A critical evaluation of a percutaneous diagnostic and treatment strategy for chylothorax after thoracic surgery.

OBJECTIVE: Because chylothorax complicating thoracic surgery is difficult to diagnose and failure of nonoperative management necessitates further surgery, we critically evaluated an evolving percutaneous strategy for diagnosing and treating chylothorax.

METHODS: After thoracic surgery, 37 patients with a clinical diagnosis of chylothorax were referred for lymphangiography for definitive diagnosis and percutaneous treatment. Successful localization of the cisterna chyli by lymphangiogram facilitated percutaneous cannulation of the thoracic duct and its embolization. In patients in whom cannulation was not possible, the thoracic duct was percutaneously disrupted.

DIAGNOSIS: Lymphangiography was successful in 36 of the 37 patients (97%). Contrast extravasation, confirming clinical diagnosis, was present in 21 of the 36 (58%).

MANAGEMENT: Twenty-one of 36 patients underwent 22 lymphangiographically directed percutaneous interventions: 12 embolizations and 10 disruptions. Mortality was zero, with two manageable complications. Patients without percutaneous intervention were discharged a median of 7 days (range 4-58) after first lymphangiography, 8 days (range 2-19) after percutaneous embolization, and 19 days (range 6-48) after first disruption. Eight patients had nine subsequent reoperations for chylothorax, two with negative lymphangiograms; no embolization patient required reoperation.

CONCLUSIONS: There is a discrepancy between the clinical diagnosis of chylothorax after thoracic surgery and the presumed gold standard of diagnosis, contrast extravasation at lymphangiogram. Percutaneous treatment by thoracic duct embolization or disruption is safe and may obviate reoperation, but embolization of the thoracic duct is preferable to its disruption.