Chylous Pleural Effusion Research Articles

Intrapleural Infection Causing Pleurodesis in a Patient With Refractory Chylothorax Related to Yellow Nail Syndrome

SESSION TITLE: Disorders of the Pleura SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Yellow nail syndrome (YNS) is a rare cause of chylothorax, and empyema is an unusual complication in these patients. While tunneled intrapleural catheter (IPC) related infections are uncommon, they may lead to post-infectious pleurodesis. Herein we report a case of refractory chylothorax due to YNS with empyema leading to post-infectious pleurodesis. CASE PRESENTATION: A 66 year old man with YNS, manifested by chronic chylous pleural effusions managed by placement of tunneled IPCs 4 years prior, was admitted to the hospital with increasing dyspnea and oxygen requirement. Imaging revealed patchy opacities in the bases of the lungs bilaterally, and broad antibiotic coverage was initiated. Ultrasound demonstrated increased septations within the pleural fluid compared to previous imaging, and bilateral thoracenteses were performed with Enterococcus faecalis growth noted from the left effusion. Evacuation of the pleural space was accomplished via instillation of fibrinolytic agents via the left IPC, and was later repeated on the right following decrease in output with noted increase in septations on ultrasound. Antibiotic coverage was continued for a total of three weeks. On follow-up, the catheters had both stopped draining for three weeks, and ultrasound revealed small residual effusions allowing removal of both catheters. There was no recurrence of the effusions at 6 months, demonstrating pleurodesis. DISCUSSION: Yellow nail syndrome is a rare disorder characterized by thickened and yellow nails with lymphedema and multiple respiratory manifestations. The cause is unknown, but the mechanism of the clinical manifestations is thought to be acquired lymphatic dysfunction. A recent review of the literature has identified less than 400 cases with an estimated prevalence in the general population of < 1:1,000,000. While parapneumonic effusions and empyemas are quite common complications of bacterial pneumonia, empyemas appear to be uncommon within YNS, with one study documenting empyema in only 3.5% of patients (3/85). A 2013 study of over 1000 patients with malignant pleural effusions by Fysh et al. demonstrated that IPC related infections were uncommon, occurring in <5% of cases, but of these, 62% (31/50) achieved post-infectious pleurodesis. CONCLUSIONS: Our patient required long term IPC management for chronic chylothoraces; however, following treatment for empyema, achieved bilateral pleurodesis with durable response. Though infections are undesirable, pleurodesis is a positive outcome that is commonly noted in IPC related infections. Reference #1: Fysh, E. T., et al. (2013). “Clinical outcomes of indwelling pleural catheter-related pleural infections: an international multicenter study.” Chest 144(5): 1597-1602. Reference #2: Valdes, L., et al. (2014). “Characteristics of patients with yellow nail syndrome and pleural effusion.” Respirology 19(7): 985-992. Reference #3: Vignes, S. and R. Baran (2017). “Yellow nail syndrome: a review.” Orphanet J Rare Dis 12(1): 42 DISCLOSURE: The following authors have nothing to disclose: Bryan Kelly, Ryan Kern No Product/Research Disclosure Information

Diaphragmatic fenestration for refractory chylothorax after congenital cardiac surgery in infants

ObjectiveMedically refractory chylous pleural effusion after congenital heart surgery is associated with significant morbidity and mortality, especially in infants. We reviewed our experience with diaphragmatic fenestration procedure in this group of patients. MethodsA retrospective chart review of all patients who had diaphragmatic fenestrations for chylous effusion at our institution over a 2-year period was performed. ResultsA total of 9 diaphragmatic fenestration procedures were performed in 8 patients who had failed medical management of chylous pleural effusions. All procedures except 1 were performed on the right side. The median age at time of procedure was 4.6 months (range, 3 weeks to 14 months). The average time between primary congenital cardiac surgery and fenestration was 26 days (range, 4-53 days). Three patients had single ventricle repair. Average time of chest tube removal after procedure was 4 days. Average time to extubation was 3 days. All patients but 1 were able to advance to full feedings without reaccumulation of chylous effusion within 12 days. No complications developed in the patients. Recurrent effusion over a median follow-up period of 19 months did not develop in the patients. ConclusionsDiaphragmatic fenestration is an effective and safe strategy for management of persistent chylous effusions after congenital cardiac surgery.

