A review of traumatic chylothorax

BACKGROUND

Traumatic chylothorax is an extremely rare complication following thoracic trauma or surgery. The aetiology of traumatic chylothorax is dominated by iatrogenic causes, with a reported incidence of 0.5% to 3% following oesophageal surgery. The mortality from a chylothorax post oesophagectomy can be as high as 50%. Iatrogenic causes in total account for approximately 80% of traumatic causes. Non-iatrogenic traumatic chylothoraces are exceedingly uncommon. The complication rate in blunt thoracic trauma is said to be 0.2% to 3%, whilst in penetrating trauma, the incidence is 0.9% to 1.3%. If recognised late or managed poorly, this condition has devastating complications, including nutritional depletion, physiological derangements and immunological depression. This review revisits the anatomy of the thoracic duct, the physiology of chyle production and associated dynamics as well as the current management strategies available for traumatic chylothorax.

METHODS

A review of selected English literature from 1980 to 2015 was undertaken. Databases used included Pubmed, Cochrane and Science Direct. Publications of both traumatic and postoperative chylothorax were reviewed. The appropriate literature was analysed by comparing and contrasting content with particular emphasis on management issues. Keywords and phrases were used to achieve a streamlined and focused review of the topic.

CONCLUSION

Chylothorax remains a rare complication of thoracic surgery and thoracic trauma. The potential complications can result in serious morbidity and can even be fatal. Understanding the pathophysiology of a chyle leak underpins the principles of management. The overall success of conservative management ranges from 20% to 80%. The timing of surgical intervention remains debatable. Benefits of early surgical intervention are clearly documented, resulting in a gradual shift toward early operative treatment with reports suggesting thoracic duct ligation yielding a 90% success rate. Technological advances such as thoracic duct embolisation, with a potential success rate of 90%, and thoracoscopic interventions are attractive alternatives to orthodox open surgery.

The changing management of chylothorax in the modern era

Initial conservative therapy is applied to all cases of chylothorax (CTx) with expected excellent outcomes. The indication for aggressive surgical treatment of early CTx remains uncertain and requires rigorous scientific scrutiny. Lymphangiography and lymphoscintigraphy are useful to localize the leak and assess thoracic duct patency as well as to differentiate partial from complete thoracic duct transection. The aetiology of the CTx, flow rate and patient condition dictate the preferred management. Octreotide/somatostatin and etilefrine therapy is highly efficacious in the conservative management of CTx. For patients in whom conservative management fails, those who are good surgical candidates, and those in whom the site of the leak is well identified, surgical repair and/or ligation using minimally invasive techniques is highly successful with limited adverse outcomes. Similarly, if the site of the chylous effusion cannot be well visualized, a thoracic duct ligation via video-assisted thoracic surgery is the gold standard approach. A pleuroperitoneal or less often a pleurovenous shunt is a final option and may be curative in some patients.

Nonoperative management of traumatic chylothorax

Chylothorax is known for its rarity, and its diagnosis following blunt chest trauma is exceptional. Only a small number of cases have been reported in the literature. Severe consequences, such as cardiopulmonary abnormalities and metabolic, nutritional, and immunologic disorders, can result from chylothorax. Management of chylothorax is challenging. It can either be managed nonoperatively or surgically. Surgical treatment is required in cases of persistent or high output fistulae. We report here in three cases of blunt trauma chest following road traffic crash associated with chylothorax. All of them were successfully managed nonoperatively with inter costal tube drainage and supportive treatment sans need of any operative intervention.