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Background: Chylothorax, a rare but serious complication following esophagectomy, can lead to dehydration, malnutrition, and even mortality. Surgical intervention is considered when conservative treatment is ineffective; however, in some refractory cases, the cause of chylothorax remains unclear. We report a case of refractory chylothorax caused by abdominal chyle leakage into the pleural space via an unenclosed esophageal hiatus. Case presentation: A 66-year-old man was diagnosed with advanced esophageal squamous cell carcinoma. The patient underwent robot-assisted thoracoscopic subtotal esophagectomy in the prone position with retrosternal gastric tube reconstruction following neoadjuvant chemotherapy. The thoracic duct was ligated and resected because of tumor invasion. Chylothorax and chylous ascites were observed 2 weeks after surgery but did not improve despite conservative management with medications and drainage. Lymphoscintigraphy through the inguinal lymph node showed tracer accumulation in the fluid in both the abdominal and pleural spaces. Lipiodol lymphangiography revealed abdominal lymphoid leakage, but no leakage was detected from the thoracic duct or mediastinum. We considered that the chylothorax was caused by chylous ascites flowing into the pleural space via an unenclosed esophageal hiatus, and we performed surgical intervention. Laparotomy revealed abdominal chyle leakage and a fistula at the esophageal hiatus with the inflow of ascites into the thoracic cavity. Lipiodol lymphangiography was additionally performed for treating abdominal lymphorrhea after surgery, and resulted in the improvement of the chylothorax and ascites. The patient was discharged with no recurrence of chylothorax or chylous ascites. Conclusions: Refractory chylothorax can occur due to chylous ascites flowing into the pleural space via an unenclosed esophageal hiatus. When the site of chylothorax leakage is unclear, the possibility of inflowing chylous ascites via the unenclosed esophageal hiatus should be explored. Esophageal hiatus closure and lipiodol lymphangiography could be effective in treating refractory chylothorax of unknown cause after esophagectomy. [ABSTRACT FROM AUTHOR]

We report here a rare case of neuroblastoma in a neonate who presented as a hydropic baby with respiratory distress due to recurrent chylothorax. The neuroblastoma regressed after six cycles of chemotherapy and the infant was discharged in good condition.

Abstract Background Chylothorax is a postoperative complication in patients with lung cancer. Diet-control approaches have been the mainstay for managing this condition. However, a surgical intervention is needed for the patients if conservative treatment is ineffective. Because of the lack of accurate indicators to assess the prognosis of the postoperative complication at an early stage, the criteria of surgical treatment were not consistent. Methods We reviewed 2942 patients who underwent pulmonary resection and lymph node dissection for primary lung cancer at our hospital between March 2021 and December 2022. The prognostic implications of clinical indicators were assessed in patients with postoperative chylothorax who were managed with a low-fat diet. Binary logistic regression was used to explore the predictive value of these indicators for patient prognosis. Results Postoperative chylothorax occurred in 108 patients and 79 patients were treated with a low-fat diet management while 29 patients were managed with TPN. In contrast to drainage volume, the pleural effusion triglyceride level after 2 days of low-fat diet exhibited enhanced predictive efficacy in predicting patient prognosis. When the pleural fluid triglyceride level of 1.33 mmol/L was used as the diagnostic threshold for prognosis, the sensitivity and specificity reached 100% and 80.6%, respectively. Conclusions The pleural effusion triglyceride level after 2 days of low-fat diet can serve as a valuable prognostic indicator in patients undergoing lung surgery and experiencing chylothorax. This predictive approach will help thoracic surgeons to identify patients with poor prognosis in a timely manner and make decision to perform necessary surgical interventions.

This paper summarized the nursing practicve of a newborn with congenital bilateral chylothorax. The key points of nursing included intensive nursing management of airway, closed thoracic drainage nursing, correct evaluation of neonatal pain and corresponding nursing measures, nursing and observation of special medication, strict implementation of disinfection and isolation measures, and total parenteral and enteral nutrition nursing at the same time. After careful treatment and nursing, the newborn baby was cured and discharged on the 44th day of hospitalization. (本文总结1例先天性双侧乳糜胸早产儿的护理经验。护理重点包括气道集束化护理管理; 胸腔闭式引流护理; 新生儿疼痛评估及管理; 特殊用药的护理及观察; 严格落实消毒隔离措施; 同时做好全胃肠外及肠内营养护理; 实施早产儿发育支持护理。经过精心的治疗与护理, 患儿于住院第44天治愈出院。)

We report here a rare case of neuroblastoma in a neonate who presented as a hydropic baby with respiratory distress due to recurrent chylothorax. The neuroblastoma regressed after six cycles of chemotherapy and the infant was discharged in good condition. [ABSTRACT FROM AUTHOR]

Key Clinical Message: We describe a premature hydropic infant with Noonan syndrome and a therapy refractory chylothorax. This was shown to be due to a central conducting lymphatic anomaly. After therapy with a MEK‐inhibitor the infant recovered clinically and radiologically completely, possibly by restoring lymphatic valve function. [ABSTRACT FROM AUTHOR]

Background: Chylothorax is a postoperative complication in patients with lung cancer. Diet-control approaches have been the mainstay for managing this condition. However, a surgical intervention is needed for the patients if conservative treatment is ineffective. Because of the lack of accurate indicators to assess the prognosis of the postoperative complication at an early stage, the criteria of surgical treatment were not consistent. Methods: We reviewed 2942 patients who underwent pulmonary resection and lymph node dissection for primary lung cancer at our hospital between March 2021 and December 2022. The prognostic implications of clinical indicators were assessed in patients with postoperative chylothorax who were managed with a low-fat diet. Binary logistic regression was used to explore the predictive value of these indicators for patient prognosis. Results: Postoperative chylothorax occurred in 108 patients and 79 patients were treated with a low-fat diet management while 29 patients were managed with TPN. In contrast to drainage volume, the pleural effusion triglyceride level after 2 days of low-fat diet exhibited enhanced predictive efficacy in predicting patient prognosis. When the pleural fluid triglyceride level of 1.33 mmol/L was used as the diagnostic threshold for prognosis, the sensitivity and specificity reached 100% and 80.6%, respectively. Conclusions: The pleural effusion triglyceride level after 2 days of low-fat diet can serve as a valuable prognostic indicator in patients undergoing lung surgery and experiencing chylothorax. This predictive approach will help thoracic surgeons to identify patients with poor prognosis in a timely manner and make decision to perform necessary surgical interventions. [ABSTRACT FROM AUTHOR]