Retrograde Lymph Flow Leads to Chylothorax in Transgenic Mice with Lymphatic Malformations

Chylous pleural effusion (chylothorax) frequently accompanies lymphatic vessel malformations and other conditions with lymphatic defects. Although retrograde flow of chyle from the thoracic duct is considered a potential mechanism underlying chylothorax in patients and mouse models, the path chyle takes to reach the thoracic cavity is unclear. Herein, we use a novel transgenic mouse model, where doxycycline-induced overexpression of vascular endothelial growth factor (VEGF)-C was driven by the adipocyte-specific promoter adiponectin (ADN), to determine how chylothorax forms. Surprisingly, 100% of adult ADN-VEGF-C mice developed chylothorax within 7 days. Rapid, consistent appearance of chylothorax enabled us to examine the step-by-step development in otherwise normal adult mice. Dynamic imaging with a fluorescent tracer revealed that lymph in the thoracic duct of these mice could enter the thoracic cavity by retrograde flow into enlarged paravertebral lymphatics and subpleural lymphatic plexuses that had incompetent lymphatic valves. Pleural mesothelium overlying the lymphatic plexuses underwent exfoliation that increased during doxycycline exposure. Together, thefindings indicate that chylothorax in ADN-VEGF-C mice results from retrograde flow of chyle from the thoracic duct into lymphatic tributaries with defective valves. Chyle extravasates from these plexuses and enters the thoracic cavity through exfoliated regions of the pleural mesothelium.

Establishment of triglyceride cut-off values to detect chylous ascites and pleural effusions

ObjectivesLipoprotein electrophoresis is the gold standard for the detection of chylous ascites and pleural effusions. It is, however, not suitable as a front-line test and not widely available. Most clinicians must rely solely on the quantitative determination of lipids. The aim of this work was to establish lipid cut-off values for the presence of chylomicrons in pleural and peritoneal fluid. Design and methodsTriglyceride and cholesterol levels from 113 peritoneal and 154 pleural fluid samples investigated for chylomicrons via lipoprotein electrophoresis were considered. Receiver operating characteristic analyses were performed and cut-off levels determined. Results54 peritoneal and 59 pleural fluid samples were positive for chylomicrons. In peritoneal fluid, triglycerides and triglycerides/cholesterol ratio exhibited areas under the curve (AUC) not significantly different from each other, but significantly larger than cholesterol alone. The AUC for triglycerides in pleural fluid was significantly larger than the AUCs for cholesterol and the triglycerides/cholesterol ratio. Triglyceride cut-offs with maximum Youden-Index, sensitivity >95%, and specificity >95% were calculated to be 187, 148, and 246mg/dl (2.13, 1.69, and 2.80mmol/l) for peritoneal fluid, and 240, 94, and 240mg/dl (2.74, 1.07, and 2.74mmol/l) for pleural fluid. ConclusionsTriglyceride levels are the best parameter to detect chylous body fluids when lipoprotein electrophoresis is not available. Single-point triglyceride cut-offs of 187 and 240mg/dl (2.13 and 2.74mmol/l) or alternatively equivocal ranges of 148–246 and 94–240mg/dl (1.69–2.80 and 1.07–2.74mmol/l) were established for peritoneal and pleural fluid, respectively.

