Chylothorax Treatment & Management

  • Author: Sasha D Adams, MD; Chief Editor: Julian Katz, MD   more...
 
Updated: Jan 4, 2012
 

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.[3, 4, 5] 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.
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Surgical Care

The timing of surgical management is controversial and depends on the etiology of the chylothorax and the patient's overall condition.[6] 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.[7]

  • 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.)[8]
  • 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.[9, 10]
    • 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.
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Contributor Information and Disclosures
Author

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.

Coauthor(s)

James Cipolla, MD  Attending Surgeon, Department of Traumatology and Critical Care, St Luke's Hospital; Attending Surgeon, Department of Traumatology, Reading Hospital; Assistant Clinical Professor of Surgery, University of Pennsylvania School of Medicine

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.

Specialty Editor Board

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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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.

Alex J Mechaber, MD, FACP  Senior 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

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 & Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author Rosemary Kozar, MD, PhD, to the writing and development of this topic.

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. Shah D, Sinn JK. Octreotide as therapeutic option for congenital idiopathic chylothorax: a case series. Acta Paediatr. Nov 16 2011;[Medline].

  4. Foo NH, Hwang YS, Lin CC, Tsai WH. Congenital chylothorax in a late preterm infant and successful treatment with octreotide. Pediatr Neonatol. Oct 2011;52(5):297-301. [Medline].

  5. Horvers M, Mooij CF, Antonius TA. Is Octreotide Treatment Useful in Patients with Congenital Chylothorax?. Neonatology. Nov 10 2011;101(3):225-231. [Medline].

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

  7. 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].

  8. Callari C, Perretta S, Diana M, Dagostino J, Dallemagne B, Marescaux J. Thoracoscopic management of chylothorax after esophagectomy. Surg Endosc. Nov 15 2011;[Medline].

  9. 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].

  10. Guo W, Zhao YP, Jiang YG, Niu HJ, Liu XH, Ma Z, et al. Prevention of postoperative chylothorax with thoracic duct ligation during video-assisted thoracoscopic esophagectomy for cancer. Surg Endosc. Nov 2 2011;[Medline].

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

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

  13. 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].

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

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

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

  17. 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].

  18. 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].

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

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

  21. 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].

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

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

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

  25. 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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Anteroposterior upright chest radiograph shows a massive left-sided pleural effusion with contralateral mediastinal shift. Image courtesy of Allen R. Thomas, MD.
A CT scan of the chest of a 3-year old child showing left side effusion and underlying parenchymal infiltrate and atelectasis. Image courtesy of Ibrahim Abdulhamid, MD.
 
 
 
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