Professional Documents
Culture Documents
Review
Chylothorax
B . A . M E R R I G A N , D . C . W I N T E R and G . C . O ' S U L L I V A N
Depurtment of S i i t p y , Mercy Hospital and Universiy College Cork, Cork, Ireland
Correspondence to: Mr G. C . O'Sullivun, Department of Surgery, Mercy Hospital, Grenville Place, Cork, Ireland
Background Chylothorax is a condition that is debilitating to the point of threatening life. There is
controversy over its management, in particular the relative merits of conservative measures and the
timing of surgical intervention.
Method The literature is reviewed from the basic sciences of chyle composition and flow, to
diagnostic approaches, the complications of chyle loss and appropriate management strategies.
Results and Conclusion Prompt diagnosis is essential to institute an effective therapeutic regimen.
Surgery achieves fast, safe and effective reversal of this dire situation. Minimally invasive
thoracoscopic techniques are gaining wide recognition. Early intervention, which should be
aggressive and complete to avoid the immune and nutritional consequences of extended chyle
depletion, is recommended.
Chylothorax is a debilitating condition to the point of
threatening life. Diagnosis and subsequent management
present significant problems for the clinician, and the
adverse effects of chyle loss on nutritional status and
immune function result in devastating consequences for
the patient. This paper reviews the literature from the
basic sciences of chyle composition and flow, to diagnostic
approaches, the complications of chyle loss and
appropriate management strategies. Prompt diagnosis is
essential to institute an effective therapeutic regimen.
Early intervention is recommended, which should be
aggressive and complete to avoid extended chyle
depletion. Surgery achieves fast. safe and effective
reversal of this dire situation.
15
16 B. A . M E R R I G A N , D . C . W I N T E R and G . C . O ' S U L L I V A N
Table 1 Features of lymph fluid
Relative density
PH
Colour
Sterile
Bacteriostatic
Fat (g/9
Protein (g/l)
Albumin
Globulin
Albumin :globulin ratio
Fibrinogen (mg/l)
Glucose (mmol/l)
Urea (mmol/l)
Cell count (per dl)
Lymphocytes?
Erythrocytes
Enzyme concentration (units/ml)
Pancreatic lipase
Amylase
Aspartate aminotransferase
Alanine aminotransferase
Alkaline phosphatase
Acid phosphatase
Electrolyte concentration (mMol/l)
Sodium
Potassium
Chloride
Calcium
Phosphate
1.012-1'015
7.4-7.8
Milky (colourless in
starvation)
Yes
Yes
5-30*
20-30
12-42
11-31
3: 1
160-240
2.7-1 1.1
1.4-3.0
40 000-680 000
5000-60000
0.5-2.4
50-83
22-40
5-21
2-4.8
0.3-0.8
104-108
3.8-5.0
85-130
3.4-6'0
0'8-4'2
CHYLOTHORAX
17
Congenital
Atresia of the thoracic duct
Trauma at birth
Trauma
Iatrogenic
Surgery
Cervical
Thoracic
Abdominal
Therapeutic and diagnostic procedures
Central venous cannulation
Translumbar arteriography
Oesophageal sclerotherapy
Non-iatrogenic
Blunt
Penetrating
Intrinsic
Neoplasm
Venous thrombosis
Pulmonary lymphangiomatosis
Extrinsic
Neoplasm
Lymphoma
Metastatic disease
Lymphadenitis
Infection
Spontaneous
Aetiology of chylothorax
Chylothorax may be classified according to aetiology as
congenital, traumatic or obstructive (Table 2). Congenital
chylous effusions are extremely rare and the true
incidence is difficult to document. They are usually
idiopathic but may be associated with Downs and
Noonans syndromes, tracheo-oesophageal fistula and
polyhydramni~s~.
There may be a history of birth trauma,
but the underlying defect is congenital. There may be
complete atresia of the thoracic duct or absence of
communications between small peripheral lymphatics and
the larger central vessels as a result of hypoplasia.
