Management of Thoracic Duct Lymphocele

Thoracic duct lymphoceles often respond to conservative treatment initially, but persistent cases require surgical re-exploration. 1

Diagnosis and Confirmation

Diagnosis is established through fluid analysis with diagnostic criteria including pleural fluid triglyceride level >110 mg/dL and ratio of pleural fluid to serum triglyceride level >1.0 2
Imaging techniques to identify the thoracic duct and site of leakage include:
- Lymphangiography (gold standard) - can be performed via pedal or intranodal approaches, with intranodal decreasing procedure time and risk of wound infection 1, 3
- CT imaging with 1mm collimation and multiplanar reformation can identify the thoracic duct and cisterna chyli in nearly 100% of cases with normal anatomy 1, 3
- MRI provides better visualization of thoracic duct segments than CT alone 1, 3

Initial drainage of chylous fluid provides both diagnostic confirmation and symptom relief 2
Dietary modifications are recommended:
- Diet low in long-chain triglycerides (<5% of total energy intake) 2
- Enrichment with medium-chain triglycerides (>20% of total energy intake) 2
Adjunctive pharmacological therapy may include:
- Somatostatin to reduce lymphatic flow 2
- Etilefrine to reduce lymphatic flow 2
Conservative management success rates approach 50% in nonmalignant etiologies 2

Failure of conservative management after 2 weeks 2
High output (>500-1000 mL/day) is a key indicator for more aggressive management 2
Persistent lymphocele despite conservative measures 1

First-line invasive treatment for high output chyle leaks 2, 3
Technical success rates of 85-88.5% across all causes 2, 3
Clinical success rates of up to 97% for nontraumatic chylous effusions 2
Complications are generally minor (2-6%) and self-limited 2
Case reports demonstrate successful resolution of mediastinal lymphoceles after TDE 4

Indicated when TDE fails or is not available 2
Surgical options include:
- Complete resection of the lymphocele 5
- Thoracic duct ligation 2
- Pericardio-peritoneal window when conservative treatment and pericardiocentesis fail 1
Various strategies to prevent lymphocele recurrence include:
- Limiting dissection to the anterior walls of the vessels 1
- Careful use of electrocautery and clips during dissection 1
- Meticulous multilayered closure 1
- Drain placement 1

Chylothorax occurs in about 2-3% of transthoracic esophagectomies 1
High mortality if conservative treatment becomes prolonged due to hypoalbuminaemia and leucocyte depletion 1
Chyle production of greater than 10 ml/kg/day at approximately the fifth postoperative day may predict the likelihood of spontaneous closure 1
In cases of failed thoracic duct ligation, reassessment with combined CT and unilateral pedal lymphangiography can identify the cause and locate the leak in 75% of idiopathic chylothoraces 1

Daily chyle output should be monitored to guide treatment decisions 2
Nutritional status, especially protein levels, should be assessed regularly as 1000 mL of chyle may contain up to 30g of protein 2
Replacement of fluid and protein losses is necessary to maintain nutritional status 2

Thoracic duct anatomical variations are common, with the typical course present in only 40-60% of patients, which may complicate interventional procedures 6
Failure to recognize thoracic duct attachment during surgical procedures may result in chylothorax 7
Higher postoperative mortality rates (4.5-50%) have been reported with surgical thoracic duct ligation compared to TDE 2