Lymphangioma in Patients with Pulmonary Lymphangioleiomyomatosis: Results of Sirolimus Treatment

Objective: Lymphangioleiomyomatosis (LAM) is a rare disease caused by abnormal proliferation of smooth muscle-like cells mainly in lungs and axial lymph nodes, that belongs to the group of PEComa tumours. Chylous pleural and abdominal effusions, lymhangioleiomiomas, angiomyolipomas are noticed in disease course. Sirolimus has been approved for LAM treatment, and also it has been reported to decrease the size of angiomyolipomas, lymphangiooedma, pleural and peritoneal chylous effusion. The aim of the study was to assess the significance of sirolimus therapy in patients with LAM and lymphangioma in retroperitoneal space. Method: Fourteen women with confirmed diagnosis of LAM (13 with sporadic LAM, and one TSC/LAM) and presence of lymphangioma in abdominal cavity were retrospectively reviewed. Seven patients displayed chyloperitoneum and chylothorax. Mean time of sirolimus exposure was 19 ± 12.99 months. Results: After ten months of treatment a complete regression of chylothorax and chyloperitoneum occurred in 13 patients, and partial regression occurred in one patient. Treatment resulted in decrease of lymphangioma volume (1603.85 ± 2437.56 cm3 vs. 198.01 ± 315.43 cm3; p=0.00026), stabilisation of pulmonary function parameters such as (FVC, FEV1, TLC, DLCO), improvement of distance in 6MWT (514.46 ± 101.72 m vs. 526.79 ± 139.33 m; p=0.002), blood oxygenation (68.93 ± 13.6 mmHg vs. 78.23 ± 11.14 mmHg; p=0.04), and decrease of serum VEGF-D concentration (2591 ± 1085 pg/mL vs. 1274 ± 708 pg/mL; p=0.003). Conclusion: Sirolimus has proved to be an effective treatment of lymphangioma, chylous pleural and peritoneal effusions in LAM patients.

Bilateral chylothorax complicating bibasilar pneumonia: A case report

A 24-year-old previously healthy, HIV-negative lady with acute respiratory symptoms for one week, presented with bilateral chylous pleural effusions and bibasilar pneumonia. She responded rapidly to antimicrobial therapy and bilateral tube thoracostomies. Analysis of a sample of right pleural fluid confirmed exudative chylous effusion. No organisms were identified on fluid microscopy or culture. The left pleural fluid was macroscopically chylous. She had no features of tuberculosis. Bilateral chylothorax complicating bibasilar pneumonia is considerably rare.

Indocyanine Green Lymphography and Lymphaticovenous Anastomosis for Generalized Lymphatic Dysplasia with Pleural Effusion and Ascites in Neonates

The fatality rate of generalized lymphatic dysplasia (GLD) with chylous pleural effusion and ascites is particularly high when it persists over a prolonged period. The purpose of this report was to determine the utility of indocyanine green (ICG) lymphography and lymphaticovenous anastomosis (LVA) in GLD with chylous pleural effusion and ascites in neonates. We tested the lymphatic function in the 4 extremities for 8 GLD neonate patients using ICG lymphography, and on the basis of the results, we performed LVA for 5 of them. LVA was performed at the extremities under general anesthesia using incisions <1 cm in length. The outcome of LVA was evaluated with the amount of ascites discharged from thoracostomy tube or abdominal tube, except for 1 patient who had no drainage tube. In all cases, ICG lymphography showed varying degrees of dermal backflow in the limbs with lymphostasis. After LVA surgery, effusion stopped in 2 cases and decreased in 1 case. In the cases where effusion stopped, backflow as observed with ICG lymphography was minimal, and in the case where effusion decreased but did not stop, backflow was moderate. The application of ICG and LVA could possibly be used to diagnose and treat lymphatic pleural effusion or ascites.

Transcatheter Fontan takedown.

