Chylothorax
Key points
Definition: Collection of lymphatic fluid within the pleural space
Anatomy and Physiology
Lymphatic fluid= Lymph + Chyle (lymph + Emulsified fats)
Lymph carries interstitial fluid from tissues
Emulsified fats are long chain fatty acids absorbed from the intestine which cannot be absorbed directly into the intestine. They are carried as chyle into the lymphatic circulation.
Medium and short chain fatty acids are directly absorbed into the portal circulation
Chyle from the intestine is taken up by lacteals, which join with larger lymphatics that are carrying lymph fluid from the rest of the body
Converge to form the cisterna chyli, which empties into the thoracic duct.
The right thoracic duct is another major channel for the lymph from the right side of the chest, arm, head and neck.
Anatomy of the Thoracic Duct is “constant only in its variability”
Begins at 3x2 cm cisterna chyli, near the midline at second lumbar vertebra
Enters the right thorax via the Aortic hiatus
Between aorta, oesophagus and azygous vein.
Crosses to the left chest at the fourth thoracic vertebra.
Continues into the left neck.
Rises 3–4 cm above the clavicle.
Drains into Left subclavian vein near junction of subclavian and internal jugular veins.
The wall of the thoracic duct contains smooth muscles.
Flow rate is between 50 and 200 ml/hour.
Types of Chyle leakage
Chylopericardium
Chylothorax
Chylous ascites
Chylous fistula
Major Effects of chyle leak
Fluid loss
Electrolyte loss
Protein loss
Lymphocyte loss
Causes of Chylothorax
Congenital:
Idiopathic
Congenital diaphragmatic hernia
Congenital Pulmonary Airway malformations
Lymphatic malformations/Telangiectasia
Down’s, Noonan’s, Turner’s syndromes
Acquired:
Post operative (Any thoracic surgery)
Mediastinal tumours
Pleural tumours
TORCH infections
Traumatic injury (blunt and penetrating) (accidental and NAI)
SVC thrombosis
Treatment: General, Medical and Surgical therapies
A. General Therapy:
Chest drain insertion
Replacement of losses
Fluid, electrolyte balance
Nutritional support
Prevention and control of infection
B. Medical Therapy
Nil by mouth
Medium Chain Triglycerides
Parenteral nutrition
Somatostatin analogues/Octreotide
Inhaled nitric oxide
Steroids
Escalating and Deescalating approaches
Wait at least 2 weeks for response before escalating or deescalating
C. Surgical Therapy
Thoracic duct embolisation
Pleurodesis
Pleurectomy
Pleuroperitoneal shunt
Thoracic duct ligation
Pleuro peritoneal Shunt (Richard Aziz Khan)
Denver Shunt
Double valved pumping chamber
Both limbs can be trimmed
2 sizes of pumping chambers
Paediatric chamber: 1 ml - up till 6 months of age
Adult chamber: 2 ml - Beyond 6 months of age
Valve open at positive pressure of 1cm water
Manual pumping is necessary
General Anaesthesia
2 incisions: Lower chest anterior axillary line and Mid rectus abdominally.
50-100 pumps initially
50 pumps QDS for one month
Reduce frequency after
Thoracic duct ligation
Right sided thoracoscopic approach
At the proximal supradiaphragmatic location in the right side of the chest offers the most predictable and easiest exposure.
Fatty diet before surgery can help locate the leak
Camera: 7th ICS
Ports: 6th and 8th ICS
Drain residual fluid
Break adhesions
Apply clips if leak seen
Preserve greater splanchnic nerve
Identify aorta, oesophagus and azygous vein
If leak if found, ligate caudal to the leak.
Ligate between aorta, azygous vein and oesophagus
80% Success rate
Avoid:
Aggressive search
Damaging intercostal vessels
Damaging aorta and oesophagus
Dividing the thoracic duct
Damaging the thoracic duct
Page written by Prof. Ashok Daya Ram MBBS, FRCS, FRCPS, FEBPS, FRCS (Paed Surgery), Consultant Paediatric and Neonatal Surgeon, Norfolk and Norwich University Hospital, Norwich, UK. March 2025
Page edited by Mrs Charnjit Seehra BSc March 2025