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Semin Respir Crit Care Med 2001; 22(6): 617-626
DOI: 10.1055/s-2001-18797
Copyright © 2001 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel.: +1(212) 584-4662

Chylothorax

Clinton H. Doerr1 , Daniel L. Miller2 , Jay H. Ryu1
  • 1Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
  • 2Division of General Thoracic Surgery, Mayo Clinic, Rochester, Minnesota
Further Information

Publication History

Publication Date:
05 December 2001 (online)

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ABSTRACT

Chylothorax or chylous pleural effusion occurs when chyle accumulates in the pleural space usually secondary to disruption of thoracic lymphatics. Chyle is a milky, white, opalescent fluid that is formed when long-chain triglycerides in the diet are transformed into chylomicrons and very-low-density lipoproteins, which are then secreted into intestinal lacteals. These lymphatic channels coalesce to form the thoracic duct, which transports chyle and ultimately drains it into the left subclavian vein. Any injury to the duct (or its major tributaries) as it courses through the thoracic cavity can lead to a chylous effusion. Diagnosis depends on direct analysis of the fluid by assaying the triglyceride content and, at times, lipid electrophoretic pattern (chylomicrons). Management depends on the underlying cause and the individual clinical circumstances. Nonoperative options include observation, treatment of the underlying disease, dietary modification employing strict medium-chain triglyceride diet or total parenteral nutrition, therapeutic thoracentesis, tube thoracostomy with chemical pleurodesis, and embolization of the thoracic duct. Surgical management may include pleurectomy, talc poudrage, pleuroperitoneal shunting, and repair or ligation of the thoracic duct via thoracoscopy or thoracotomy.

KEYWORD

Chylothorax - chylous effusion - thoracic duct

REFERENCES

  • 1 Staats B A, Ellefson R D, Budahn L L, Dines D E, Prakash U BS, Offord K. The lipoprotein profile of chylous and nonchylous pleural effusions.  Mayo Clin Proc . 1980;  55 700-704
    PubMedGoogle Scholar
  • 2 Staats B A. Lipid Metabolism. In: Lenfant C, ed. Lung Biology in Health and Diseases: The Pleura in Health and Disease Vol. 30. New York, NY: Marcel Dekker 1985: 287-307
    Google Scholar
  • 3 Clark B, Hubscher G. Biosynthesis of glycerides in subcellular fractions of intestinal mucosa.  Biochim Biophys Acta . 1961;  46 479-494
    CrossrefPubMedGoogle Scholar
  • 4 Greenberger N J, Skillman T G. Medium-chain triglycerides: physiologic consideration and clinical implications.  N Engl J Med . 1969;  280 1045-1058
    PubMedGoogle Scholar
  • 5 Zilversmit D B. The composition and structure of lymph chylomicrons in dog, rat, and man.  J Clin Invest . 1965;  44 1610-1622
    CrossrefPubMedGoogle Scholar
  • 6 Havel R J, Goldstein J L, Brown M S. Lipoproteins and lipid transport. In: Bondy PK, Rosenberg LE, eds. Metabolic Control and Disease Philadelphia, Pa: WB Saunders 1980: 393-494
    Google Scholar
  • 7 Johnstone D W, Feins R H. Chylothorax.  Chest Surg Clin N Am . 1994;  4 617-628
    PubMedGoogle Scholar