Chylothorax is accumulation of chyle in pleural space. Causes include traumatic, such as after esophagectomy, and nontraumatic, most commonly malignancy. Lymphoma usually presents as asymptomatic lymphadenopathy, and chylothorax tends to occur late in disease course. Chylothorax as initial presentation of lymphoma is rare with only case reports. We present a case of 43‐year‐old female who presented with dyspnea only with no B symptoms and found to have left‐sided chylothorax, and was later diagnosed to have stage IV follicular lymphoma. This case highlights an atypical presentation of follicular lymphoma, to help physicians to reach diagnosis earlier in similar cases. [ABSTRACT FROM AUTHOR]

BACKGROUND: The prognosis of congenital chylothorax and ascites ranges from spontaneous resolution to death, but no established examination exists to predict the prognosis. We aimed to develop a clinically useful method to evaluate lymphatic abnormalities using indocyanine green (ICG) lymphography in infants with congenital chylothorax and ascites. METHODS: We retrospectively evaluated infants with congenital chylothorax and chylous ascites who underwent ICG lymphography in our hospital between 2012 and 2022. The ICG lymphography findings was evaluated. We defined the dermal backflow in the trunk as the lymphatic flow from the end of the limb back through the lymphatic vessels on the surface of the trunk. The association between the dermal backflow in the trunk and clinical outcomes, as follows, are investigated: the duration of the drainage period, the duration of endotracheal intubation, and the length of hospital stay. RESULTS: Twenty infants had a dermal backflow in the trunk, and ten did not. Clinical outcomes in infants with and without dermal backflow in the trunk were as follows (median): the duration of the drainage period (20 vs. 0 days, p = 0.001), the duration of endotracheal intubation (12 vs. 2 days, p = 0.04), and the length of hospital stay (62 vs. 41 days, p = 0.04), respectively. In multivariate linear regression analysis adjusted for gestational age, the duration of the drainage period was correlated with the dermal backflow in the trunk [exp(B) = 2.62; p = 0.003]. CONCLUSIONS: The dermal backflow in the trunk in ICG lymphography was useful in predicting the clinical course of congenital chylothorax and ascites. [ABSTRACT FROM AUTHOR]

Patients undergoing esophagectomy are at risk of malnutrition and benefit from perioperative enteral feeding. Esophagectomy carries a risk of chyle leak, and this risk may be influenced by early enteral feed composition. We evaluated the impact of early enteral medium-chain triglyceride-rich feed on the prevalence and severity of chyle leak post-esophagectomy, length of stay, and postoperative weight change. This retrospective study included consecutive patients undergoing esophagectomy at a single center between January 2015 and December 2022. Patients received enteral feed on postoperative days 1–5 with Nutrison Energy or Protein Plus Energy ('standard') (January 2015– June 2021) or Nutrison Peptisorb Plus High Energy High Protein ('HEHP') enteral feed (June 2021 to December 2022). All patients transitioned to 'standard' supplemental jejunal feeding on postoperative day 6 onwards and were discharged on oral IDDSI level 4 diet. Patients who did not commence early enteral feeding were excluded from analysis. A total of 329 patients were included. Patients who received early HEHP feed had fewer chyle leaks (5/52; 9.6%) compared with patients who received standard feed (68/277; 24.5%, P  = 0.017). The HEHP group had a shorter total length of hospital stay (P  = 0.011). Weight change from preoperative baseline was equivalent in both groups at 6 weeks (P  = 0.066) and 3 months (P  = 0.400). In the context of routine jejunostomy use and early enteral feeding post-esophagectomy, HEHP feed on postoperative days 1–5 was associated with significantly fewer chyle leaks and shorter length of stay compared with standard feed. No difference was noted in postoperative weight change between groups. [ABSTRACT FROM AUTHOR]

The use of octreotide in managing intrathoracic chyle leak following esophagectomy has gained popularity in the adult population. While the benefits of octreotide have been confirmed in the pediatric population, there remains limited evidence to support its use in the adults post-esophagectomy. Thus, we performed a single-institution cohort study to characterize its efficacy. The study was performed using a prospective, single-center database, from which clinicopathologic characteristics were extracted of patients who had post-esophagectomy chyle leaks. Kaplan–Meier and multivariable Cox regression analyses were performed to investigate the effect of octreotide use on chest tube duration (CTD), hospital length of stay (LOS), and overall survival (OS). In our cohort, 74 patients met inclusion criteria, among whom 27 (36.5%) received octreotide. Kaplan–Meier revealed no significant effect of octreotide on CTD (P  = 0.890), LOS (P  = 0.740), or OS (P  = 0.570). Multivariable Cox regression analyses further corroborated that octreotide had no effect on CTD (HR = 0.62, 95% confidence interval [CI]: 0.32–1.20, P  = 0.155), LOS (HR = 0.64, CI: 0.34–1.21, P  = 0.168), or OS (1.08, CI: 0.53–2.19, P  = 0.833). Octreotide use in adult patients with chyle leak following esophagectomy lacks evidence of association with meaningful clinical outcomes. Level 1 evidence is needed prior to further consideration in this population. [ABSTRACT FROM AUTHOR]