Early failure of the Fontan circulation is rare in the current era but remains associated with a high mortality rate. Surgical Fontan takedown has evolved as one of the strategies to stabilize the circulation, improve survival, and allow for a future attempt at Fontan completion. We have completed Transcatheter fontan takedown in three patients with extracardiac conduits 0.8-6 months following their Fontan operations. Superior vena cava flow was redirected into only the pulmonary arteries by occluding the conduit with a vascular plug between the pulmonary arteries and fenestration and unrestrictive inferior vena cava flow was redirected into only the atrium by stenting and enlarging the fenestration. There were no procedure related complications. All patients had resolution of large-volume chylous pleural effusions. One patient had resolution of protein-losing enteropathy, two patients had improvement of plastic bronchitis. Two of three patients remain alive at latest follow-up (4-24 months). This early experience suggests that Transcatheter fontan takedown is technically feasible and may be an alternative to surgical takedown in select patients with early failure of the Fontan circulation.

Abstract No. 462 - Lymphatic intervention for various kinds of lymphorrhea

tion has been shown to be effective in the treatment of recurrent chylous effusions. Many embolic agents have been described in the successful occlusion of the thoracic duct. In this study, we evaluate the role and efficacy of using EVOH copolymer (Onyx) in the treatment of traumatic chylous pleural effusions. Background: A retrospective review was performed of consecutive patients with post-operative chylous pleural effusions treated with thoracic duct embolization using EVOH copolymer at a single institution from 2012-2014. Demographic data, surgical history, procedure details, and toxicities were systematically reviewed. Clinical Findings/Procedure Details: 4 patients (M1⁄42) were identified that met inclusion criteria. Median age at treatment was 67. Median follow was 125 days (range 24-246). Two patients had undergone robotic assisted surgery and 2 had undergone open thoracotomy. 3 patients had thoracic duct ligation performed at the time of their initial surgery. Median time from surgery to embolization was 7 days (range 3-15). Daily chest tube drainage range was 150 -2000 ml. All patients underwent bilateral ultrasound guided inguinal nodal lymphangiogram. The thoracic duct was then accessed using a 21 or 22 gauge Chiba needle. A thoracic duct leak was identified in 3 patients. Coils were placed initially in the central duct prior to embolization of the leak limit potential systemic flow. Onyx 34 (ev3 Neurovascular, Irvine, California) was used in 4 patients with additional Onyx 18 in 1 patient for embolization. Volume used was 1-2 ml in all patients. All patients had resolution of the chylous effusion within 1 day of embolization. The subjects were discharged from the hospital between 4-7 days post-procedure. 30 days post-procedure complications included an abdominal wall hematoma in 1 patient who was subsequently started on anticoagulation. No patients developed recurrent chyle leaks during the follow up period. Conclusion and/or Teaching Points: EVOH copolymer is a safe and effective agent for percutaneous thoracic duct embolization. This is the largest reported series to date demonstrating the efficacy of this embolic agent in treating chylous effusions in the post-traumatic setting.

Therapeutic effects of short- and intermediate-term tolvaptan administration for refractory ascites in patients with advanced liver cirrhosis.

Tolvaptan, an oral arginine vasopressin V2 receptor antagonist, became available for hepatic ascites. We evaluated the therapeutic efficacy and safety of tolvaptan administration to treat refractory ascites. Data were collected from 15 hospitalized patients with cirrhosis (hepatitis C, 10; alcoholism, five) after adding tolvaptan (3.75-11.25 mg/day) to conventional diuretics. Bodyweights and serum sodium and creatinine concentrations were measured. Tolvaptan was continued for 4 weeks or longer for a median follow-up period of 42 days (range, 28-56). In the first week (introduction phase), tolvaptan significantly reduced median weight (66.6, 65.9 and 63.1 kg on days 0, 1 and 7, respectively; P < 0.004). The numbers of good responders (≥3 kg reduction in 4 days), responders (<3 kg weight reduction) and non-responders (no weight reduction) were seven (46.7%), six (40.0%) and two of the 15 (13.3%), respectively. The two non-responders had concomitant chylous pleural effusion or spontaneous bacterial peritonitis. All patients continued tolvaptan for 2 weeks or longer and six (40%, three good responders and three responders) were treated for a median of 42 days without additional intervention. During this intermediate-term administration of tolvaptan, the median weight reduction was statistically significant (65.4, 61.9 and 56.9 kg on days 0, 7 and 42, respectively; P < 0.030) and there was no serum sodium imbalance or renal dysfunction; but two of these six developed hepatic coma. Tolvaptan safely alleviated fluid retention caused by hepatic cirrhosis. Intermediate-term administration of tolvaptan apparently helped maintain weight reduction achieved during the introduction phase.