  • 8 Sassoon C S, Light R W. Chylothorax and pseudochylothorax.  Clin Chest Med . 1985;  6 163-171
    PubMedGoogle Scholar
  • 9 Miller Jr I J. Diagnosis and management of chylothorax: techniques of mediastinal surgery.  Chest Surg Clin N Am . 1996;  6 139-148
    PubMedGoogle Scholar
  • 10 Green P HR, Glickman R M. Intestinal lipoprotein metabolism.  J Lipid Res . 1981;  22 1153-1173
    PubMedGoogle Scholar
  • 11 Gangl A, Ockner R K. Intestinal metabolism of lipids and lipoproteins.  Gastroenterology . 1975;  68 167-186
    PubMedGoogle Scholar
  • 12 Ngan H, Fok M, Wong J. The role of lymphography in chylothorax following thoracic surgery.  Br J Radiol . 1988;  61 1032-1036
    CrossrefPubMedGoogle Scholar
  • 13 Cerfolio R J, Allen M S, Deschamps C. Postoperative chylothorax.  J Thorac Cardiovasc Surg . 1996;  112 1361-1366
    CrossrefPubMedGoogle Scholar
  • 14 Cope C. Diagnosis and treatment of postoperative chyle leakage via percutaneous transabdominal catheterization of the cisterna chyli: a preliminary study.  JVIR . 1998;  9 727-734
    PubMedGoogle Scholar
  • 15 Cox S J, Kinmonth J B. Lymphography of the thoracic duct: a new technique for improving visualization.  J Cardiovasc Surg . 1975;  16 120-122
    PubMedGoogle Scholar
  • 16 Sachs P B, Zelch M G, Rice T W. Diagnosis and localization of laceration of the thoracic duct: usefulness of lymphangiography and CT.  Am J Roentgenol . 1991;  157 703-705
    PubMedGoogle Scholar
  • 17 Freundlich I M. The role of lymphangiography in chylothorax: a report of six nontraumatic cases.  Am J Roentgenol . 1975;  125 617-627
    PubMedGoogle Scholar
  • 18 Kent R B, Pinson T W. Thoracoscopic ligation of the thoracic duct.  Surg Endosc . 1993;  7 52-53
    CrossrefPubMedGoogle Scholar
  • 19 Suga K, Kume N, Hara A. Abnormal lymphatic flow demonstrated by lymphoscintigraphy in chylothorax: correlation with lymphography.  Clin Nuc Med . 1999;  24 716-717
    PubMedGoogle Scholar
  • 20 Valentine V G, Raffin T A. The management of chylothorax.  Chest . 1992;  102 586
    CrossrefPubMedGoogle Scholar
  • 21 Ryu J H, Habermann T M. Pulmonary lymphoma: primary and secondary disease.  Semin Respir Crit Care Med . 1997;  18 341-352
    PubMedGoogle Scholar
  • 22 Klin B, Kohelet D, Bar-Nathan N. Chylothorax complicating repair of congenital diaphragmatic hernia.  Isr J Med Sci . 1992;  28 891-892
    PubMedGoogle Scholar
  • 23 Pace-Balzan A, Moriarty B. Bilateral chylothorax following left radical neck dissection (case report).  J Laryngol Otol . 1988;  102 288-290
    PubMedGoogle Scholar
  • 24 Nakai S, Zielke K. Chylothorax: a rare complication after anterior and posterior spinal correction: report on six cases.  Spine . 1986;  11 830-833
    PubMedGoogle Scholar
  • 25 van der Vliet A J, van der Linden J C, Greep J M. Chylothorax after gastric resection.  Neth J Surg . 1985;  37 16-19
    PubMedGoogle Scholar
  • 26 Papaioannou Y, Vomvoyannis A, Andritsakis G. Combined chylopericardium and chylothorax after total correction of Fallot's tetralogy.  Thorac Cardiovasc Surg . 1984;  32 115-116
    PubMedGoogle Scholar
  • 27 Fairfax A J, McNabb W R, Spiro S G. Chylothorax: a review of 18 cases.  Thorax . 1986;  41 880-885
    CrossrefPubMedGoogle Scholar
