Surgical Management of Chylous Reflux and Effusions

Abstract

Chylous disorders are uncommon but serious and frequently life-threatening conditions. Chylous reflux through incompetent abdominal and pelvic lymphatics causes lymphatic congestion and lymphedema; chylous effusion results when dilated lymph vessels rupture and chyle accumulates in body cavities or in joints. Rupture of skin lymphatics results in chylous leak. Conservative therapy is usually the first line of treatment using dietary manipulation and aspiration of the effusion. In patients with primary chylous disorders who fail conservative management, the selective use of ligation of lymphatic fistulas, excision of dilated lymphatics, sclerotherapy, lympho-venous reconstruction (LVR), and placement of a peritoneovenous shunt (PVS) are additional treatment options suggested. Specifically, for chylothorax, ligation of the leaking lymphatics or the thoracic duct (TD) along with pleurodesis via thoracotomy or VATS is frequently effective; LVR may be considered as a surgical option in selected patients. Ligation of the incompetent retroperitoneal lymphatics and oversewing ruptured lymphatics can produce long-term improvement in lymphangiectasia and lymphatic reflux. Chylous ascites can be treated with ligation of the mesenteric or retroperitoneal lymphatic fistula, or LVR or bypass grafting in cases with large lymph vessel and patent venous system, or PVS, although the role of PVSs in the treatment of chylous ascites remains controversial. Endovascular treatment such as percutaneous embolization is increasingly used, but surgical treatment still plays an essential role especially in patients who fail to or not eligible for endovascular therapy. Individualized treatment based on the etiology, the site of lymph leaks, the amount of drainage volume, and the extent of chylous disease is required to achieve treatment success. In this chapter we review principles, indications, results, and problems of these surgical techniques.