How do you manage postoperative chylothorax?

Chylothorax is one of the complications I considered the most fearful. Patients having this PO complication deteriorate so quickly that when you start considering reoperation might be too late. It’s not the same a chylothorax after esophageal surgery than after lung surgery. Prior publications have shown that chylothorax after lung surgery is more likely to seal by itself. However, we’ll refer here only to the basics and some ideas that are common to both PO.

You usually suspect chylothorax when after POD#1 or 2 the chest tube output is more than you expected. Let’s say you did a lobectomy + MLND and CT output is 1200 cc on POD#1. That should give a suspicion clue. Esophageal cases can drain that much on POD#1, 2 or even 3, especially when the patient had preoperative chemorads. But, it’s not until the patient is fed that you realize that chyle is pouring out. CT output becomes milky and if any doubt exists you can test triglycerides in the fluid. Have in mind that if the patient is fasting, the fluid won’t be milky and only a high output will be the clue to the diagnosis. If the fluid has a value of triglycerides of more than 110 mg/dl, chylothorax is almost certain. If the value is below 50 mg/dl the diagnosis will be unlikely. In between are the grays. Chylomicrons can be measure and if they are present they confirm the diagnosis as well.

Once the diagnosis is made, a prompt solution should be looked for. If the output is less than 500 cc/day a little bit of time can be taken to think what to do. However, if the output is more than 1000 cc/day a surgical repair will be very likely. In any event, NPO should be the rule. In my experience no diet ever worked. It sounds neat to think about the medium chain TGL going through the portal vein and not thought the lymphatics, but at least in my experience that has never worked. Just put the patient NPO and start total parenteral nutrition right away. If the output is significant (>800 ml/d) and you don’t replace looses fast, you’ll start having trouble soon –low urinary output, problems with electrolytes, hypotension, renal failure and a very fats general deterioration of the general status of the patient-. There’s no guarantee that doing an adequate reposition of fluid and electrolytes won’t lead you to the same complications. This is why you shouldn’t wait too much to take back the patient to the OR if the output doesn’t slow down. Most would say that you can wait 7 days, but I rather just wait 3 to 4 days at the most.

In summary, surgery involves to mass ligate the thoracic duct. I achieve this more efficiently doing a right thoracotomy, but right VATS can be tried. Don’t even bother to look for the duct, just mass ligate with two silks all the tissue between the aorta’s adventitia and the esophagus, including the inferior hemiazigos vein. We can address this is another post, but the question is how many days do you think is worthwhile to wait until you take a patient back to the OR for PO chylothorax when drainage of more than 700 cc/day doesn’t slow down?


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