A review of traumatic chylothorax.

BACKGROUND: Traumatic chylothorax is an extremely rare complication following thoracic trauma or surgery. The aetiology of traumatic chylothorax is dominated by iatrogenic causes, with a reported incidence of 0.5% to 3% following oesophageal surgery. The mortality from a chylothorax post oesophagectomy can be as high as 50%. Iatrogenic causes in total account for approximately 80% of traumatic causes. Non-iatrogenic traumatic chylothoraces are exceedingly uncommon. The complication rate in blunt thoracic trauma is said to be 0.2% to 3%, whilst in penetrating trauma, the incidence is 0.9% to 1.3%. If recognised late or managed poorly, this condition has devastating complications, including nutritional depletion, physiological derangements and immunological depression. This review revisits the anatomy of the thoracic duct, the physiology of chyle production and associated dynamics as well as the current management strategies available for traumatic chylothorax.

METHODS: A review of selected English literature from 1980 to 2015 was undertaken. Databases used included Pubmed, Cochrane and Science Direct. Publications of both traumatic and postoperative chylothorax were reviewed. The appropriate literature was analysed by comparing and contrasting content with particular emphasis on management issues. Keywords and phrases were used to achieve a streamlined and focused review of the topic.

CONCLUSION: Chylothorax remains a rare complication of thoracic surgery and thoracic trauma. The potential complications can result in serious morbidity and can even be fatal. Understanding the pathophysiology of a chyle leak underpins the principles of management. The overall success of conservative management ranges from 20% to 80%. The timing of surgical intervention remains debatable. Benefits of early surgical intervention are clearly documented, resulting in a gradual shift toward early operative treatment with reports suggesting thoracic duct ligation yielding a 90% success rate. Technological advances such as thoracic duct embolisation, with a potential success rate of 90%, and thoracoscopic interventions are attractive alternatives to orthodox open surgery.