The Thoracic Duct and Chylothorax

Sarah Singh, MD, Luis Godoy, MD, David Tom Cooke, MD, FACS

Key Points

  • Chylothorax is an accumulation of lymphatic fluid within the pleural space secondary to injury or obstruction of the thoracic duct or an associated or accessory ductal branch.
  • Chylothorax is characterized by the accumulation of whitish, opalescent fluid, often after the patient begins a diet.
  • A pleural fluid triglyceride level > 110 mg/dl is diagnostic.
  • The most common causes of chylothorax are iatrogenic injury to the thoracic duct system or spontaneous duct rupture from a neoplastic process.
  • The basics of conservative therapy include drainage of the chylous effusion and initiation of a low triglyceride diet or nothing by mouth (nil per os; NPO) with total parenteral nutrition (TPN).
  • Interventional radiologic thoracic duct coil embolization (TDE) is an effective option prior to surgery. Prompt surgical ligation of the thoracic duct needs to be performed if nonsurgical modalities fail.
  • Modern techniques of thoracic duct identification using indocyanine green (ICG) fluorescence have been proposed to avoid iatrogenic chylothorax.

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