Fat-Modified Breast Milk Resolves Chylous Pleural Effusion in Infants With Postsurgical Chylothorax but Is Associated With Slow Growth.

Chylothorax occurs in ~3%-5% of infants undergoing cardiac surgery. Standard treatment requires discontinuation of breast milk feeding, due to the abundance of long-chain triglycerides and transition to a medium-chain triglyceride (MCT)-based formula. To determine the effectiveness of fat-modified breast milk (MBM) for the treatment of chylothorax compared with MCT formula. Infants diagnosed with chylothorax following surgery for congenital heart disease between January 2008 and December 2009 at The Hospital for Sick Children were eligible for this nonrandomized open-label study. Treatment infants (n = 8) received mother's own milk that had been modified by removing the fat layer via centrifugation and adding MCT, nutrients, and essential fatty acids to provide an estimated 74 kcal/100 mL and 1.4 g/100 mL protein (MBM group). Control infants (n = 8) received an MCT formula (MCT group). The feeding intervention was a minimum of 6 weeks after chest tube removal per The Hospital for Sick Children standard chylothorax treatment protocol. Daily volume and duration of chest tube drainage were not different between the MBM and MCT groups. While there was no statistically significant difference in rates of weight gain (g/d) between feeding groups, infants in the MBM group, who tended to be younger, experienced a decline in mean weight (P = .04) and length (P = .01) for age z scores. Fat-modified breast milk resolved chylothorax; however, strategies to address poor growth need to be developed and evaluated in larger trials prior to widespread clinical adoption of this novel treatment.

Congenital chylothorax: a prospective nationwide epidemiological study in Germany

BackgroundCongenital chylothorax (CCT) is a rare disease of unknown aetiology. Treatment approaches vary; none has been evaluated prospectively.ObjectiveTo prospectively determine incidence, treatment and outcome of infants with CCT born in...

Minimal lymphatic leakage in an infant with chylothorax detected by lymphoscintigraphy SPECT/CT.

A 7-month-old girl with history of persistent left chylous pleural effusion was referred for lymphoscintigraphy. A previous chest computed tomography (CT) scan demonstrated a small to moderate-sized left pleural effusion but could not identify the lymphatic leakage site. Lymphoscintigraphy using filtered (99m)Tc sulfur colloid showed minimal focal activity in the lower chest. A correlative single-photon emission computed tomography (SPECT)/CT localized this activity to distal paraesophageal region, being highly suggestive of the site of lymphatic leakage. Subsequent lymphangiography confirmed these findings, revealing an abnormal lymphatic branch at the level of T10 and T11 vertebrae with retrocrural extravasation toward the left hemithorax. Thoracic duct embolization was accomplished at and proximal to the site of chyle leak using a platinum coil and n-Butyl cyanoacrylate glue. The patient was followed up for >24 months and demonstrated no recurrence of pleural effusion. No ascites or other complications related to the procedure were noted. The case demonstrates that (99m)Tc sulfur colloid lymphoscintigraphy SPECT/CT can be a useful modality for detecting the chyle leakage site in children with chylothorax even when the amount of leakage is minimal.

Surgical treatment of chylothorax caused by lymphangioleiomyomatosis.