  • 28 Zahour B J, Drucker M H, Franco A A. Chylothorax as a complication of aortocoronary bypass: two case reports and a review of the literature.  Scand J Thorac Cardiovasc Surg . 1988;  22 93-95
    PubMedGoogle Scholar
  • 29 Bowerman R E, Solomon D A, Bognolo D, Brauner L R. Chylothorax: report of a case complicating orthotopic heart transplantation.  J Heart Lung Transplant . 1993;  12 665-668
    PubMedGoogle Scholar
  • 30 Basha I S, Carlin B W, Kaplan P D. Chylothorax complicating right upper lobectomy.  South Med J . 1991;  84 1053-1054
    PubMedGoogle Scholar
  • 31 Vallieres E, Shamji F M, Todd T R. Postpneumonectomy chylothorax.  Ann Thorac Surg . 1993;  55 1006-1008
    CrossrefPubMedGoogle Scholar
  • 32 Bolger C, Walsh T N, Tanner W A, Keeling P, Hennessy T P. Chylothorax after oesophagectomy.  Br J Surg . 1991;  78 587-588
    CrossrefPubMedGoogle Scholar
  • 33 Shimizu J, Hayashi Y, Oda M. Treatment of postoperative chylothorax by pleurodesis with the streptococcal preparation OK-432.  J Thorac Cardiovasc Surg . 1994;  42 233-236
    PubMedGoogle Scholar
  • 34 Terzi A, Furlan G, Magannelli G. Chylothorax after pleuropulmonary surgery: a rare but unavoidable complication.  Thorac Cardiovasc Surg . 1994;  42 81-84
    Article in Thieme ConnectPubMedGoogle Scholar
  • 35 Hillerdal G. Chylothorax and pseudochylothorax.  Eur Respir J . 1997;  10 1157-1162
    CrossrefPubMedGoogle Scholar
  • 36 Dougenis D, Walker W S, Cameron E W, Walbaum P R. Management of chylothorax complicating extensive esophageal resection.  Surg Gyn Obst . 1992;  174 501-506
    PubMedGoogle Scholar
  • 37 Ruggiero R P, Caruso G. Chylothorax: a complication of subclavian vein catheterization.  J Parent Enter Nutr . 1985;  9 750-753
    PubMedGoogle Scholar
  • 38 Nygaard S D, Berger H A, Fick R B. Chylothorax as a complication of oesophageal sclerotherapy.  Thorax . 1992;  47 134-135
    PubMedGoogle Scholar
  • 39 Chernick V, Reed M H. Pneumothorax and chylothorax in the neonatal period.  J Pediatr . 1970;  76 624-632
    PubMedGoogle Scholar
  • 40 Robinson C LN. The management of chylothorax.  Ann Thorac Surg . 1985;  39 90-95
    CrossrefPubMedGoogle Scholar
  • 41 Smeltzer D M, Stickler G B, Fleming R E. Primary lymphatic dysplasia in children: chylothorax, chylous ascites, and generalized lymphatic dysplasia.  Eur J Pediatr . 1986;  145 286-292
    CrossrefPubMedGoogle Scholar
  • 42 Jarman P R, Whyte M K, Sabroe I, Hughes J M. Sarcoidosis presenting with chylothorax.  Thorax . 1995;  50 1324-1325
    CrossrefPubMedGoogle Scholar
  • 43 Brenner W I, Boal B H, Reed G E. Chylothorax as a manifestation of rheumatic mitral stenosis: its postoperative management with a diet of medium-chain triglycerides.  Chest . 1978;  73 672-673
    PubMedGoogle Scholar
  • 44 Taylor J R, Ryu J H, Colby T V, Raffin T A. Lymphangioleiomyomatosis: clinical course in 32 patients.  N Engl J Med . 1990;  323 1254-1260
    CrossrefPubMedGoogle Scholar
  • 45 Faul J L, Berry G J, Colby T V. Thoracic lymphangiomas, lymphangiectasis, lymphangiomatosis, and lymphatic dysplasia syndrome.  Am J Respir Crit Care Med . 2000;  161 1037-1046
    CrossrefPubMedGoogle Scholar