Chylothorax is a rare condition where the extravasated chyle accumulates into the pleural space. It is most commonly associated with malignancies, infective or inflammatory disorders and iatrogenic causes. Extremely rarely, it could occur spontaneously. We present the case of a healthy 40-year-old woman who presented with acute right shoulder and neck pain associated with shortness of breath and loss of consciousness. This was preceded by a yoga class two weeks prior. Chest imaging showed right pleural effusion, and tapping revealed a milky fluid which was confirmed to be chylothorax. Conservative management failed and the patient was successfully treated with video-assisted thoracoscopic drainage, thoracic duct ligation and mechanical pleurodesis. Chylothorax association with yoga is not reported in the literature. [ABSTRACT FROM AUTHOR]

Purpose: To analyze ultrasound features of cervical thoracic duct for patients with constrictive pericarditis and chylothorax. Methods: Patients were retrospectively assessed. The patients were divided into a non‐pleural effusion (PE) group (n = 54), a chylothorax group (n = 23), and non‐chylothorax group (n = 28). Conventional ultrasound was used to obtain the maximum inner diameter and collapse of the inferior vena cava, the inner diameter of left cervical thoracic duct, and the frequency of opening of the valve at the end of the left thoracic duct. Contrast ultrasonography was used to score the reverse flow of the thoracic tube. Results: The percentage of PE was 48.5%, and the percentage of chylothorax was 21.9%. The three groups had significant differences in five parameters. The inner diameter of left cervical thoracic duct was correlated with the degree of central venous pressure. Contrast ultrasonography was effective in quantitative assessment of the degree of intravenous‐thoracic cord reverse flow which correlated with all parameters of central venous pressure. Conclusion: Thoracic duct dilation and regurgitation secondary to central venous pressure can lead to chyloreflux disorder and may be the mechanism of chylothorax occurrence in constrictive pericarditis. [ABSTRACT FROM AUTHOR]

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Background: Thoracic duct ligation (TDL) during esophagectomy has been proposed to reduce the risk of postoperative chylothorax. Because of its role in immunoregulation, some authors argued that it had an unfavorable TDL effect on survival. The aim of this study was to analyze the effect of TDL on overall survival (OS). Methods: PubMed, MEDLINE, Scopus, and Web of Science were searched through December 2023. The primary outcome was 5-year OS. The restricted mean survival time difference (RMSTD), hazard ratios (HRs), and 95% confidence intervals (CI) were used as pooled effect size measures. The GRADE methodology was used to summarize the certainty of the evidence. Results: Five studies (3291 patients) were included. TDL was reported in 54% patients. The patients' age ranged from 49 to 69, 76% were males, and BMI ranged from 18 to 26. At the 5-year follow-up, the combined effect from the multivariate meta-analysis is -3.5 months (95% CI −6.1, −0.8) indicating that patients undergoing TDL lived 3.5 months less compared to those without TDL. TDL was associated with a significantly higher hazard for mortality at 12 months (HR 1.54, 95% CI 1.38–1.73), 24 months (HR 1.21, 95% CI 1.12–1.35), and 28 months (HR 1.14, 95% CI 1.02–1.28). TDL and noTDL seem comparable in terms of the postoperative risk for chylothorax (RR = 0.66; p = 0.35). Conclusions: In this study, concurrent TDL was associated with reduced 5-year OS after esophagectomy. This may suggest the need of a rigorous follow-up within the first two years of follow-up. [ABSTRACT FROM AUTHOR]

Key Clinical Message: Pleural effusion is rare during neonatal period with an estimated prevalence of 0.06%. It may sometimes uncommonly be secondary to pulmonary sequestration. Besides common conditions like hydrops fetalis, congenital heart disease, congenital chylothorax, chromosomal abnormalities; pulmonary sequestration should also be considered while evaluating the cause for neonatal pleural effusion. [ABSTRACT FROM AUTHOR]

Objective: A single centre experience with chylothorax in post cardiac surgical patients. Methods: Retrospective review. Results: Chylothorax developed in 55 out of 873 operated patients (6.3%). Median age of the chylothorax cohort was 95 days (range 1–995). Neonates constituted 36% and 49% were infants. Group-1(35 patients-treated during the years 2011–2015) included those who were managed with low fat diet initially with other standard measures including steroid, octreotide, pleurodesis, lymphangiogram or thoracic duct ligation whenever required.Group-2 (20 patients, treated between year 2016–2018) were managed with nil per oral, total parenteral nutrition, extended use of milrinone and no use of chest tube suction with other above standard measures when required.Group-1 and group-2 were comparable in terms of their age and weight (p > 0.05).We observed lower volume of chest drainage, shorter intubation time, length of intensive care stay and hospital stay in group-2 compared to group-1 though they were statistically not significant (p > 0.05). Occurrence of massive chylothorax (>20 ml/kg/day) in group-1 was significantly higher [18 patients (51%) in group-1 vs 4 patients in group-2 (20%) (Chi-square 5.25, p = 0.02)]. In hospital mortality in group-1 was higher compared to group-2 (5/35 = 14.5% vs 1/20 = 5%), however, it was statistically not significant [risk ratio 2.86; 95% CI 0.36, 22.77; p = 0.59)]. Acute kidney injury was observed in about 25% of patients who had chylothorax. A higher mortality was observed in patients with chylothorax who had acute kidney injury [5/14 (35%)] compared to those who did not have acute kidney injury [1/41 (2.4%)] (Chi-square 11.89, p = 0.001)]. Summary: In a heterogenous cohort of post-cardiac surgical patients who developed chylothorax, our suggested new regime (nil per oral, parenteral nutrition, extended use of milrinone and no suction applied to the chest drains) contributed to reduce the frequency of massive chylothorax occurrence significantly. [ABSTRACT FROM AUTHOR]

The development of a chylothorax after robot-assisted laparoscopic splenectomy combined with pericardial devascularization (LSPD) is rare. The robot-assisted procedure is similar to the standard LSPD, but surgeons must remain vigilant about potential chylothorax caused by recurrence of portal hypertension in patients with cirrhosis, an event that leads to variceal bleeding in the gastric fundus or a massive chylothorax caused by a thoracic duct fistula. We report a rare case of massive chylothorax after robot-assisted LSPD and review the literature to help elucidate the mechanisms of portal hypertension after LSPD, reduce surgical complications, and improve long-term patient outcomes. After LSPD, portal pressure monitoring, coagulation function testing, and portal vein CT imaging help in excluding portal vein thromboses and ensuring appropriate anticoagulation to reduce the development of thoracic duct fistulas. If portal hypertension recurs after surgery and a high-output chylothorax develops, conservative treatment becomes ineffective. Treatment with an active trans-jugular intrahepatic portosystemic shunt (TIPS) is recommended to lower the portal pressure.