Lymphangioleiomyomatosis (LAM) is a rare progressive disease caused by infiltration of smooth muscle-like cells in lymph vessels as well as the lung. We report a case of pulmonary LAM in a 22-year-old female with shortness of breath, recurrent pneumothorax and chylous pleural effusions. Multiple ligation of thoracic in lower part of thoracic duct was performed and biopsy of thoracic duct confirmed the diagnosis of LAM. The operation was successful and the patient was discharged. Although the thoracic duct involvement is extensive, multiple ligation in lower part of thoracic duct may be a good choice.

Dasatinib-induced Chylous Pleural Effusions

Tyrosine kinase inhibitors have revolutionized treatment of chronic myeloid leukemia through their targeted treatment of the BCR-ABL transcript. Imatinib was the first of this class and was found to induce fluid retention and volume overload resulting in pleural effusions. In cases of imatinib-resistant chronic myeloid leukemia, dasatinib provides another treatment option, as a second-generation tyrosine kinase inhibitor, which is 325 times more efficacious in vitro when compared with imatinib. However, a common adverse pulmonary effect is the development of a pleural effusion. Dasatinib-induced toxicity and the development of exudative pleural effusions are dose dependent. Chylous pleural effusions have been described with dasatinib toxicity; however, not all pleural effusions documented with dasatinib are chylous. In our patient, serial chest radiographs show the regression of her effusions with dasatinib discontinuation. Despite the regression of the patient’s effusions, chylomicrons were still present in low concentrations. We suspect the development of chylous pleural effusions from dasatinib exposure is related to lymphatic dysregulation.

Sirolimus Decreases Circulating Lymphangioleiomyomatosis Cells in Patients With Lymphangioleiomyomatosis

Lymphangioleiomyomatosis (LAM), sporadic or in women with tuberous sclerosis complex (TSC), is characterized by cystic lung destruction, lymphatic involvement (eg, chylous pleural effusions, lymphangioleiomyomas), and renal angiomyolipomas (AMLs). The multisystem manifestations of LAM appear to result from metastatic dissemination of LAM cells bearing inactivating mutations or having loss of heterozygosity (LOH) of the tumor suppressor genes TSC1 or TSC2, which leads to hyperactivation of the mammalian target of rapamycin. Sirolimus slows the decline of lung function, reduces chylous effusions, and shrinks the size of AMLs. The purpose of this study was to determine the effect of sirolimus on circulating LAM cells. Cells from blood were isolated by a density-gradient fractionation system and from urine and chylous effusions by centrifugation. Blood cells were incubated with anti-CD45-fluorescein isothiocyanate (FITC) and anti-CD235a-R-phycoerythrin (PE) antibodies, and urine and chylous effusion cells were incubated with anti-CD44v6-FITC and anti-CD9-R-PE antibodies. Cells were sorted and analyzed for TSC2 LOH. LAM cells with TSC2 LOH were identified in 100% of blood specimens and 75% of urine samples from patients before therapy. Over a mean duration of 2.2 ± 0.4 years of sirolimus therapy, detection rates of LAM cells were significantly decreased to 25% in blood (P &lt; .001) and 8% in urine (P = .003). Following therapy, a greater loss of circulating LAM cells was seen in postmenopausal patients (P = .025). Patients receiving sirolimus had a progressive loss of circulating LAM cells that depended on time of treatment and menopausal status.

Octreotide: A Drug Often Used in the Critical Care Setting but Not Well Understood

While the canonical function of somatostatin (SST) is to inhibit the secretion of growth hormone, it has a number of other physiologic effects that are less widely appreciated. Octreotide, an analog of SST, is not uncommonly used in the critical care setting, particularly for the treatment of variceal hemorrhage. Herein, we discuss the biology and pharmacology of SST, octreotide, and other SST analogs. We also review the evidence behind their use in esophageal variceal bleeds, hepatorenal syndrome, hypoglycemia due to sulfonylurea poisoning, and chylous pleural effusions.