Traumatic damage to the thoracic duct is largely
iatrogenic in nature. Unrecognized section or laceration
of the duct during surgical procedures on the lung,
oesophagus, aortic isthmus or mediastinal tumours has
been described. The occurrence of chylothorax has most
often been described following oesophageal resection
(Table 3)9,20-26.
Increased rates are reported for the transhiatal technique in comparison with the thoracic
approach9. Unusual and unexpected cases of iatrogenic
chylothorax exist, for example following repeated
sclerotherapy for oesophageal ~ a r i c e s ~Extrathoracic
~.
procedures, such as radical neck dissection, may also
result in thoracic duct damage. It is a rare complication of
central venous cannulation where it is associated with
subclavian vein thrombosis, is usually bilateral and
frequently
Approximately 20 per cent of cases of traumatic
chylothorax are due to non-iatrogenic causes29.
Penetrating injury to the neck, chest or abdomen may
directly lacerate the duct. Blunt trauma, for example crush
injury, or sudden forceful hyperextension of the spine may
result in ductal damage. In this circumstance the duct is
0 1997 Blackwell Science Ltd, British Journal of Surgery 1997,84, 15-20
No. of
resections
Incidence
Reference
SkinnerZn
Hankins et al.z
King et al. 22
Orringer et aLZ3
Woods et aLZ4
Tam et al. 25
Bolger el aL
Dougenis et aLZh
1983
1987
1987
1988
1989
1989
1991
1992
80
26
100
320
50
316
537
255
2
4
1.0
34
2
0.6
2.0
3.9
(%)
18 B . A. M E R R I G A N , D . C. W I N T E R and G . C. O'SULLIVAN
classical of a pleural effusion. The diagnosis in postoperative patients, where the surgical procedure was in
the vicinity of the thoracic duct, should be considered
when there are increased losses on chest drainage or a
recurring pleural collection of fluid. The diagnosis may
not be obvious in a fasting or postoperative patient
because the fluid is often straw-coloured' or bloodstained,
and there are few signs other than low-grade pyrexia7.
Fluid sampling reveals triglyceride and lymphocyte levels
that are higher than corresponding plasma values.
Measurement of plasma protein content may reveal
hypoalbuminaemia secondary to albumin losses associated
with the lymphatic leak. The diagnosis may be confirmed
by administration of cream or other foodstuff of high fat
content by mouth or via the nasogastric tube; this is the
most reliable test in the clinical setting. It induces a
dramatic change in the colour and content of the effused
fluid owing to the transport of absorbed fat in the lacteal
system23.3"32.
Unlike in the normal patient there may not
be an increase in the level of plasma triglycerides after the
high-fat meal'".
Patients with insidious chyle leaks usually present to the
hospital with chest discomfort and dyspnoea, or as an
incidental finding on chest radiography. Confirmatory
investigations may be delayed if the possibility of chylothorax is not considered. Chest radiography, with lateral
views, defines the size of the effusion and allows
assessment Of the clarity of the contralateral lung field.
Bilateral chylous effusions do occur and are associated
with a poor prognosis2'. More complex radiological
investigations may be undertaken to confirm the
pathological diagnosis and to identify the anatomy of the
lesion. Lymphangiography provides useful information
regarding the site and size of the leak""", and enables
differentiation between thoracic duct damage and
anastomotic leaks in the postoperative group. It may also
identify complete transection or partial laceration of the
It is, however, complex and time consuming.
Computed tomography has no additional role in
iatrogenic injuv''. It can be a useful tool when chylothorax is a late presentation after cancer surgery or is
associated with trauma, or where an underlying tumour is
suspected.
Management
There is considerable controversy over the management
of this condition. Some authors advocate a conservative
a p p r ~ a c h - ' ~while
,
others favour early operative intervention2',-''. However, most agree that either approach
must be considered in the light of the specific aetiological
type of chylothorax and the patient's general condition. It
is important not to procrastinate while the condition
deteriorates to a level at which surgery would be
detrimental.