Chylothorax is a serious postoperative complication of oesophageal cancer, and to date, there is no standardized and effective intraoperative diagnostic tool that can be used to identify the thoracic duct and determine the location of lymphatic fistulas. A 50-year-old patient with oesophageal squamous cell carcinoma developed chylothorax after thoracolaparoscopy combined with radical resection of oesophageal cancer. Twelve hours after surgery, 1200 mL of clear fluid was drained from the thoracic drainage tube, and a chyle test was sent. A thoracothoracic duct ligation procedure was performed on the first day after surgery. Although fluid accumulating in the posterior mediastinum was observed, the location of the lymphatic fistula could not be determined. During the surgery, indocyanine green (ICG) was injected into the bilateral inguinal lymph nodes, and a fluorescent lens was used to determine the location of the lymphatic fistula so the surgeon could ligate the thoracic duct. ICG fluorescence imaging technology can help surgeons effectively manage chylothorax after oesophageal cancer surgery. To our knowledge, this is the first report to describe the use of ICG fluorescence imaging technology to treat postoperative chylothorax in patients with oesophageal cancer in China.

ObjectivesEarly removal of chest tubes reduces pain and morbidity. This study aimed to remove chest tubes immediately after robotic pulmonary resection with complete thoracic lymphadenectomy by administering ice cream to rule out chylothorax.MethodsThis quality improvement study utilized prospectively gathered data from one thoracic surgeon. Patients were given 3.6 fl oz of ice cream in the recovery room within 1 h after their operation. Chest tubes were removed within 4 h if there was no chylous drainage and air leak on the digital drainage system.ResultsFrom January 2022 to August 2023, 343 patients underwent robotic pulmonary resection with complete thoracic lymphadenectomy. The median time to ingest the ice cream was 1.5 h after skin closure. The incidence of chylothorax was 0.87% (3/343). Two patients were diagnosed with chylothorax after consuming ice cream within 4 h of surgery. One patient, whose chest tube remained in place due to an air leak, had a chylothorax diagnosed on postoperative day 1 (POD1). All three patients were discharged home on POD1 with their chest tubes in place, adhering to a no-fat, medium-chain triglyceride diet. All chylothoraces resolved within 6 days. None of the remaining patients developed chylothorax postoperatively with a minimum follow-up period of 90 days.ConclusionsProviding ice cream to patients after pulmonary resection and complete thoracic lymphadenectomy is an effective and reliable technique to rule out chylothorax early in the postoperative period and facilitates early chest tube removal. Further studies are needed to ensure that this simple, inexpensive test is reproducible.

Chylothorax, which accounts for 1% to 3% of pleural effusions, typically results from either surgery (traumatic) or underlying malignancy (nontraumatic). Less common causes of nontraumatic chylothorax are numerous and include congenital lymphatic abnormalities, connective tissue diseases, cirrhosis, and infection, among others. 1 We describe what appears to be the first reported case of chylothorax caused by chylous ascites in Crohn disease. This case highlights the importance of using diagnostic evidence to link new symptoms to preexisting diseases whenever possible, as well as the systemic nature of Crohn disease. [ABSTRACT FROM AUTHOR]

Chylothorax is a rare condition where the extravasated chyle accumulates into the pleural space. It is most commonly associated with malignancies, infective or inflammatory disorders and iatrogenic causes. Extremely rarely, it could occur spontaneously. We present the case of a healthy 40-year-old woman who presented with acute right shoulder and neck pain associated with shortness of breath and loss of consciousness. This was preceded by a yoga class two weeks prior. Chest imaging showed right pleural effusion, and tapping revealed a milky fluid which was confirmed to be chylothorax. Conservative management failed and the patient was successfully treated with video-assisted thoracoscopic drainage, thoracic duct ligation and mechanical pleurodesis. Chylothorax association with yoga is not reported in the literature.

Chylothorax after cardiac surgery is a rare complication associated with severe morbidity and mortality. This report documents successful treatment with percutaneous thoracic duct embolization for chylothorax after total arch replacement. A 69-year-old man underwent replacement of the aortic arch to treat a ruptured aortic aneurysm. After surgery, the left thoracic drain discharged 2,000 to 3,000 mL serosanguineous fluid per day, even though the patient took nothing orally and was administered subcutaneous octreotide therapy. On postoperative day 9, percutaneous thoracic duct embolization was performed, and the drain could be removed. The chylothorax did not recur, and the patient was discharged on postoperative day 17.

A 45-year-old male patient with spontaneous chylothorax and osteolysis in the right 1st and 2nd ribs was diagnosed with Gorham–Stout disease based on clinical manifestations and bone biopsy. The chylothorax temporarily decreased after a successful selective lymphatic embolization. The patient presented with recurrent chylothorax, mild chest discomfort, and progressive osteolysis (despite administering sirolimus) during the follow-up period of 15 months.

Fetal pleural effusion has been reported to be associated with chromosomal abnormalities, genetic syndromes, obstructive uropathy, lymphatic vessel abnormalities such as Noonan syndrome, RASopathy and congenital lymphatic anomalies, thoracic cavity defects, Rh or ABO incompatibility, non-immune hydrops fetalis, infections, congenital cardiac anomalies, metabolic diseases and hematologic diseases such as α-thalassemia. This review provides an overview of syndromic and single gene disorders associated with fetal pleural effusion that is useful for genetic counseling and fetal therapy at prenatal diagnosis of fetal pleural effusion.

