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Chylothorax Treatment & Management

  • Author: Sasha D Adams, MD; Chief Editor: BS Anand, MD  more...
 
Updated: Mar 11, 2016
 

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,[4, 5] 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.[6, 7, 8] Reported effective doses of intravenous somatostatin range from 3.5 to 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.[4, 9]

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 an article by Panthongviriyakul and Bines.[10]

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.) [11]

Surgical options depend on the site of injury and the etiology of the chylothorax and include the following:

  • 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. [12, 13]  Thoracic duct ligation also appears to be an effective option for persistent refractory chylothorax, and it may be a first-line option for cases of right-side effusion with an output rate over 20 mL/kg. [5]
  • A retrospective study (2002-2014) of 14 infants with congenital chylothorax suggests that thoracoscopic parietal pleural clipping may be safe and effective to disrupt the pleural lymphatic channel flow. [14] Of the infants who underwent the procedure (n = 6), chest tube output decreased from an average of 86.96 mL/kg/day 2 days before surgery to an average of 6.5 mL/kg/day 2 days after surgery. [14]
  • A pleuroperitoneal shunt can be successful for refractory chylothorax but can be complicated by infection and obstruction. [4]
  • 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.

Mortality and morbidity rates for cases of chylothorax are approximately 10% in major clinical medical centers. Complications include malnutrition and immunosuppression.

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Contributor Information and Disclosures
Author

Sasha D Adams, MD Assistant Professor, Department of Surgery, Division of Trauma, Critical Care and Emergency General Surgery, University of North Carolina, Chapel Hill; Surgeon, Trauma, Critical Care and Emergency General Surgery, University of North Carolina Memorial Hospital

Sasha D Adams, MD is a member of the following medical societies: American College of Surgeons, Association for Academic Surgery, Eastern Association for the Surgery of Trauma, Association of Women Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

James Cipolla, MD Attending Surgeon, Department of Traumatology and Critical Care, Program Director, Surgical Critical Care Fellowship, St Luke's University Hospital; Associate Professor of Surgery, Temple University School of Medicine; 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, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief 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, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Acknowledgements

Mounzer Al Samman, MD Assistant Professor, Department of Internal Medicine, Division of Gastroenterology, 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. Rosemary Kozar, MD, PhD, Assistant Professor, Department of Surgery, Division of General Surgery, University of Texas at Houston School of Medicine

Disclosure: Nothing to disclose.

References
  1. Ergaz Z, Bar-Oz B, Yatsiv I, Arad I. Congenital chylothorax: clinical course and prognostic significance. Pediatr Pulmonol. 2009 Aug. 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. 2009 Jul-Aug. 24(4):369-73. [Medline].

  3. Borasino S, Diaz F, Masri KE, Dabal RJ, Alten JA. Central venous lines are a risk factor for chylothorax in infants after cardiac surgery. World J Pediatr Congenit Heart Surg. 2014 Oct. 5(4):522-6. [Medline].

  4. Bender B, Murthy V, Chamberlain RS. The changing management of chylothorax in the modern era. Eur J Cardiothorac Surg. 2016 Jan. 49 (1):18-24. [Medline].

  5. Pini Prato A, Bava GL, Dalmonte P, et al. 16 years of experience with persistent chylothorax in children. Minerva Pediatr. 2015 Dec 17. [Medline].

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

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

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

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

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

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

  12. 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. 2009 Jul. 88(1):246-51; discussion 251-2. [Medline].

  13. 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. 2011 Nov 2. [Medline].

  14. Clark ME, Woo RK, Johnson SM. Thoracoscopic pleural clipping for the management of congenital chylothorax. Pediatr Surg Int. 2015 Dec. 31 (12):1133-7. [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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