Conservative management involves drainage of the
pleural cavity, measures that reduce chyle flow and
supportive nutrition. The introduction of this protocol has
led to the lowering of mortality rates for post-traumatic
chylothorax from over 50 per cent at the turn of the
.
50 per
century to 10 per cent at p r e ~ e n t ' ~Approximately
cent of congenital and traumatic cases resolve with such
management, but it is difficult to predict when this will
O C C U ~ * . ~ . *There
~.
is some evidence to suggest that failure is
related to increased back pressure from high-pressure
venous states4". Intercostal fluid drainage evacuates chyle,
management
0 1997 Blackwell Science Ltd, British Journal ofsurgery 1997, 84, 15-20
CHYLOTHORAX
19
Conclusion
The morbidity and mortality associated with chylothorax is
considerable. Early surgery should be undertaken in
postoperative cases because the response to conservative
management is poor. It is reasonable to attempt conservative management in an otherwise stable and healthy
patient. However, the application of criteria for surgical
intervention as outlined above is recommended in all
cases to avoid unnecessary delay.
Acknowledgements
Figs 1 and 2 were drawn by Gillian Lee Illustrations.
References
information as it stains the surrounding structures7.
Decortication to favour complete lung expansion may be
nccessary if there is a thickened serosal membrane.
Pleurodesis by parietal pleurectomy has been advocated
for situations in which the leak cannot be identified".
Thoracoscopic ligation is reported to cause less
postoperative pain and morbidity77.i2,33
and there may be
other advantages over open surgery. The traditional
approach for bilateral chylothorax has been through the
right thorax, but left-sided collaterals have occasionally
necessitated a further left thoracotomy7. The point of the
leak may be better visualized by means of magnification,
and dual thoracotomy may be avoided if one side can be
managed endoscopically. An innovative method for
thoracoscopic sealing of duct leaks with fibrin glue has
had wide re~ognition~"."~'~.
Successful management of
chylothorax in premature neonates using this technique
has also been described's. Accurate preoperative
identification of the damaged point with lymphangiography reduces the quantity of glue requireds'-".
Radiotherapy and/or chemotherapy may be employed
to relieve the obstruction to flow as a first-line manoeuvre
in malignant chyIothorax3", but success is
Pleurodesis with talc or tetracycline may be effective5". No
more than 2 g talc should be used because fibrosis can
impair lung function"". The benefit of palliative surgery
where there is associated malignancy must be balanced
against the anticipated duration of survival (less than
4 months in one study"'). Pleuroperitoneal shunts can be
inserted as an alternative to thoracotomy's."l."' and a
thoracoscopically assisted procedure allows more accurate
and controlled positioning". Shunted peritoneal fluid
passes into the venous system, via the right lymphatic
duct. However, this procedure has a limited success rate,
particularly if the right atrial pressure is raised'". Disadvantages include shunt occlusion, chest wall discomfort
and inconvenience of use (the chamber must be
compressed frequently)"3.
Impaired defence mechanisms, nutritional compromise,
generalized organ dysfunction and the presence of
0 1997 Blackwell Science Ltd, British Journal ofsurgery 1997, 84, 15-20
20 B. A . M E R R I G A N , D . C . W I N T E R and G . C . O S U L L I V A N
Ann Surg 1964; 160: 373-83.
17 Puntis JW, Roberts JD, Handy D. How should chylothorax
be managed? Arch Dis Child 1987; 38: 593-6.
18 Shackleford RT, Fisher AM. Traumatic chylothorax. South
Med J 1938; 31: 766-75.
19 Valentine VG, Faffin TA. The management of chylothorax.
Chest 1992; 102: 586-91.
20 Skinner DB. En bloc resection for neoplasms of the
oesophagus and cardia. J Thorac Curdiovusc Surg 1983; 85:
59-71.