Abstract Background Postoperative lymphatic leakage is a complication of ineffective conservative treatment for retroperitoneal mass. Herein, we report a case of lymphatic leakage that arose after retroperitoneal tumor resection and that was treated with retrograde transvenous thoracic duct embolization. Case presentation A 28-year-old man with persistent abdominal pain was diagnosed with a large retroperitoneal metastatic tumor measuring 10 cm and a subdiaphragmatic lymph node originating from a testicular tumor. After high orchidectomy and neoadjuvant chemotherapy, the subdiaphragmatic lymph node and retroperitoneal tumor were resected together with the abdominal aorta; the latter was reconstructed using a prosthetic graft. Postoperatively, the patient developed chylothorax. No improvement was observed after conservative treatment that included fasting and somatostatin therapy. The leakage site could not be identified using antegrade lymphangiography of the bilateral inguinal lymph nodes, but was detected using retrograde transvenous lymphangiography. The leakage site was successfully embolized. Conclusion This case report describes successful treatment with retrograde transvenous thoracic duct embolization for chylothorax following resection of a retroperitoneal tumor and lymph node. This approach is a less invasive and more effective mode of treatment for chylothorax and should be considered before surgical thoracic duct ligation when the leakage point cannot be identified using the antegrade approach.

Rui-Gui Zhang,1– 3 Yu-Mei Liu,2– 4 Zhi-Ye Yao,2,3 Jing-Xuan Fang,4 Yuan Li,2– 4 Man-Li Zheng,2,3 Xin Sun,2,3 Shu-Sheng Wen,4,5 Xi-Meng Wang,4,6 Jian Zhuang,4 Dan-Dong Luo,4 Shao-Ru He1– 3 1The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510260, People’s Republic of China; 2Department of Neonatal Pediatrics, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, People’s Republic of China; 3Department of Pediatrics, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, People’s Republic of China; 4Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, People’s Republic of China; 5Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, People’s Republic of China; 6Global Health Research Center, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, People’s Republic of ChinaCorrespondence: Shao-Ru He, Department of NICU, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences, No. 106 of Zhongshan 2nd Road, Yuexiu District, Guangzhou, 510080, People’s Republic of China, Tel +8620-83827812, Email Hshru_rsh@163.comBackground: Studies of chylothorax after congenital heart disease in infants are rare. Chylothorax has a higher incidence in infancy, but its risk factors are not well understood.Objective: The purpose of this study is to investigate the risk factors of chylothorax after congenital heart surgery in infants.Methods: This retrospective study included 176 infants who underwent congenital heart disease surgery at the Guangdong Cardiovascular Institute, China, between 2016 and 2020. According to the occurrence of chylothorax, the patients were divided into a control group (n = 88) and a case group (n = 88). Univariate and multivariate logistic regression were performed to analyse the incidence and influencing factors of chylothorax after congenital heart surgery in infants.Results: Between 2016 and 2020, the annual incidence rate fluctuated between 1.55% and 3.17%, and the total incidence of chylothorax was 2.02%. Multivariate logistic regression analysis showed that postoperative albumin (p = 0.041; odds ratio [OR] = 0.095), preoperative mechanical ventilation (p = 0.001; OR = 1.053) and preterm birth (p = 0.002; OR = 5.783) were risk factors for postoperative chylothorax in infants with congenital heart disease.Conclusion: The total incidence of chylothorax was 2.02% and the annual incidence rate fluctuated between 1.55% and 3.17% between 2016 and 2020. Premature infants, longer preoperative mechanical ventilation and lower albumin after congenital heart surgery may be risk factors for chylothorax. In addition, infants with chylothorax are inclined to be infected, need more respiratory support, use a chest drainage tube for longer and remain longer in hospital.Keywords: congenital heart surgery, congenital heart disease, postoperative chylothorax, infant, risk factor

Introduction: Chylothorax is associated with longer length of stay, higher morbidity, mortality, and hospitalization cost. The main principle of chylothorax therapy is to reduce the chylous flow. The current nutritional management of patients with chylothorax are a low fat diet with long chain triglyceride (LCT) restriction, enteral nutrition with high medium chain triglyceride (MCT), and total parenteral nutrition. However, low fat diet with LCT restriction takes quite a long time (around 3 weeks) and requires close monitoring due to risk for malnutrition, essential fatty acid, and micronutrient deficiencies. The nutritional management determines the success of conservative therapy in chylothorax patients. The aim of this study was to determine whether a high MCT enteral diet is more superior than total parenteral nutrition regarding the resolution of chylothorax. Method: Literature searching was conducted using advanced searching in three large databases: Pubmed, Science Direct, and ProQuest using eligibility criteria determined by the authors. Quality of evidences were assessed based on GRADE Guidelines. Level evidence was determined based on Oxford Center of Evidence-based Medicine (CEBM). Result: Three systematic reviews and one cohort met the PICO and eligibility criteria that had been set. Two studies concluded that enteral nutrition was better than parenteral nutrition. One study concluded that parenteral nutrition could be considered first and one study could not conclude which kind of nutrition was better. Conclusion: Administration of high MCT enteral nutrition can be the first line therapy in patients with chylothorax and still need close monitoring during the administration. One of the factors that need to be monitored is the daily production of chylothorax volume. The results shown by these studies are inconsistent and warrant further research of high-quality studies regarding the treatment of chylothorax.