Bilateral pleural effusion complicating umbilical venous catheterization

Umbilical venous lines are sometimes complicated with pleural and or pericardial effusion, often due to line migration. Bilateral chylous pleural effusion without pericardial effusion in a 28 weeks, extremely low birth infant who was on total parenteral nutrition. Investigations including chest x ray and 2D echocardiogram showed bilateral chylous pleural effusions but appropriate tip position of the umbilical venous line. Removal of the umbilical venous line and cessation of total parenteral nutrition resulted in complete resolution of the pleural effusion. In any newborn with central venous catheter in situ, acute deteriorations specially, those related to pleural and pericardial effusions should alert the clinicians to remove the catheter and should not be misguided by apparently appearing normal correct catheter position by x-ray or 2D echocardiogram.

Lymphangioleiomyomatose

LAM is one of the rare lung diseases. Approximately 200-400 female patients are to be expected in Germany. Only rare reports exist describing a male LAM patient. LAM exists in two forms: a spontaneous mosaic mutation (S-LAM) and a germ line mutation resulting in a combination of pulmonary and systemic symptoms called tuberous sclerosis (TSC-LAM). Although the influence of estrogen is not yet entirely recognized, pregnancy and estrogen containing anticonception will worsen the course of the disease. Ten year prognosis of the disease is well over 80% but variability is large. Rapid progression exists.The clinical picture of S-LAM is dominated by pneumothorax, chylous pleural effusions, dyspnoea upon exertion. (HR) CT demonstrates the easily recognizable and characteristic cystic transformation of the parenchyma. The cellular sequels of the disease involve constant activation of the mTORC1 complex with protein synthesis, proliferation, enzymatic parenchymal transformation, improved cellular survival and metastasis into the lungs most likely from an extrapulmonary source. Following extensive research on the pathologic activation of the mTORC1 pathway, an initial way of halting progression has been found in using mTORC1 inhibitors (Sirolimus, Everolimus). Complimentary strategies are currently investigated in order to improve the therapeutic effect. These measures will improve LAM prognosis in the future. Therapy resistant LAM is a valid indication for lung transplantation.

Are There Early Clinical Factors to Decide Early Surgical Management for Secondary Chylothorax? A Review of 32 Cases

Background: Chylothorax may be primary (spontaneous) or secondary and more often arising as a postoperative complication of thoracic surgery. It occurs when the thoracic duct or its lymphatic tributaries become blocked or perforated or divided resulting in a chylous pleural effusion. Loss of chyle leads to nutritional deficiencies, dehydration, ionic perturbation and lymphocytes leaks thus increasing the vulnerability for infections and respiratory dysfunction. It is a life-threatening complication increasing the postoperative hospital stay. Management of chylothorax is firstly medical which leads to the cessation of leaks in most of the cases. Surgical treatment by thoracic duct ligation is sometimes necessary after failure of medical treatment. The appropriate time for surgical treatment is a subject of controversy. Methods: Reviewing a series of patients treated between 2000 to 2010 in a single center with the same protocol management, the aim of the study was to identify early clinical variables allowing early surgical treatment in postoperative chylothorax. Results: Thirty-two patients were identified in the study period. There were 21 males (65.6%) and 11 females (34.4%) with a mean age of 55.7 years (range from 9 to 79 years) (Table 1). Twenty-two patients (68.75%) had chylothorax after a surgical intervention, seven patients (21.8%) had chylothorax due to medical causes and three patients (9.3%) after chest trauma. Thirty-eight percent of patients treated conservatively were after lung cancer resection and 35% of patients treated surgically where after esophageal resection. Chylothorax was stopped in 33% of patients after lymphangiography. Cumulative leak per day was 1007 ml/day for operated patients and 397 ml/day for patient treated conservatively. Esophageal resection surgery and the amount of fluid leak were the two factors founded to be associated for the decision of an earlier surgical treatment. Conclusion: Chylothorax arising after esophageal resection with a flow rate of leak of more than 500 ml/day should be proposed to an earlier surgical treatment. Lymphangiography remains a key stone assessment with a double aim diagnostic and therapeutic in chyle leakage.