Current Management of Postoperative Chylothorax

Hossein Fahimi, MD, Filip P. Casselman, MD, Massimo A. Mariani, PhD,

Wim J. van Boven, MD, Paul J. Knaepen, MD, and Henry A. van Swieten, PhD
Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands

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.

suspicion whenever the postoperative pleural or epicardial effusion was unexpectedly large. The diagnosis was
confirmed by presence of triglycerides and chylomicrons
in the fluid.
All patients were initially treated conservatively by
closed drainage and (medium chain triglycerides) diet.
When the chyle leakage remained higher than 200 mL on
a 24-hour basis after 2 weeks, the conservative treatment
was considered unsuccessful. Surgical intervention was
then indicated. To identify the leakage exactly, patients
undergoing VATS received a meal of cream mixed with
Sudan black 1 hour preoperatively.

aceration 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 [17].
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 [1215]. 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

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
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@knmg.nl.

2001 by The Society of Thoracic Surgeons

Published by Elsevier Science Inc

(Ann Thorac Surg 2001;71:448 51)

2001 by The Society of Thoracic Surgeons

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

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Ann Thorac Surg

2001;71:448 51

FAHIMI ET AL
CURRENT MANAGEMENT OF CHYLOTHORAX

449

Table 1. Operated Patients Treated for Chylothorax

Year

Patient
No.

Age
(Years)

Gender

1999
1998
1998
1996
1996
1995
1994
1994

1
2
3
4
5
6
7
8

73
80
56
76
66
51
66
49

M
M
M
M
M
M
M
M

1994
1994
1994

9
10
11

31
53
71

1991

12

67

Primary Operation

Side

Treatment

TAA
TAA
TAAA
Lobectomy RLL
Mediastinoscopy
CABG, LIMA
R Pneumonectomy
CABG, LIMA

L
LR
L
R
LR
L
R
L

F
F
M

L VATS, Sympathectomy
Sleeve Lobectomy RUL
CABG, LIMA

L
R
Peric.

R Pneumonectomy

L VATS, clip fibrine glue

R VATS clip
Conservative
Conservative
Thoracotomy, LLL lobecomy, fibrin glue
Conservative
R VATS clip
L VATS leakage not localized, fibrin glue
and talcage
L VATS clips fibrin glue
Conservative
L VATS leakage not localized, fibrin glue
and talcage
Conservative

Y year of treatment;
R right;
L left;
M male;
F female;
VATS video-assisted thoracoscopic surgery;
CABG coronary
artery bypass grafting;
LIMA left internal mammary artery;
TAA thoracic aortic aneurysm;
TAAA thoraco-abdominal aortic
aneurysm;
RUL right upper lobe;
RLL right lower lobe;
LLL left lower lobe;
Peric. pericardium.

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
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, 57, 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

450

FAHIMI ET AL
CURRENT MANAGEMENT OF CHYLOTHORAX

Fig 1. Treatment for postoperative chylothorax flow chart.

postoperative chylothorax when daily leakage exceeds

200 mL after 2 weeks of conservative therapy. The flow
chart demonstrates our current approach (Fig 1).
We believe that one should consider even an earlier
intervention in case of high flow leaks. Longer conservative therapy increases the risk of developing pleural
adhesions and complicating VATS in addition to the
needless loss of chyle.

References
1. Sieczk EM, Harvey JC. Early thoracic duct ligation for
postoperative chylothorax. J Surg Oncol 1996;61:56 60.
2. Sachs PB, Zelch MG, Rice TW, et al. Diagnosis and localization of laceration of the thoracic duct: usefulness of lymphangiography and CT. Am J of Roetngen 1991;157:7035.
3. Ceves PG, Vecchioni R, DAmico DF, et al. Postoperative
chylothorax. J Thorac Cardiovasc Surg 1975;69:96671.
4. Joyce LD, Lindsy WG, Nicolott DM. Chylothorax after median sternotomy for intrapericardial surgery. J Thorac Cardiovasc Surgery 1976;71:476 80.

