Chylothorax Treatment & Management

Updated: Nov 20, 2020
  • Author: Sasha D Adams, MD; Chief Editor: BS Anand, MD  more...
  • Print

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. [4] Congenital chylothorax typically involves supportive management and may include thoracostomy drainage. [9] Nontraumatic chylothorax may pose a management challenge owing to the fact that the site of the leak may occur in less predictable locations. [15]

Always consider conservative management, [14, 16, 17] 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. [18, 19, 20, 21] 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.


Surgical Care

The timing of surgical management is controversial and depends on the etiology of the chylothorax and the patient's overall condition. [14, 22]

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. [23]

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.) [24]

Surgical options depend on the site of injury and the etiology of the chylothorax.

Thoracic duct ligation

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. [25, 26]

Caronia et al reported successful resolution of chylothorax in a 24 yr old man using a left approach. The leak, which was isolated within the left upper chest cavity and refractory to conservative treatment, was successfully closed between the descending thoracic aorta and the vertebral column through a left mini-thoracotomy. The authors concluded that alternative approaches to thoracic duct ligation should be considered when the standard approach is not feasible. [27]

Rouiller et al reported successful resolution of chylothorax in a 60 yr old man using a bilateral approach. [28] The right thoracic duct was ligated after an unsuccessful course of conservative therapy. Although the ligation was successful, imaging demonstrated persistence of chylous passage through a left-sided thoracic duct. Complete resolution was achieved following ligation of the left-sided thoracic duct. [28]

Prophylactic thoracic duct ligation for reducing postoperative chylothorax during esophagectomy requires further investigation; findings from systematic reviews and meta-analyses appear to have been mixed as to whether it is effective [29]  or not. [30]

Thoracic duct ligation 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. [16]

Thoracoscopic parietal pleural clipping

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. [31] 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. [31]

Other interventions

A pleuroperitoneal shunt can be successful for refractory chylothorax but can be complicated by infection and obstruction. [14]

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.

Lymphatic embolization may be effective in patients with traumatic leak and pulmonary lymphatic perfusion syndrome. [32]