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Ann Thorac Surg 2001;71:448-450
© 2001 The Society of Thoracic Surgeons

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Original article: general thoracic

Current management of postoperative chylothorax

^a Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands

Accepted for publication May 20, 2000.

Address reprint requests to Dr van Swieten, Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
e-mail: hauswie{at}knmg.nl

	Abstract

Top Footnotes Abstract Introduction Patients and methods Results Comment References

 
Background. This study was performed to review our experience with postoperative chylothorax and describe our current approach. In addition, we wanted to estimate the impact of video-assisted thoracoscopic surgery (VATS) on our current management policy.

Methods. From January 1991 to December 1999, 12 patients developed chylothorax after various thoracic procedures. Their mean age was 61.5 (range 31 to 80 years). The procedures were cardiac, aortic, and pulmonary operations.

Results. All patients were initially treated conservatively. In addition, 7 patients needed surgical intervention, including one thoracotomy and six VATS. The site of thoracic duct laceration was identified and treated with VATS in 4 patients. In 2 patients, the leak could not be localized by VATS, and fibrin glue or talcage were applied in the pleural space. All patients were discharged without recurrent chylothorax.

Conclusions. VATS is an effective tool in the management of persisting postoperative chylothorax. Its easy use, low cost, and low morbidity rate suggest an earlier use of VATS in the treatment of postoperative chylothorax.

	Introduction

Top Footnotes Abstract Introduction Patients and methods Results Comment References

 
Laceration of the main thoracic duct can occur during any thoracic procedure, causing a chylothorax. Postoperative chylothorax occurs in less than 1% of thoracic procedures with a prevalence ranging from 0.5% to 2% [1, 2]. Postoperative chylothorax is a severe complication with a high mortality, which can approach 50% in untreated patients. It causes nutritional deficiencies, respiratory dysfunctioning, dehydration, immunosuppression, and therefore it increases vulnerability for infections [1–7].

Various treatment modalities including simple close drainage, TPN, medium chain triglyceride diet, and surgical intervention have been proposed throughout the years [8–11]. In recent years video-assisted thoracoscopic surgery (VATS) has gained popularity in the treatment of chylothorax [12–15]. The use of VATS in the treatment of chylothorax is an attractive option because of its easy manageability and low morbidity. This article reviews our experience with postoperative chylothorax over the past 10 years and describes our current approach for its treatment.

	Patients and methods

Top Footnotes Abstract Introduction Patients and methods Results Comment References

 
From January 1991 to December 1999, 12 patients developed postoperative chylothorax. There were 10 male and 2 female patients with a mean age of 61.5 years (range 31 to 80 years). Chylothorax occurred after various thoracic procedures (Table 1). The diagnosis was based on clinical suspicion whenever the postoperative pleural or epicardial effusion was unexpectedly large. The diagnosis was confirmed by presence of triglycerides and chylomicrons in the fluid.

	Results

Top Footnotes Abstract Introduction Patients and methods Results Comment References

 
Five patients responded to conservative treatment. One patient was treated with an open thoracotomy concomitantly during a lobectomy. Six patients underwent a VATS procedure. Administration of a meal of cream mixed with Sudan black enabled us to localize the leaking spot accurately in 4 patients. The lesions were subsequently repaired by suture or clips. In 2 patients, including the patient with chylopericardium (patient no. 11), the site of injury could not be identified. Fibrin glue was then sprayed in the mediastinal region suspected for leakage and a talcage was performed. Patient no. 3 had a bilateral chylothorax. He underwent a right VATS because the right pleural effusion was more severe. Details on the individual therapeutic approach are also given in Table 1.

Within 5 days postoperatively, the leakage was completely ceased and the drain was removed. There was no hospital mortality and all patients were discharged without recurrent chylothorax.

	Comment

Top Footnotes Abstract Introduction Patients and methods Results Comment References

 
The thoracic duct can be injured during any thoracic procedure. Pleuro-pulmonary procedures, esophageal resection, intrapericardial and mediastinal procedures, and even less invasive procedures like subclavian puncture may lead to thoracic duct injury and subsequent chylothorax [3, 5–7, 16, 17]. Chylothorax occurring after a coronary bypass surgery is usually reported as the consequence of the harvesting of the left mammary artery, by reason of anatomical connection with the thoracic duct. This is also confirmed in our series.

Postoperative chylothorax has an average prevalence of 0.5% [1]. The mortality can reach 50% in cases when an adequate treatment is not promptly performed. The morbidity is severe. Huge losses of calories, fluids, and proteins cause nutritional deficiency, dehydration, and immunologic dysfunction. Moreover, large amounts of pericardial and pleural effusion compromise the cardiorespiratory function [1, 7, 8, 18].

A prompt diagnosis and an accurate early treatment are therefore essential. Whenever a pleural effusion develops after a thoracic procedure, chylothorax should be suspected. Mostly, it occurs from 2 days to 4 weeks postoperatively and varies from slight to severe forms determined by the volume and rate of chyle loss [16, 19]. Chyle has a creamy appearance, and contains chylomicrons and long chain triglycerides.

Various treatment modalities from conservative to operative intervention have been proposed. However, large comparative series do not exist, probably because of the low incidence of postoperative chylothorax.

Medical management alone is frequently unsuccessful in case of high flow leaks [20]. However, Etilefrine, a sympathomimetic drug causing smooth muscle contraction of the thoracic duct, has been recently reported to improve the results of nonsurgical management of massive chylothorax [21].

Lampson reported treatment of chylothorax in 1948 by ligation of the thoracic duct in the chest [22]. This technique gained popularity in persisting chylothorax. Thoracic, abdominal, and cervical approaches to the thoracic duct subsequently have been described [1].

In recent years, VATS has become the preferred surgical approach in the treatment of spontaneous and postoperative chylothorax because of easy manageability and low morbidity [12, 13, 20]. The essential step in chylothorax is the identification of the site of duct laceration. Once identified, the leakage can be treated with suture, clips, fibrin glue, or talcage. However the effectiveness of fibrin glue as a single means is doubtful except for tiny leaks. Pleurectomy should be avoided because of the risk of injury to intercostal lymph vessels. Sachs reported application of lymphangiography as a useful method of preoperative localization and reported the value of computed tomography as additional but not essential [2]. In our experience, administration of a cream meal mixed with Sudan black is helpful for identification of leakage site. This simple, efficient, and noninvasive method makes it preferable in comparison with lymphangiography and computed tomography.

Although the number of our patients is not large, a series of 12 patients is noteworthy considering the rarity of this complication.

Since introduction of VATS in our department, we have relied on this technique for the treatment of chylothorax whenever conservative treatment was unsuccessful. VATS has the advantage of being efficient and has a low morbidity. The treatment was successful in all patients and the hospital stay was therefore shortened.

We advocate the use of VATS in the treatment of postoperative chylothorax when daily leakage exceeds 200 mL after 2 weeks of conservative therapy. The flow chart demonstrates our current approach (Fig 1).

View larger version (28K): [in this window] [in a new window]   Fig 1. Treatment for postoperative chylothorax flow chart.

	Footnotes

Top Footnotes Abstract Introduction Patients and methods Results Comment References

 
This article has been selected for the open discussion forum on the STS Web site: http://www.sts.org/section/atsdiscussion/

	References

Top Footnotes Abstract Introduction Patients and methods Results Comment References

 

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