From the Guidelines
Chylothorax treatment should start with conservative management, including thoracentesis, dietary modifications, and adjunctive therapy, with invasive treatments like thoracic duct embolization (TDE) considered if conservative measures fail after 2 weeks, especially in cases with high daily outputs or underlying neoplastic etiologies. The initial approach to treating chylothorax involves confirming the diagnosis by draining the fluid for studies, which also provides palliative relief [1@]. Conservative measures include management of the underlying disease, thoracentesis, and dietary modifications such as total parenteral nutrition or a nonfat diet to reduce production of chyle and consequently flow through the thoracic duct [1@]. Adjunctive therapy may include somatostatin, etilefrine, or nitric oxide, with the underlying etiology determining the efficacy, although the evidence remains scarce [1@].
Key Considerations
- The success of conservative therapy approaches 50% in nonmalignant etiologies but is only minimally beneficial in neoplastic etiologies [1@].
- Invasive treatments, including surgical thoracic duct ligation, pleurodesis, and TDE, are considered if conservative treatment has not resolved the chylothorax after 2 weeks, in higher-output chylothoraces, and in underlying neoplastic etiologies [1@].
- TDE has shown higher clinical success in treating traumatic compared to nontraumatic chyle leaks, with reported success rates of over 70% in some series [1@].
- Acute complications associated with TDE are minor and generally self-limited, estimated at 2% to 6%, while long-term complications may occur in up to 14% of patients [1
From the Research
Treatment Options for Chylothorax
- Conservative treatment is often the initial approach, which may include dietary measures, medications such as octreotide, and pleural drainage 1, 2, 3, 4, 5
- Nutritional support is crucial, with options including a low-fat diet supplemented with intermediate-chain triglycerides (ICT), fat-free enteral nutrition, or parenteral nutrition 1
- Octreotide has been shown to be safe and effective in reducing chylothorax flow, although there is no consensus on when to start therapy, the most appropriate dose, or the time to withdraw treatment 1, 2
Surgical Intervention
- Surgical treatment, such as thoracic duct ligation, may be necessary if conservative treatment fails, especially in cases with high flow rates (>800 mL/d) 3, 4, 5
- Video-assisted thoracoscopic thoracic duct ligation (VATS) has been shown to be effective in managing chylothorax, with success rates ranging from 66.7% to 95% 3, 5
- Additional procedures, such as pleurodesis and/or thoracic duct embolization/disruption, may be considered in cases with high surgical failure rates, such as nontraumatic bilateral chylothorax 5
Interventional Radiological Treatments
- Percutaneous thoracic duct embolization or the percutaneous destruction of lymphatic vessels have been shown to be effective in managing chylothorax, with success rates ranging from 70% to 80% 4
- These procedures have a lower complication rate (roughly 3%) compared to surgical interventions, but are currently available in only a small number of centers 4