  • 46 Nordkild P, Mromann-Andersen H, Struve-Christensen E. Yellow nail syndrome: the triad of yellow nails, lymphedema and pleural effusions.  Acta Med Scand . 1986;  219 221-227
    PubMedGoogle Scholar
  • 47 Van Renterghem D, Hamers J, De Schryver A. Chylothorax after mantle field irradiation for Hodgkin's disease.  Respiration . 1985;  48 188-189
    PubMedGoogle Scholar
  • 48 Gil-Suay V, Martinez-Moragon E, de Diego A, Sanchis J. Chylothorax complicating a thoracic aortic aneurysm.  Eur Respir J . 1997;  10 737-739
    PubMedGoogle Scholar
  • 49 Tie M L, Poland G A, Rosenow III C E. Chylothorax in Gorham's syndrome: a common complication of a rare disease.  Chest . 1994;  105 208-213
    CrossrefPubMedGoogle Scholar
  • 50 Ten Hoor T, Hewan-Lowe K, Miller J I, Loss M. A transitional variant of Castleman's disease presenting as a chylous pleural effusion.  Chest . 1999;  115 285-288
    CrossrefPubMedGoogle Scholar
  • 51 Davis S N, Clark F. Multiple myeloma as a cause of chylothorax.  J Royal Soc Med . 1986;  79 49
    PubMedGoogle Scholar
  • 52 Monteagudo M, Lima J, Garcia-Bragado F, Alvarez J. Chylous pleural effusion as the initial manifestation of Waldenstrom's macroglobulinemia.  Eur J Respir Dis . 1987;  70 326-327
    PubMedGoogle Scholar
  • 53 Zimhony O, Davidovitch Y, Shtalrid M. Chronic lymphocytic leukemia complicated by chylothorax.  J Intern Med . 1994;  235 375-377
    PubMedGoogle Scholar
  • 54 Judson M A, Postic B. Chylothorax in a patient with AIDS and Kaposi's sarcoma.  South Med J . 1990;  83 322-324
    PubMedGoogle Scholar
  • 55 Pandya K, Lal C, Tuchschmidt J. Bilateral chylothorax with pulmonary Kaposi's sarcoma [letter].  Chest . 1988;  94 1316-1317
    PubMedGoogle Scholar
  • 56 Ferrer J. Pleural tuberculosis.  Eur Respir J . 1997;  10 942-947
    PubMedGoogle Scholar
  • 57 Tutor J D, Schoumacker R A, Chesney P J. Chylothorax associated with histoplasmosis in a child.  Ped Infect Dis J . 2000;  19 262-263
    PubMedGoogle Scholar
  • 58 Kitchen N D, Hocken D B, Greenhalgh R M, Kaplan D K. Use of the Denver pleuroperitoneal shunt in the treatment of chylothorax secondary to filariasis.  Thorax . 1991;  46 144-145
    PubMedGoogle Scholar
  • 59 Smith S, Schulman A, Weir E K, Beatty D W, Joffe H S. Lymphatic abnormalities in Noonan syndrome: a case report.  S Afr Med J . 1979;  56 271-274
    PubMedGoogle Scholar
  • 60 Hamada H, Fujita K, Kubo T, Iwasaki H. Congenital chylothorax in a trisomy 21 newborn.  Arch Gyn Obst . 1992;  252 55-58
    PubMedGoogle Scholar
  • 61 Harvey J G, Houlsby W, Sherman K, Gough M H. Congenital chylothorax: report of unique case associated with ``H'' -type tracheo-oesophageal fistula.  Br J Surg. . 1979;  66 485-487
    PubMedGoogle Scholar
  • 62 Browse N L, Allen D R, Wilson N M. Management of chylothorax.  Br J Surg . 1997;  84 1711-1716
    CrossrefPubMedGoogle Scholar
  • 63 Moss R, Hinds S, Fedullo A J. Chylothorax: a complication of nephrotic syndrome.  Am Rev Respir Dis . 1989;  140 1436-1437
    PubMedGoogle Scholar
  • 64 Kollef M H. Recalcitrant chylothorax and chylous ascites associated with hypothyroidism.  Milit Med . 1993;  158 63-65
    PubMedGoogle Scholar