Ann Thorac Surg

2001;71:448 51

5. Van Mulders A, Lacquet LM, Van Meghem W, Deneffe G.

Chylothorax complicating pneumonectomy. Thorax 1984;38:
9545.
6. Lam H, Lim STK, Wong J, Ong GB. Chylothorax following
resection of the oesophagus. Br J Surg 1979;66:1059.
7. Hertzog P, Toty L, Personne C, Rotten D. Chylothorax apres
chirurgie pleuro-pulmonaire. a` propos de 12 cas personnels.
Ann Chir 1975;14:15971.
8. Di F, Kun L, Qing Su C. Ligation of the thoracic duct without
thoracotomy for the treatment of postoperative chylothorax:
a newly designed surgical procedure. J R Coll Surg Edinb
1995;40:601.
9. Dougenis D, Walker WS. Management of chylothorax complicating extensive esophageal resection. Surg Gynaec Obstetr 1992;174:501 6.
10. Bressler S, Wiener D, Thomson SA. Traumatic chylothorax
following esophageal resection. J Thorac Surg 1953;26:321 4.
11. Plumme SK, Ambresino D, Boile W. Management of persistent chylothorax [Letter]. Lancet 1981;11:423 4.
12. Mihalka J, Burrows FA, Burke RP, Jarovski JJ. One lung
ventilation during video-assisted thoracoscopic ligation of a
thoracic duct in a three-year-old child. J Cardiothorac Vasc
Anesth 1994;8:559 62.
13. Kent RB, Pinson TW. Thoracoscopic ligation of the thoracic
duct. Surg Endosc 1993;7:523.
14. Daniel TM, Kern JA, Tribble CG, et al. Thoracoscopic surgery for diseases of the lung and pleura. Ann Surg 1993;217:
56675.
15. Wakabayashi A. Expanded applications of diagnostic and
therapeutic thoracoscopy. J Thorac Cardiovasc Surg 1991;
102:7213.
16. Stringel G, Mercer S, Bass J. Surgical management of persistent postoperative chylothorax in children. Can J Surg
1984;27:543 6.
17. Courouclis S, Dahback O, Ekelund L, Jonsson K, Schuller H.
Aetiological and therapeutical problems in chylothorax.
Scan J Thorac Cardiovasc Surg 1976;71:476 80.
18. Rubin JW, Moore HV, Ellison RG. Chylothorax: therapeutic
alternatives. Am Surg 1977;43:2927.
19. Hugges RL, Mintzer RA, Hidvegi DF, Freinkel RK, Cugell
DW. The management of chylothorax: Clinical Conference
in Pulmonary Diseases from North Western University
Medical School, Chicago. Chest 1979;76:212 8.
20. Peillon C, DHont C, Melki J, Fattaouh F, et al. Usfulness of
video thoracoscopy in the management of spontaneous and
postoperation chylothorax. Surg Endosc 1999;13:11069.
21. Guillem P, Billeret V, Houcke ML, Triboulet JP. Successful
management of post-esophagectomy chylothorax/
chyloperitoneum by Etilefrine. Dis Esophagus 1999;12:155 6.
22. Lampson RS. Traumatic chylothorax: a review of the literature and report of a case treated by mediastinal ligation of
the thoracic duct. J Thorac Surg 1948;17:778 91.

INVITED COMMENTARY
Postoperative chylothorax remains an uncommon but
potentially life-threatening complication of various intrathoracic procedures, and the ideal management of this
condition is still controversial. Generally, so-called conservative therapy is tried first, and includes low-fat diet,
total parenteral nutrition, and pleural drainage. Somatostatin and more recently Etilefrine [1], a sympathomimetic drug used in the management of postural hypotension, also causing smooth muscle contraction of the
thoracic duct, have been reported as significant additives
to this regimen. However, it usually takes several weeks
2001 by The Society of Thoracic Surgeons
Published by Elsevier Science Inc

for the chylothorax to resolve and it is almost always

unsuccessful in patients with high flow leaks. Indeed, it
has been clearly demonstrated that a high volume of
chylous output could reliably predict the failure of continuing medical treatment [2]. The type of the initial
operation is also predictive when the site and the mechanism of lymphatic vessels injury could be anticipated.
As a matter of fact, chylothorax after radical esophagectomy for cancer is usually from direct injury to the
thoracic duct, as it is also the case in those chylothoraces
occurring after surgery of the thoracic aorta, and could
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