21 Hankins JR, Miller JE, Attar S, McLoughlin JS. Transhiatal
oesoohagectomv for carcinoma of the oesophagus.
. - Ann
Tho& furg 1987; 44: 123-7.
22 Kine RM. Pairolero PC. Trastek VF. Pavne WS. Bernatz PE.
1vo;Lewis oesophagectomy for carcinoma of the oesophagus:
early and late functional results. Ann Thoruc Surg 1987; 44:
119-22.
23 Orringer MB, Bluett M, Deeb GM. Aggressive treatment of
chylothorax complicating transhiatal oesophagectomy without
thoracotomy. Surgery 1988; 104: 720-6.
24 Woods SD, McGuire U,Chung SC, Crofts TJ, Li AK.
Intrathoracic stapled anastomosis after oesophagectomy for
carcinoma. Aust N Z J Surg 1989; 59: 647-51.
25 Tam PC, Fox M, Wong J. Reexploration for complications
after oesophagectomy for cancer: J Thorac Curdioksc Surg
1989; 98: 1122-7.
26 Dougenis D, Walker WS, Cameron EW, Walbaum ER.
Management of chylothorax complicating extensive
oesophageal surgery. Surg Gynecol Obstet 1992; 174: 501-6.
27 Nygaard SD, Berger HA, Fick RB. Chylothorax as a
complication of oesophageal sclerotherapy. Thorax 1992; 47:
134-5.
28 Milsom JW, Kron IL, Rheuban KS, Rodgers BM.
Chylothorax: an assessment of current surgical management.
J Thoruc Curdiovusc Surg 1985; 89: 221-7.
29 Breaux JR, Marks C. Chylothorax causing reversible T-cell
depletion. J Trauma 1988; 28: 705-7.
30 Roy PH, Carr DT, Payne WS. The problem of chylothorax.
Muyo Clin Proc 1967; 42: 457-67.
.31 Teba L, Dedhia HV, Bowen R, Alexander JC. Chylothorax
review. Crit Cure Med 1985; 13: 49-52.
32 Marts BC, Naunheim KS, Fiore AC, Pennington DG.
Conservative versus surgical management of chvlothorax. A m
J Surg 1992; 1 6 4 532-41
33 Sachs PB, Zelch MB, Rice TW,Geisinger MA, Risius B,
Lammert GK. Diagnosis and localization of laceration of the
thoracic duct: usehness of lymphangiography and CT. AJR
A m J Roentgen01 1991; 157: 703-5.
34 Vallieres E, Shamji FM, Todd TR. Postpneumonectomy
chylothorax. Ann Thoruc Surg 1993; 55: 1006-8.
35 Ngan H, Fok M, Wong J. The role of lymphography in
chylothorax following thoracic surgery. Br J Radio1 1988; 61:
1032-6.
36 Chavez CM, Conn JH. Thoracic duct laceration. Closure
under conservative management based on lymphangiography
evaluation. J Thoruc Curdiovasc Surg 1966; 51: 724-8.
37 Johnstone DW, Feins RH. Chylothorax. Chest Surg Clin
North Am 1994; 4: 617-28.
38 Selle JG, Snyder WH, Schreiber JT. Chylothorax: indications
for surgery. Ann Surg 1973; 177: 245-9.
39 Ferguson MK, Little AG, Skinner DB. Current concepts in
the management of postoperative chylothorax. Ann Thoruc
SUP 1985; 40: 542-5.
40 Bond SJ, Guzzetta PC, Snyder ML, Randolph JG.
Management of paediatric postoperative chylothorax. Ann
Thoruc Surg 1993; 56: 469-72.
41 al Khayat M, Kenyon GS, Fawcett HV, Powell-Tuck J.
Nutritional support in patients with low volume fistulas
I
0 1997 Blackwell Science Ltd, British Journal of Surgery 1997, 84, 15-20