Objective: To use a nationwide database of hospitalizations to investigate underweight status as a risk factor for postesophagectomy complications. Methods: We identified all patients who underwent esophagectomy with a diagnosis of esophageal cancer and known body mass index in the 2018-2020 Nationwide Readmissions Database. All hospital visits for esophagectomy and within 30 days of initial discharge were analyzed for postoperative complications, including chylothorax. Patients who were underweight were propensity score matched with patients who were not. Multivariable logistic regression was performed to identify complications that were significantly associated with underweight status. Results: There were 1877 patients with esophageal cancer meeting inclusion criteria. Following propensity score matching, 433 patients who were underweight were matched to 433 patients who were not. In the multivariable model of the matched sample, which adjusted for age, sex, Charlson Comorbidity Index, history of chemotherapy or radiation therapy, and preoperative surgical feeding access, patients who were underweight were estimated to have 2.06 times the odds for chylothorax (95% confidence interval [CI], 1.07-4.25, P = .035). Underweight status was also significantly associated with acute bleed (odds ratio [OR], 1.52; 95% CI, 1.12-2.05, P = .007), pneumothorax (OR, 2.33; 95% CI, 1.19-4.85; P = .017), pneumonia (OR, 2.30; 95% CI, 1.53-3.50, P

Mediastinal haemangiomas pose diagnostic and therapeutic challenges owing to their rarity and complex anatomy. A 36-year-old man, with a history of smoking and drinking, presented with a posterior mediastinal mass with back pain. Initial investigations suggested a lymphangioma. However, owing to persistent symptoms and complex pathology, we performed surgical intervention involving open resection of the tumour, which was closely associated with the descending aorta and extended into the right posterior mediastinum. The surgical approach was influenced by the proximity of the tumour to vital structures, necessitating an open procedure. Postoperative complications included chylothorax, managed with a fat-free diet. The final pathological diagnosis was consistent with a benign vascular tumour with a low proliferative rate. Two months post-surgery, computed tomography revealed no complications, and the patient's pain had decreased. A multidisciplinary approach and surgical intervention played important roles in the diagnosis and treatment of this posterior mediastinal haemangioma. [ABSTRACT FROM AUTHOR]

Pseudochylothorax is a rare disease entity. It is characterized by a milky white pleural fluid with a cholesterol/triglyceride ratio >1. According to published reports, most patients had associated diseases, including rheumatoid arthritis and tuberculosis, with only one patient having oropharynx carcinoma associated with lung metastases. Herein, we describe the development of pseudochylothorax in a patient with rheumatoid arthritis and lung squamous cell carcinoma. Cancer cells were confirmed in the pleural fluid, but there was no thoracic duct damage caused by cancer invasion or tuberculosis-related lesions in the lung field or intrathoracic lymph nodes. Anticancer treatment included immune checkpoint inhibitors, and the appearance of a cavity within the mass and pneumothorax were associated with lung cancer treatment. Although the mechanism of pseudochylothorax onset was unknown, we do believe that this clinical course would provide some suggestive information on treatment for patients with a similar course in the future. [ABSTRACT FROM AUTHOR]

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Background: Pleural effusion and chylothorax are common complications in the treatment of congenital diaphragmatic hernia (CDH). We set out to identify risk factors for chylothorax development in patients with CDH and to investigate the association of pleural effusion and chylothorax with neonatal morbidity and mortality. Methods: In this retrospective cohort study, we included 396 neonates with CDH treated at our institution between January 2013 and June 2019. Preoperative and postoperative chest radiographs and clinical data were evaluated and correlated with morbidity, complications and mortality. Results: Laboratory-confirmed chylothorax occurred in 58 (18.6%) of all CDH cases. Pleural effusion was frequently observed as a postoperative complication but also occurred as a pre-existing condition. Neonates with large defects of size C and D, patch repair, the need for presurgical and/or postsurgical ECMO support, pulmonary hypertension, liver-up phenomenon and lower relative fetal lung volume were associated with higher occurrences of chylothorax. After stepwise logistic regression, larger CDH defects (p < 0.0001) and the need for postsurgical ECMO (p = 0.0158) remained significant risk factors for CTX to occur (AUC 0.71). The same potential risk factors were used to assess their association with both presurgical and postsurgical pleural effusion. After stepwise logistic regression, only the need for presurgical ECMO remained significantly associated with presurgical PE (p < 0.01, AUC 0.65) and patch repair as the therapeutic intervention remained significantly associated with the occurrence of postsurgical PE (p < 0.0001, AUC 0.80). Patients with CTX had longer durations of both MV (p < 0.0001) and subsequent ventilatory assistance with spontaneous breathing (p = 0.0004), increased total lengths of hospitalization (p < 0.0001), increased durations of ECMO (p < 0.01) and increased incidences of CLD (p < 0.0001) compared to patients without CTX. No significant difference could be found for survival in both groups (p = 0.12). Conclusions: Our data suggest that the incidence of chylothorax is associated with large diaphragmatic defects, the need for postsurgical ECMO and the development of chronic lung disease, but not with survival. [ABSTRACT FROM AUTHOR]

Background: Postoperative lymphatic leakage is a complication of ineffective conservative treatment for retroperitoneal mass. Herein, we report a case of lymphatic leakage that arose after retroperitoneal tumor resection and that was treated with retrograde transvenous thoracic duct embolization. Case presentation: A 28-year-old man with persistent abdominal pain was diagnosed with a large retroperitoneal metastatic tumor measuring 10 cm and a subdiaphragmatic lymph node originating from a testicular tumor. After high orchidectomy and neoadjuvant chemotherapy, the subdiaphragmatic lymph node and retroperitoneal tumor were resected together with the abdominal aorta; the latter was reconstructed using a prosthetic graft. Postoperatively, the patient developed chylothorax. No improvement was observed after conservative treatment that included fasting and somatostatin therapy. The leakage site could not be identified using antegrade lymphangiography of the bilateral inguinal lymph nodes, but was detected using retrograde transvenous lymphangiography. The leakage site was successfully embolized. Conclusion: This case report describes successful treatment with retrograde transvenous thoracic duct embolization for chylothorax following resection of a retroperitoneal tumor and lymph node. This approach is a less invasive and more effective mode of treatment for chylothorax and should be considered before surgical thoracic duct ligation when the leakage point cannot be identified using the antegrade approach. [ABSTRACT FROM AUTHOR]

