Comprehensive treatment of chylothorax of various etiologies

Relevance. Treatment of chylothorax in patients depends largely on the underlying cause. In some cases, it is associated with disruption of the intact lymphatic duct (due to trauma or surgery), while in others, it is due to venous and lymphatic hypertension (in cases of congenital heart disease, lymphatic duct malformations, heart disease, and cancer). The main goal of conservative treatment is to reduce the flow of chyle through the thoracic duct to ensure spontaneous resorption, reduce systemic lymph production through diet (dry food, fasting, somatostatin/octreotide, midodrine, and sirolimus, parenteral nutrition), replenish nutrient losses, drain the pleural cavity, and use pleurodesis (talc, bleomycin, tetracycline, povidone, hypertonic glucose solution). This treatment is aimed at eliminating the underlying cause of chylothorax. If conservative therapy is ineffective and the chylothorax persists at 1000 ml or more, surgical treatment is performed (video-assisted thoracoscopy, clipping, or ligation of the thoracic duct).
Goal: to develop a step-by-step plan for the comprehensive treatment of patients with chylothorax of various etiologies.
Material and Methods. The study included 21 patients with chylothorax of various etiologies (emergency admissions (17) and transfers (4) from other hospitals) admitted to the thoracic department.
Results. Treatment of chylothorax depends on the underlying cause, individual manifestations, and the intensity of chyle production. In some cases of non-traumatic chylothorax, pulmonary bypass grafting and biopsy were used to identify the cause. Conservative treatment was based on pleural drainage and included a low-fat diet, transfusion therapy, somatostatin/octreotide, and sirolimus. The primary goal was to reduce chyle production by decreasing fat absorption and preventing malnutrition. Nutritional interventions included total parenteral nutrition or enteral diets. In cases of ineffective non-traumatic chemotherapy and postoperative traumatic chemotherapy, VTS + CLP were performed (pleurodesis and pleurectomy were performed if necessary, regardless of the etiology, as it is not always possible to completely relieve chylorrhea). Reducing chyle leakage ensures spontaneous resorption, and in cases of venous and lymphatic hypertension due to heart failure or oncologic pathology, additional specific treatment is required.
Conclusion. The treatment strategy for chemotherapy is determined based on the etiopathogenesis and intensity of lymph leakage, using a step-by-step treatment plan, from the least invasive to the most invasive methods. Malignant neoplasms, chronic chylous effusion complicated by pulmonary embolism, and cardiac disease, despite the complex treatment aimed at reducing chylothorax volume, including VTS and CLP, require additional specific therapy. Traumatic chemotherapy (postoperative). In most cases, along with conservative management, chylothorax requires vascular thoracic surgery and duct clipping, and in some cases, pleurodesis is also needed. Conversely, with typical mechanical trauma and normal lymphatic duct pressure, conservative management is sufficient.

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