Treatment options in patients with chylothorax

Abstract

Background: Chylothorax arises when lymphatic fluid (chyle) accumulates in the pleural cavity because of leakage from lymphatic vessels. It is most commonly seen after thoracic surgery (in 0.5% to 1% of cases) and in association with tumors. No prospective or randomized trials have yet been performed to evaluate the available treatment options.

Method: This review is based on a selective search of the PubMed database for pertinent publications from the years 1995 to 2013. Emphasis was laid on articles that enabled a comparative assessment of treatment options.

Results: Initial conservative treatment (e.g., parenteral nutrition or a special diet) succeeds in 20% to 80% of cases. When such treatment fails, the standard approach up to the present has been to treat surgically, e.g., with ligation of the thoracic duct, pleurodesis, or a pleuroperitoneal shunt. The success rates of such procedures have ranged from 25% to 95%. Most of the patients undergoing such procedures are severely ill; complication rates as high as 38% have been reported, with mortality as high as 25%. In more recent publications, however, morbidity and mortality were lower. Interventional radiological treatments, such as percutaneous thoracic duct embolization or the percutaneous destruction of lymphatic vessels, succeed in about 70% of cases and lead to healing in up to 80% of cases, even after unsuccessful surgery. The complication rate of percutaneous methods is roughly 3%.

Conclusion: Interventional radiological procedures have now taken their place alongside conservative treatment and surgery in the management of chylothorax, although they are currently available in only a small number of centers.

Figure 1

Typical course of the thoracic duct, which extends prevertebrally from the cisterna chyli, first on the right side, then (from about T4) on the left side, finally curving posteriorly to end in the left venous angle. Variations are frequent

Figure 2

Percutaneous embolization of the thoracic duct: transabdominal fine-needle puncture of a lymph vessel (arrow marks the tip of the needle and the puncture site)

Figure 3

Treatment algorithm for chylothorax. Conservative treatment is performed first; there is no consensus as to how long this should be tried. If it fails, the basic choices are between interventional radiology and surgery. If surgery fails, interventional radiology may still achieve success. Surgery is required when percutaneous treatment is not available, does not appear feasible, or fails. At present there are no prospective studies that could provide guidance about specific measures in individual cases. MCT diet, diet containing medium-chain triglycerides; TIPS, transjugular intrahepatic stent shunt

Figure 4

Percutaneous embolization of the thoracic duct. Upper arrow: lymph leak identifiable as contrast medium extravasation. At the level of the extravasation, an embolization coil has been placed in the duct. The thoracic duct (left-pointing arrows) is closed with tissue adhesive labelled with contrast medium