Key Clinical Message: Chylothorax is a rare entity associated with morbidity. Surgical thoracic duct ligation (TDL) by thoracoscopic approach is the recommended choice for persistent chylothorax. However, thoracoscopy is not feasible in case of previous pleurodesis. We describe a successful laparoscopic transhiatal en‐mass TDL in a 61‐year‐old lady for persistent spontaneous chylothorax after failed optimal conservative management and three sessions of pleurodesis. The study shows that laparoscopic transhiatal thoracic duct ligation is an effective alternative in a case where thoracoscopy is not feasible due to various reasons. [ABSTRACT FROM AUTHOR]

Chylothorax is a lymphatic chylous pleural effusion typically associated with traumatic (iatrogenic, non-iatrogenic) and non-traumatic (infections, malignancy, lymphatic disorders) aetiologies. Drug-induced chylothorax is uncommon and mostly reported in association with BCR-ABL tyrosine kinase inhibitor therapy. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the efficacy of pleurodesis using OK-432 after cardiac surgery in the neonatal period or early infancy. Methods: We retrospectively reviewed the data of 11 consecutive patients who underwent cardiac surgery in the neonatal period or early infancy and pleurodesis using OK-432 for persistent postoperative pleural effusion in two institutions. Results: The median age at surgery was 8 days (interquartile range [IR], 2–18) with a body weight of 2.84 kg (IR, 2.30–3.07). The maximum amount of pleural drainage before pleurodesis was 94.7 (IR, 60.2–107.7) ml/kg/day. Pleurodesis was initiated at postoperative day 20 (IR, 17–22) and performed in bilateral pleural spaces in seven patients and unilateral in four. The median numbers of injection were 4 (IR, 3–6) times per patient and 3 (IR, 2–3) times per pleural space. In 10 patients, pleural effusion was decreased effectively, and drainage tubes were removed without reaccumulation within 15 (IR, 12–28) days after initial pleurodesis. However, in one patient, with severe lymphedema, pleural effusion was uncontrollable, resulting in death due to sepsis. Adverse events were observed in nine patients; temporal deterioration of lung compliance and arterial blood gas occurred in two, insufficient drainage requiring new chest tube(s) in five, temporal atrial tachyarrhythmia in one, and lymphedema in four. Conclusions: Pleurodesis using OK-432 is effective and reliable for persistent postoperative pleural effusion in neonates and early infants. Most of the complications, which derived from inflammatory reactions, were temporary and controllable. However, severe lymphedema is difficult to control. [ABSTRACT FROM AUTHOR]

Neoadjuvant chemoimmunotherapy is becoming an increasingly important part of the management of lung cancer to facilitate surgical resection. This study aimed to summarize the treatment‐related adverse events (TRAEs) and wound complications of neoadjuvant chemoimmunotherapy in non‐small cell lung cancer (NSCLC). Eligible studies of neoadjuvant chemoimmunotherapy for NSCLC were identified from PubMed, Embase and Web of Science. The endpoints mainly included TRAEs and wound complications. Stata18 software was used for statistical analysis with p < 0.05 considered statistically significant. Twenty studies including a total of 1072 patients were eligible for this study. Among the patients who received neoadjuvant chemoimmunotherapy, the pooled prevalence of any grade TRAEs was 77% (95% confidence interval [CI] [0.64–0.86]), grade 1–2 TRAEs was 77% (95% CI [0.58–0.89]) and grade ≥3 TRAEs was 26% (95% CI [0.16–0.38]). Surgery‐related complications rate was 22% (95% CI [0.14–0.33]). Among the wound complications, the pooled rate of air leakage was 10% (95% CI [0.04–0.23]), pulmonary/wound infection was 8% (95% CI [0.05–0.13]), bronchopleural fistula was 8% (95% CI [0.02–0.27]), bronchopulmonary haemorrhage was 3% (95% CI [0.01–0.05]), pneumonia was 5% (95% CI [0.02–0.10]), pulmonary embolism was 1% (95% CI [0.01–0.03]), pleural effusion was 7% (95% CI [0.03–0.14]) and chylothorax was 4% (95% CI [0.02–0.09]). Overall, neoadjuvant chemoimmunotherapy in NSCLC results a high incidence of grade 1–2 TRAEs but a low risk of increasing the incidence of ≥3 grade TRAEs and wound complications. These results need to be confirmed by more large‐scale prospective randomized controlled trials and studies. [ABSTRACT FROM AUTHOR]

Objective: To examine and discuss patients diagnosed with acquired and congenital chylothorax in the neonatal period in the light of the literature. Methods: The files of newborns followed-up in the neonatal intensive care unit (NICU) and diagnosed with congenital and acquired chylothorax were reviewed retrospectively. Patients with isolated chylothorax were classified as Group 1 and those with multiple lymphatic flow disorders were classified as Group 2. Antenatal and clinical features were recorded and compared between the groups. Results: Thirteen infants were diagnosed with chylothorax; 92.3% (n = 12) of the patients were congenital. The rate of antenatal diagnosis was 61.5% (n = 8). Eight patients (61.5%) were diagnosed with hydrops fetalis. Among the cases in Group 1 and Group 2, receiving ocreotide and the incidence of sepsis (p = 0.05) were partially significant. Seven of the patients (66.6%) responded to medium chain triglycerides (MCT), and complete resolution was seen in 6 (85.7%) of the responders. Complete resolution of chylothorax fluid was observed in 7 (77.7%) of nine patients who responded to ocreotide treatment. Conclusions: In neonatal chylothorax, the postnatal period includes a multidisciplinary approach that requires drug therapy, dietary modifications, drainage of pleural fluid, and rarely, surgery. [ABSTRACT FROM AUTHOR]

