CHYLOTHORAX

Yusmaidi
Subdivisi Bedah Thorax
Bag. Bedah FK-UNSRI
 Introduction

 Chylothorax refers to the presence of

lymphatic fluid in the pleural space
secondary to leakage from the thoracic
duct or one of its main tributaries.
 In 1875, H. Quinke described the first
traumatic chylothorax. In 1948, R.S.
Lampson performed the first thoracic duct
ligation.
 Pathophysiology

A tear or leak in the thoracic duct

causes chylous fluid to collect in the
pleural cavity, which can cause acute
or chronic alterations in the
pulmonary mechanics.
 In a normal adult, the thoracic duct
transports up to 4 L of chyle per day,
allowing a rapid and large
accumulation of fluid in the chest
 Frequency
The prevalence after various cardiothoracic
surgeries is 0.2-1%.
 Mortality/Morbidity
Mortality and morbidity rates are approximately
10% in major clinical medical centers.
 Sex
Chylothorax has no predilection for either sex.
 Age
Chylothorax has no predilection for age.
 Clinical

 History
 Usually, the patient remains asymptomatic until a
large amount of chyle accumulates in the pleural
space.
 The average latent period between the insult and
the onset of symptoms is 7-10 days. Symptoms
include the following:
 Dyspnea
 Tachypnea
 Classic symptoms of pleural effusion
 Rarely, patients may experience a rapid
accumulation of fluid in the pleural space, causing
a tension chylothorax.
 Clinical

 Physical
Findings on examination are nonspecific
and include the following:
 Decreased breath sounds
 Shifting dullness
If the patient has an existing chest tube,
excess drainage of 400-600 cc per 8-hour
period is concerning for a chylous leak,
particularly in postsurgical patients.
 Causes
 Nontraumatic
 Malignant 50% of chylothorax diagnoses and are separated into
lymphomatous (60%) and nonlymphomatous.
 Nonmalignant etiologies are separated into idiopathic,
congenital, and miscellaneous.
 Miscellaneous (cirrhosis, tuberculosis, sarcoidosis, amyloidosis, and
filariasis).
 Traumatic
 Trauma (25%).
 Iatrogenic injury
 Nonsurgical traumatic injury penetrating trauma).
 Pseudochylothorax
 accumulation of cholesterol crystals in a chronic existing
effusion.
 The most common cause of pseudochylothorax is chronic
rheumatoid pleurisy, followed by tuberculosis and poorly treated
empyema.
 Differential Diagnoses

 Empyema, Pleuropulmonary
Hemothorax

 Other Problems to Be Considered

AIDS-related complex
Congestive heart failure
Exudative pleural effusion
Malignant pleural effusion
Pseudochylothorax
 Laboratory Studies

 The following laboratory studies are not

required for diagnosis but are useful to
determine the metabolic and nutritional
status of the patient:
 Serum electrolyte tests
 Serum albumin test
 CBC count with differential to look for
lymphocyte depletion
 Imaging Studies
 Chest radiographic findings are nonspecific for
chylothorax and indistinguishable from other
causes of pleural effusion.
 Determine if effusion is bilateral.
 Look for a mediastinal shift.
 If the etiology of the chylothorax is unknown,
obtain CT scans of the chest and abdomen to rule
out malignancy.
 Lymphangiography is useful when the anatomy of
the thoracic duct needs to be defined
preoperatively or when the site of the leak is not
clinically obvious.
Anteroposterior chest radiograph
CT scan of the chest
 Treatment

 Medical Care
 Patients with chylothorax can be treated by
conservative means or surgery.
 Always consider conservative management
because the thoracic duct leak closes
spontaneously in nearly 50% of patients.
 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.
 Treatment

 Chemoradiation (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. (3.5-12 mcg/kg/h).
 adverse effects of somatostatin therapy, including
diarrhea, hypoglycemia, and hypotension.
 Treatment
 Surgical Care
 The timing of surgical management is controversial and
depends on the etiology of the chylothorax and the
patient's overall condition.
 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.
 Treatment
 Indications for surgical intervention include the
following:
1. Chyle leak greater than 1 L/d for 5 days or a
persistent leak for more than 2 weeks despite
conservative management
2. Nutritional or metabolic complications, including
electrolyte depletion and immunosuppression
3. Loculated chylothorax, fibrin clots, or trapped
lung
4. Postesophagectomy chylothorax (Patients with
this carry a high mortality rate if treated
conservatively.
 Treatment
 Surgical options depend on the site of injury and the
etiology of the chylothorax.
 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.
 A pleuroperitoneal shunt can be successful for refractory
chylothorax but can be complicated by infection and
obstruction.
 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.
 Complications

 Malnutrition
 Immunosuppression