General Surgery, University of Texas at Houston School of Medicine
Coauthor(s): Sasha D Adams, MD, Resident Physician, Department of Surgery, University of Texas at Houston School of Medicine; James Cipolla, MD, Attending Surgeon, St Luke's Hospital
Contributor Information and Disclosures

Updated: Aug 24, 2009

Treatment

Medical Care

Patients with chylothorax can be treated by conservative means or surgery. Certain principles are common to both treatment options, including treating the underlying cause, decreasing chyle production, draining and obliterating the pleural space, providing appropriate fluid and nutritional replacement, and instituting necessary respiratory care.

  • Always consider conservative management because the thoracic duct leak closes spontaneously in nearly 50% of patients. Few or no symptoms and minimal chyle loss characterize these cases.
    • Decompress the pleural space with tube thoracostomy or repeated thoracentesis to keep the lung expanded against the chest wall and mediastinum.
    • Reduce chyle production by instituting total parenteral nutrition or a fat-restricted oral diet supplemented with medium-chain triglycerides.
  • Chemoradiation may promote resolution of chylothorax and should be used in patients with malignant chylothorax who are not surgical candidates.
  • Somatostatin, or its analogue octreotide, has been used with success in a number of pediatric cases of postoperative and iatrogenic chylothorax. Reported effective doses of intravenous somatostatin range from 3.5-12 mcg/kg/h. Care must be taken to watch for adverse effects of somatostatin therapy, including diarrhea, hypoglycemia, and hypotension.

Surgical Care

The timing of surgical management is controversial and depends on the etiology of the chylothorax and the patient's overall condition.3 Preoperatively, localize the thoracic duct leak by means of lymphangiography, oral administration of cream, or injection of 1% Evans blue dye. Cream is high in long-chain fatty acids and works by increasing chyle flow. It is administered enterally at 60-90 mL/h for 3-6 hours until a change in the color of the pleural fluid is noted. Evans blue dye can either be injected into the web space of the toes for uptake into the lymphatic space or be added to cream to increase visualization. A postoperative management algorithm for children can be found in Panthongviriyakul and Bines.4

  • Indications for surgical intervention include the following:
    • Chyle leak greater than 1 L/d for 5 days or a persistent leak for more than 2 weeks despite conservative management
    • Nutritional or metabolic complications, including electrolyte depletion and immunosuppression
    • Loculated chylothorax, fibrin clots, or trapped lung
    • Postesophagectomy chylothorax (Patients with this carry a high mortality rate if treated conservatively.)
  • Surgical options depend on the site of injury and the etiology of the chylothorax.
    • Thoracic duct ligation is the criterion standard. The duct is usually ligated between the eighth and twelfth thoracic vertebrae, just above the aortic hiatus. The approach is usually through the right chest, either by an open right thoracotomy or through a thoracoscope.5
    • A pleuroperitoneal shunt can be successful for refractory chylothorax but can be complicated by infection and obstruction.
    • Pleurodesis is often used for malignant chylothorax, but it will not work in a case of loculated chylothorax or a trapped lung.
    • Surgical pleurectomy is a treatment option.

More on Chylothorax

Overview: Chylothorax
Differential Diagnoses & Workup: Chylothorax
Treatment & Medication: Chylothorax
Follow-up: Chylothorax
Multimedia: Chylothorax
References
Further Reading
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References

  1. Ergaz Z, Bar-Oz B, Yatsiv I, Arad I. Congenital chylothorax: clinical course and prognostic significance. Pediatr Pulmonol. Aug 2009;44(8):806-11. [Medline].

  2. Milonakis M, Chatzis AC, Giannopoulos NM, Contrafouris C, Bobos D, Kirvassilis GV, et al. Etiology and management of chylothorax following pediatric heart surgery. J Card Surg. Jul-Aug 2009;24(4):369-73. [Medline].

  3. Paul S, Altorki NK, Port JL, Stiles BM, Lee PC. Surgical management of chylothorax. Thorac Cardiovasc Surg. Jun 2009;57(4):226-8. [Medline].

  4. Panthongviriyakul C, Bines JE. Post-operative chylothorax in children: an evidence-based management algorithm. J Paediatr Child Health. Dec 2008;44(12):716-21. [Medline].