After fatal traumatic injuries, three urbanized free-ranging marmosets developed a milky white or pink-white thoracic alkaline effusion with high specific gravity, triglyceride levels, and predominance of small lymphocytes. Chylothorax is an uncommon thoracic fluid accumulation in animals and humans and has not been reported in free-ranging non-human primates. [ABSTRACT FROM AUTHOR]

Background: Chyle leak is a rare complication following otolaryngologic, thoracic, and trauma surgery wherein the thoracic duct is transected. Case reports and small case series describe octreotide for the medical management of chyle leak, but limited data exist to determine the ideal dose. Objective: To evaluate octreotide dosing in patients with acute chyle leak. Methods: This retrospective, single center, cohort study evaluated adult patients admitted to the otolaryngology, cardiothoracic, and trauma surgery teams over a 9-year period. Patients diagnosed with a chyle leak who received octreotide were eligible for inclusion. Groups were defined as successful medical management or failure requiring definitive surgery. The primary endpoint was daily octreotide dose between groups. Results: Forty-seven patients were included with 29 (61.7%) admitted to the otolaryngology service and 44 (93.6%) with surgical complication as the chyle leak cause. Thirty-two (68.1%) patients had successful medical management while 15 (31.9%) patients failed and required surgical intervention. There was no difference in median daily octreotide dose (250 [IQR, 170-288] µg vs 253 [IQR, 200-282] µg, P =.9). Octreotide weight-based dose, treatment duration, and route of administration were similar between groups. Daily drain output and complete bowel rest were significantly higher in the failure group. Daily drain output was identified as an independent risk factor for failure. Conclusion: Octreotide dose was similar in patients with and without successful medical management of chyle leak. Future studies are needed to determine optimal octreotide dosing and elucidate the relationship between octreotide, drain output, and surgical intervention need. [ABSTRACT FROM AUTHOR]

Chyle leak is a rare but potentially morbid complication of abdominal surgery. There have been seven reported cases of chylous ascites following cholecystectomy, but no such occurrences are reported with percutaneous cholecystostomy tube (PCT) insertion. We report the case of a 67-year-old female with stage IVb recurrent uterine papillary serous carcinoma and extensive abdominal surgical history including a paraesophageal hernia repair, and a robotic hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymphadenectomy, gastrocolic omentectomy, and hepatoduodenal lymphadenectomy. The patient presented with clinical findings suggestive of acute cholecystitis and decision was made to proceed with PCT placement. The PCT was dislodged and replaced during her course and several days after chylous output was noted from the PCT. The remainder of her hospital course was complicated by persistent distributive shock, adrenal insufficiency, and continued chyle leak. She ultimately was transitioned to inpatient hospice and died shortly after. [ABSTRACT FROM AUTHOR]

Chylothorax is the accumulation of lymphatic fluid (chyle) within the pleural space. There are multiple causes, including traumatic and non-traumatic mechanisms. Trauma can cause disruption of the thoracic duct either by direct damage or indirect crushing or avulsion mechanisms. Non-traumatic causes include infections, inflammatory processes, malignancies, and iatrogenic injury (during surgery or central venous access). The traditional management of traumatic chylothorax has been either a conservative approach, including complete nil per os, or a low-fat diet with medium-chain triglyceride supplementation with the administration of somatostatin or its analog, octreotide, versus a surgical approach consisting of thoracic duct ligation. Recently a less invasive approach via thoracic duct embolization has gained popularity. There have been a few reports of the successful use of an alpha 1-adrenergic agonist (midodrine) as an adjunct in the conservative approach. We describe the utility of midodrine in three cases of chylothorax and propose a management algorithm.

Background: Chylothorax can be classified into traumatic and nontraumatic based on the etiology. Nephrotic syndrome is a very rare cause of nontraumatic chylothorax in adults. Case presentation: A 66-year-old woman with membranous nephropathy who was non-compliant with her management, presented with dyspnea, and was found to have a large right sided chylothorax. Her chylothorax was secondary to membranous nephropathy after excluding other causes, which has been rarely reported in literature. Conclusion: This case highlights the possibility of nephrotic syndrome causing chylothorax, especially in patients with undiagnosed nephrotic syndrome or patients non-compliant with their management. When evaluating a patient with chylothorax, providers should consider nephrotic syndrome in the differential diagnosis.

Fetal pleural effusion has been reported to be associated with chromosomal abnormalities, genetic syndromes, obstructive uropathy, lymphatic vessel abnormalities such as Noonan syndrome, RASopathy and congenital lymphatic anomalies, thoracic cavity defects, Rh or ABO incompatibility, non-immune hydrops fetalis, infections, congenital cardiac anomalies, metabolic diseases and hematologic diseases such as α-thalassemia. This review provides an overview of chromosomal abnormalities associated with fetal pleural effusion which is useful for genetic counseling and fetal therapy at prenatal diagnosis of fetal pleural effusion.

Background: Congenital Chylothorax (CC) is a rare condition, which is defined as an accumulation of the chyle in the pleural cavity;moreover, it is associated with significant morbidities, including respiratory distress, malnutrition, immunodeficiency, and infections. Case Report: The diagnosis of chylothorax was made upon count cell analysis of the pleural fluid with ≥80% lymphocytesdetected before birth or within 28 days after birth. In this study, we presented five cases of CC infants. They were dischargedfrom our tertiary center at Hedi Chaker Hospital, Sfax, Tunisia, from January 2010 to December 2018. There were three malesand two females. Prenatal diagnosis was made in four cases. There were four full-term newborns and one near-term of 36weeks. Pleural effusion was on the right side in three cases, on the left side in one case, and bilateral in one case. Four casesrequired mechanical ventilation. Somatostatin was indicated in one case. The treatment was successful in four cases. One casepresented a dysmorphic syndrome and died of pneumothorax.Conclusion: The treatment of CC is based on conservative management. Somatostatin or its analog octreotide is considered anadjunctive treatment of CC. However, the refractory cases are treated with chemical pleurodesis or surgical treatment. Wepropose an algorithm for the treatment of CC.