Traitement du chylothorax

Abstract

Treatment of chylothorax remains insufficiently standardized. In the most resistant cases, treatment is dependent on the various aetiologies that disturb the normal management of the chyle within the thoracic duct. In fact, chylothorax results from a pleural chylous leak issuing from the thoracic duct or from one of its tributaries, or from those collateral lymphatic vessels that allow chyle derivation in case of abnormal function. This leak may be acquired following trauma, thoracic surgery, or various diagnostic or therapeutic medical procedures. It may appear spontaneously, due to rupture of chyle overloaded lymphatic vessels, with chyle back flowing into them from a pathological or malformed thoracic duct. Chylothorax is easily diagnosed by thoracocentesis but its mechanisms (status of the thoracic duct, valve insufficient tributaries, chyle derivation collaterals) may be studied only by lympho-angiography. Standard treatment is first medical: drainage, suppression of all oral fat intake, re-nutrition, treatment of the medical cause (such as cancer, thrombosis…) and use of products aimed at reducing chyle production. In case of therapeutic failure, surgery is required. Lympho-angiography is of paramount importance among the surgical strategy. Surgery may act on the leak itself : ligation (or embolization) of the thoracic duct, sutures of the leaking collaterals, or various other procedures. When the leaks are not evidenced, and when thoracic duct ligation is not indicated due to its “absence”, surgical treatment remains palliative, directed on the effusion itself: pleurodesis, derivation of the chyle (pleuroperitoneal shunt).