  • 65 Romero S, Martin C, Hernandez L. Chylothorax in cirrhosis of the liver: analysis of its frequency and clinical characteristics.  Chest . 1998;  114 154-159
    PubMedGoogle Scholar
  • 66 Goldfarb J P. Chylous effusions secondary to pancreatitis: case report and review of the literature.  Am J Gastroenterol . 1984;  79 133-135
    PubMedGoogle Scholar
  • 67 Berkenbosch J W, Withington D E. Management of postoperative chylothorax with nitric oxide: a case report.  Crit Care Med . 1999;  27 1022-1024
    PubMedGoogle Scholar
  • 68 Whitcomb B B, Scoville W B. Postoperative chylothorax: sudden death following the infusion of aspirated chyle.  Arch Surg . 1942;  45 747
    PubMedGoogle Scholar
  • 69 Thomson I A, Simms M H. Postoperative chylothorax: a case for recycling?.  Cardiovascular Surgery . 1993;  1 384-385
    PubMedGoogle Scholar
  • 70 Hashim S A, Roholt H B, Babayan V K, van Itallie B T. Treatment of chyluria and chylothorax with medium-chain triglyceride.  N Engl J Med . 1964;  270 756-761
    PubMedGoogle Scholar
  • 71 Lichter I, Hill G L, Nye E R. The use of medium-chain triglycerides in the treatment of chylothorax in a child.  Ann Thorac Surg . 1968;  4 352-355
    PubMedGoogle Scholar
  • 72 Jalili F. Medium-chain triglycerides and total parenteral nutrition in the management of infants with congenital chylothorax.  South Med J . 1987;  80 1290-1293
    PubMedGoogle Scholar
  • 73 Curci M R, Diffins A W. Bilateral chylothorax in a newborn.  J Pediatr Surg . 1980;  15 663-665
    PubMedGoogle Scholar
  • 74 Jensen G L, Mascili E A, Meyer L P. Dietary modification of chyle composition in chylothorax.  Gastroenterology . 1989;  97 761-765
    PubMedGoogle Scholar
  • 75 Ramos W, Faintuch J. Nutritional management of thoracic duct fistulas: a comparative study of parenteral versus enteral nutrition.  J Parent Enter Nutr . 1985;  10 519-521
    PubMedGoogle Scholar
  • 76 Bessone L N, Ferguson T B, Burford T H. Chylothorax: collective review.  Ann Thorac Surg . 1971;  12 527-559
    PubMedGoogle Scholar
  • 77 Light R W. Pleural Diseases.  Philadelphia, Pa: Lea and Febiger 1990: 269-281
    Google Scholar
  • 78 Marts B C, Naunheim K S, Fiore A C, Pennington D G. Conservative versus surgical management of chylothorax.  Amer J of Surg . 1992;  164 532-534
    PubMedGoogle Scholar
  • 79 Bond S J, Guzzetta P C, Snyder M L, Randolph J G. Management of pediatric postoperative chylothorax.  Ann Thorac Surg . 1993;  56 469-472
    PubMedGoogle Scholar
  • 80 Beghetti M, La Scala G, Belli D, Bugmann P, Kalangos A, Le Coultre C. Etiology and management of pediatric chylothorax.  J Ped . 2000;  136 653-658
    CrossrefPubMedGoogle Scholar
  • 81 Demos N J, Kozel J, Scerbos J E. Somatostatin in the treatment of chylothorax.  Chest . 2001;  119 964-966
    CrossrefPubMedGoogle Scholar
  • 82 Cope C, Salem R, Kaiser L R. Management of chylothorax by percutaneous catheterization and embolization of the thoracic duct: prospective trial.  JVIR . 1999;  10 1248-1254
    PubMedGoogle Scholar
  • 83 Lampson R S. Traumatic chylothorax: a review of the literature and report of a case treated by mediastinal ligation of the thoracic duct.  J Thorac Surg . 1948;  17 778-791
    PubMedGoogle Scholar