  5. Nath DS, Savla J, Khemani RG, Nussbaum DP, Greene CL, Wells WJ. Thoracic duct ligation for persistent chylothorax after pediatric cardiothoracic surgery. Ann Thorac Surg. Jul 2009;88(1):246-51; discussion 251-2. [Medline].

  6. Ammori JB, Pickens A, Chang AC. Tension chylothorax. Ann Thorac Surg. Aug 2006;82(2):729-30.

  7. Browse NL, Allen DR, Wilson NM. Management of chylothorax. Br J Surg. Dec 1997;84(12):1711-6. [Medline].

  8. Clarke SA, Lakhoo K, Sherwood W. Somatostatin for intractable postoperative chylothorax in a premature infant. Pediatr Surg Int. May 2005;21(5):390-1. [Medline].

  9. Hillerdal G. Chylothorax and pseudochylothorax. Eur Respir J. May 1997;10(5):1157-62. [Medline].

  10. Maskell NA, Butland RJ. BTS guidelines for the investigation of a unilateral pleural effusion in adults. Thorax. May 2003;58 Suppl 2:ii8-17.

  11. Merrigan BA, Winter DC, O'Sullivan GC. Chylothorax. Br J Surg. Jan 1997;84(1):15-20. [Medline].

  12. Mohseni-Bod H, Macrae D, Slavik Z. Somatostatin analog (octreotide) in management of neonatal postoperative chylothorax: is it safe?. Pediatr Crit Care Med. Jul 2004;5(4):356-7. [Medline].

  13. Ogi S, Fukumitsu N, Uchiyama M. A case of chylothorax diagnosed by lymphoscintigraphy using Tc-99m HSA-DTPA. Clin Nucl Med. Jun 2002;27(6):455-6. [Medline].

  14. Paes ML, Powell H. Chylothorax: an update. Br J Hosp Med. May 4-17 1994;51(9):482-90. [Medline].

  15. Postma GN, Keyser JS. Management of persistent chylothorax. Otolaryngol Head Neck Surg. Feb 1997;116(2):268-70. [Medline].

  16. Rice TW, Milstone AP. Chylothorax as a result of chronic lymphocytic leukemia: case report and review of the literature. South Med J. Mar 2004;97(3):291-4. [Medline].

  17. Sieczka EM, Harvey JC. Early thoracic duct ligation for postoperative chylothorax. J Surg Oncol. Jan 1996;61(1):56-60. [Medline].

  18. Valentine VG, Raffin TA. The management of chylothorax. Chest. Aug 1992;102(2):586-91. [Medline].

  19. Vallieres E, Shamji FM, Todd TR. Postpneumonectomy chylothorax. Ann Thorac Surg. Apr 1993;55(4):1006-8. [Medline].

  20. Wemyss-Holden SA, Launois B, Maddern GJ. Management of thoracic duct injuries after oesophagectomy. Br J Surg. Nov 2001;88(11):1442-8. [Medline].

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Further Reading

Related eMedicine Topics

Clinical Trials

National Guideline Clearinghouse

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Keywords

chylothorax, pleural effusion, pediatric chylothorax, neonatal chylothorax, thoracic duct leak, thoracic duct ligation, pleural chyle, pleural space, lymphoma, pleuroperitoneal shunt, pleurodesis, pleurectomy, chyle, postesophagectomy chylothorax, thoracentesis, lymphatic fluid, thoracic duct injury, loculated chylothorax

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Contributor Information and Disclosures

Author

Rosemary Kozar, MD, PhD, Assistant Professor, Department of Surgery, Division of General Surgery, University of Texas at Houston School of Medicine
Rosemary Kozar, MD, PhD is a member of the following medical societies: Society of University Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

Sasha D Adams, MD, Resident Physician, Department of Surgery, University of Texas at Houston School of Medicine
Sasha D Adams, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, Association for Academic Surgery, and Association of Women Surgeons
Disclosure: Nothing to disclose.

James Cipolla, MD, Attending Surgeon, St Luke's Hospital
James Cipolla, MD is a member of the following medical societies: American College of Surgeons and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Medical Editor

Mounzer Al Al Samman, MD, Department of Internal Medicine, Division of Gastroenterology, Assistant Professor, Texas Tech University School of Medicine
Mounzer Al Al Samman, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, and American Gastroenterological Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

BS Anand, MD, Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine
BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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