Invited commentary

Abstract

Postoperative chylothorax remains an uncommon but potentially life-threatening complication of various intrathoracic procedures, and the ideal management of this condition is still controversial. Generally, so-called conservative therapy is tried first, and includes low-fat diet, total parenteral nutrition, and pleural drainage. Somatostatin and more recently Etilefrine [1], a sympathomimetic drug used in the management of postural hypotension, also causing smooth muscle contraction of the thoracic duct, have been reported as significant additives to this regimen. However, it usually takes several weeks for the chylothorax to resolve and it is almost always unsuccessful in patients with high flow leaks. Indeed, it has been clearly demonstrated that a high volume of chylous output could reliably predict the failure of continuing medical treatment [2]. The type of the initial operation is also predictive when the site and the mechanism of lymphatic vessels injury could be anticipated. As a matter of fact, chylothorax after radical esophagectomy for cancer is usually from direct injury to the thoracic duct, as it is also the case in those chylothoraces occurring after surgery of the thoracic aorta, and could hardly be managed without thoracic duct ligation [3]. Its incidence after pulmonary resection is low, but has increased recently as testified by the analysis of the medical literature, probably because of more extensive types of resections and radical lymph node dissections where high flow leaks may be encountered. Chylothorax is also emerging as a probably underestimated complication of coronary artery bypass grafting, especially when the left internal mammary artery is used, by reason of anatomical connection with the thoracic duct.