  • 84 Shackelford R T, Fisher A M. Traumatic chylothorax.  South Med J . 1938;  31 766-775
    PubMedGoogle Scholar
  • 85 Goorwitch J. Traumatic chylothorax and thoracic duct ligation: case report and review of the literature.  J Thorac Surg . 1955;  29 467-479
    PubMedGoogle Scholar
  • 86 Schmidt A. Chylothorax: review of 5 years' cases in the literature and report of a case.  Acta Chir Scand . 1959;  118 5-12
    PubMedGoogle Scholar
  • 87 Stenzel W, Rigler B, Tscheliesnigg K H. Treatment of postsurgical chylothorax with fibrin glue.  Thorac Cardiovasc Surg . 1983;  31 35-36
    PubMedGoogle Scholar
  • 88 Mason P F, Ragoowansi R H, Thorpe J AC. Post-thoracotomy chylothorax: a cure in the abdomen?.  European J Cardiothorac Surg . 1997;  11 567-570
    PubMedGoogle Scholar
  • 89 Graham D D, McGahren E D, Tribble C G, Daniel T M, Rodgers B M. Use of video-assisted thoracic surgery in the treatment of chylothorax.  Ann Thorac Surg . 1994;  57 1507-1512
    CrossrefPubMedGoogle Scholar
  • 90 Peillon C, D'Hont C, Melki J. Usefulness of video thoracoscopy in the management of spontaneous and postoperative chylothorax.  Surg Endosc . 1999;  13 1106-1109
    CrossrefPubMedGoogle Scholar
  • 91 Ferguson M K, Little A G, Skinner D B. Current concepts in the management of postoperative chylothorax.  Ann Thorac Surg . 1985;  40 542-545
    CrossrefPubMedGoogle Scholar
  • 92 Milsom J W, Kron I L, Rheuban K S, Rodgers B M. Chylothorax: an assessment of current surgical management.  J Thorac Cardiovasc Surg . 1985;  89 221-227
    PubMedGoogle Scholar
  • 93 Selle J G, Snyder W H, Schreiber J T. Chylothorax: indications for surgery.  Ann Surg . 1973;  177 245-249
    CrossrefPubMedGoogle Scholar
  • 94 Merigliano S, Molena D, Ruol A. Chylothorax complicating esophagectomy for cancer: a plea for early thoracic duct ligation.  J Thorac Cardiovasc Surg . 2000;  119 453-457
    CrossrefPubMedGoogle Scholar
  • 95 Dugue L, Sauvanet A, Farges O, Goharin A, Le Mee J, Belghiti J. Output of chyle as an indicator of treatment for chylothorax complicating oesophagectomy.  Br J Surg . 1998;  85 1147-1149
    CrossrefPubMedGoogle Scholar
  • 96 Heppner G J. Bilateral chylothorax and chyloperitoneum.  JAMA . 1934;  102 1294
    PubMedGoogle Scholar
  • 97 Mares D C, Mathur P N. Medical thoracoscopic talc pleurodesis for chylothorax due to lymphoma: a case serics.  Chest . 1998;  114 731-735
    CrossrefPubMedGoogle Scholar
  • 98 Vargas F S, Milanez J RC, Filomeno L TB, Fernandez A, Jatene A, Light R W. Intrapleural talc for the prevention of recurrence in benign or undiagnosed pleural effusion.  Chest . 1994;  106 1771-1775
    CrossrefPubMedGoogle Scholar
  • 99 Murphy M C, Newman B M, Rodgers B M. Pleuroperitoneal shunts in the management of persistant chylothorax.  Ann Thorac Surg . 1989;  48 195-200
    CrossrefPubMedGoogle Scholar
  • 100 Little A G, Kadowaki M H, Ferguson M K. Pleuroperitoneal shunting: alternative therapy for pleural effusions.  Ann Surg . 1988;  208 443-450
    CrossrefPubMedGoogle Scholar
  • 101 Puntis J W, Roberts K D, Handy D. How should chylothorax be managed?.  Arch Dis Child . 1987;  62 593-596
    PubMedGoogle Scholar
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