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BACKGROUND - Utilization of tunneled indwelling pleural catheters (TIPCs) for persistent pleural effusions is increasingly more common; however, the presence of chylothorax is generally considered a contraindication for utilization of a TIPC due to concerns regarding potential nutritional, immunologic and hemodynamic complications. Therefore, in this study, a cohort of patients with persistent benign chylothorax managed with TIPCs is described.
METHODS - A retrospective analysis of patients with persistent benign chylothorax managed with a TIPC at the study center between January 1, 2008, and March 1, 2012, was completed. Extracted data included patient characteristics, chylothorax etiologies, prior interventions, outcomes and complications.
RESULTS - Eleven patients (14 hemithoraces) had persistent benign chylothorax treated with placement of a TIPC during the inclusion time frame. Etiology of the chylothorax was nontraumatic in 8 of the 11 patients, with the remaining 3 secondary to thoracic surgery. Pleurodesis was achieved in 9 of the 14 hemithoraces, with a median time to pleurodesis of 176 days. All procedures were well tolerated, and no immediate periprocedural complications were reported. One serious complication was encountered in the form of a postoperative pulmonary embolism after replacement of an occluded TIPC, resulting in the patient's death. Two patients had transient occlusions of their TIPCs successfully treated with intracatheter thrombolytic therapy. No significant adverse nutritional, hemodynamic or immunologic outcomes were reported during follow-up for any included patient.
CONCLUSIONS - Utilization of a TIPC for the management of persistent benign chylothorax should be considered early because pleurodesis may be frequently and safely achieved in this patient population.
Although infections, malignancies and heart failure are responsible for the majority of pleural effusions, there are many other causes and several uncommon but distinctive types of pleural fluid. For this update we have chosen several uncommon forms of pleural effusions or disorders in which there have been recent advances in our understanding over the past several years. Chylothorax, pseudochylothorax and urinothorax are associated with characteristic clinical contexts and pleural fluid parameters but are likely underdiagnosed. Yellow nail syndrome is a rare disorder that can be associated with chylothorax and manifests multisystem features. Recognition of these entities is important because each of these disorders is associated with distinctive aetiology and management modalities. Correct diagnosis depends on the clinician's awareness of the clinical contexts and manifestations along with diagnostic pleural fluid findings in these disorders.
© 2011 The Authors. Respirology © 2011 Asian Pacific Society of Respirology.
Chylothorax is an uncommon form of pleural effusion that can be associated with traumatic and nontraumatic causes. Optimal management and outcome for patients with chylothorax remain unclear. This retrospective single-center study assessed the modes of management for chylothorax in 74 adult patients (> or =18 years old) and associated outcomes. The role of lymphangiographic imaging was also evaluated. Initial treatment approach was nonsurgical in 57 patients (77%) but a surgical procedure (pleurodesis, thoracic duct ligation, and/or surgical repair) was eventually performed in 44 patients (59%). The rate of resolution with initial treatment measures was significantly worse for patients with nontraumatic chylothorax compared with those with traumatic causes (27% versus 50%, P = 0.048). Even after additional therapeutic maneuvers including surgery, chylous effusion recurred more commonly in nontraumatic chylothorax when compared with the traumatic group (50% versus 13%, respectively, P < 0.001). Lymphatic imaging did not seem to materially influence management. Nonsurgical approaches may lead to resolution of the chylothorax in nearly one half of patients with traumatic chylothorax but in only a minority of those with nontraumatic chylothorax. The majority of patients with nontraumatic chylothorax will eventually require surgical maneuvers, but one third of such patients still fail to resolve their chylothorax.
OBJECTIVE - To determine the biochemical parameters of chylous pleural fluids and better inform current clinical practice in the diagnosis of chylothorax.
PATIENTS AND METHODS - We retrospectively reviewed 74 patients with chylothorax (defined by the presence of chylomicrons) who underwent evaluation during a 10-year period from January 1, 1997, through December 31, 2006. The biochemical parameters and appearance of the fluid assessed during diagnostic evaluation were analyzed.
RESULTS - The study consisted of 37 men (50%) and 37 women (50%), with a median age of 61.5 years (range, 20-93 years). Chylothorax was caused by surgical procedures in 51%. The chylous pleural fluid appeared milky in only 44%. Pleural effusion was exudative in 64 patients (86%) and transudative in 10 patients (14%). However, pleural fluid protein and lactate dehydrogenase levels varied widely. Transudative chylothorax was present in all 4 patients with cirrhosis but was also seen with other causes. The mean +/- SD triglyceride level was 728+/-797 mg/dL, and the mean +/- SD cholesterol value was 66+/-30 mg/dL. The pleural fluid triglyceride value was less than 110 mg/dL in 10 patients (14%) with chylothorax, 2 of whom had a triglyceride value lower than 50 mg/dL.
CONCLUSION - Chylothoraces may present with variable pleural fluid appearance and biochemical characteristics. Nonmilky appearance is common. Chylous effusions can be transudative, most commonly in patients with cirrhosis. Traditional triglyceride cutoff values used in excluding the presence of chylothorax may miss the diagnosis in fasting patients, particularly in the postoperative state.