Practical Therapeutic Options for Postoperative Chylothorax

Practical Therapeutic Options for Postoperative Chylothorax | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Practical Therapeutic Options for Postoperative Chylothorax Lary A. Robinson, Noah A. Robinson, Youngchul Kim, Alexis Bailey, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7919123/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 20 Apr, 2026 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted 12 You are reading this latest preprint version Abstract OBJECTIVE An iatrogenic chylothorax following an esophageal or lung resection represents an uncommon complication with a significant morbidity and mortality if not treated promptly. The optimal therapeutic recommendations are not well defined and rely on the results of retrospective clinical series. We reviewed our experience with a consecutive series of patients with major postoperative chylothoraces in addition to published literature to create a rational algorithm for treatment of this frustrating problem. METHODS We conducted a retrospective cohort study of consecutive esophageal and lung resection patients from July 1, 2005 through June 30, 2021, collecting clinical data on all patients who developed a postoperative chylothorax with careful evaluation of the results of definitive therapy. RESULTS Between July 1, 2005 through June 30, 2021, we reviewed clinical data on 17 esophageal resection patients and 51 lung resection patients over a 17-year interval who underwent definitive treatment for their postoperative chylothorax. The esophageal surgery patients ultimately had curative therapy with total parenteral nutrition (TPN) (18%), medium chain triglyceride (MCT) enteral tube diet(18%), and in performing a surgical ligation of the thoracic duct(35%). For the lung surgery patients, the most effective treatments were octreotide/midodrine(29%), surgical ligation of the thoracic duct(23%) and the performance of a lymphangiogram with embolization or combined with octreotide(15%). CONCLUSIONS All patients in our cohort of esophageal and lung resection patients had curative therapy of the chylothorax with aggressive, invasive procedures mostly directed toward interruption or ligation of the thoracic duct while some patients responded well to dietary and drug therapy. Chylothorax Lung Resection Esophagectomy Lymphangiogram Lipiodol Thoracic Duct Ligation Midodrine/Octreotide Figures Figure 1 Figure 2 Figure 3 INTRODUCTION A postoperative chylous effusion after a thoracic surgical procedure is an uncommon but persistent problem that plagues all busy thoracic surgeons 2–3 times per year. This problem represents a serious and potentially fatal complication with a reported mortality as high as 47%( 1 ) when prolonged due to protein loss, malnutrition, electrolyte abnormalities, immunosuppression and sepsis. Reportedly, a significant chylothorax occurs following a thoracic mediastinal lymph node dissection in up to 2% of esophageal resections( 2 , 3 ) and 2.3% of lung resections,( 3 , 4 ) with a higher incidence in robotic-assisted resections that is felt related to a more extensive lymphadenectomy performed with the robotic-assisted approach.( 3 ) Although a variety of rarer non-surgical causes of a chylous effusion occur from obstruction or interruption of the thoracic duct, this study will focus only on postoperative iatrogenic causes.( 5 ) The optimal management of a significant chylous effusion is somewhat controversial and has been changing over time, especially as minimally invasive techniques improve. We chose to retrospectively review our 17-year experience with postoperative chylothorax after lung and esophageal resections to provide a real-world, single institution experience, not to investigate causation but to compare our treatment results and make management recommendations from our personal experience and the published literature. MATERIALS AND METHODS Study Subjects We conducted a retrospective cohort study of consecutive esophageal and lung resection patients from May 1, 2005 and June 30, 2016 and lung resection patients from January 1, 2004 and June 30, 2021 at Moffitt Cancer Center, collecting the clinical data on all patients who developed a postoperative chylothorax. We chose these 2 slightly different periods of time where we had complete inpatient and follow-up data on all of the patients for both surgical types. A chylothorax was diagnosed based on pleural fluid drainage containing an elevated triglyceride level > 110 mg/dL and the typical milky fluid appearance, generally draining > 400 mL per day. All patients underwent a mediastinal lymph node dissection. This retrospective study was approved by the Advarra IRB Pro00020692, IRB # 00000971, February 26, 2021. Individual consent was waived by the IRB in this retrospective case review. Clinical Data We retrospectively reviewed all clinicopathologic features plus the chylothorax data including amount of pleural fluid draining daily, cause of the chylothorax by consensus of at least two surgeons, initial treatment and response, other treatments including surgical treatment, time to resolution of chylothorax, chest tube duration, total hospital days, complications, in hospital recurrences, and mortality. We also reviewed effectiveness documented by resolution of the effusion. Over the course of the study period, 6 faculty thoracic surgeons performed surgery on patients in this series, and they made the treatment decisions for their patients based on their personal experience, and not a standard institutional protocol. In all surgical cases, lymph nodes were sampled from at least 3 or more lymph node stations with no attempt to calculate lymph node yields. Management The initial management of all patients with high volume chylous drainage (> 1000ml/day) was making the patient nil per os(NPO) and starting total parenteral nutrition(TPN). Octreotide and midodrine were started in all patients and if responsive with chest tube drainage 1000 mL/day were generally taken back promptly for minimally invasive surgical right thoracic duct ligation or referred to interventional radiology for a lymphangiogram. Based on their experience, the interventional radiologists at our center have found that the success of the lymphangiogram and transductal embolization relies heavily on patients being NPO for at least 48 hours, in addition to being on octreotide and midodrine. This decreases chyle flow, allowing targeting of the cisterna to either macerate or catheterize it and do an embolization. All lymphangiograms were done with Lipiodol ® (Guerbet LLC, Princeton, NJ) either intranodal or inter-digital, followed by either the preferred thoracic duct embolization, cisterna chyli maceration (disruption), or lymphangiogram only when embolization or maceration was not possible. Injecting only Lipiodol, Ⓡ which is viscous, may stop small leaks. Rarely an attempt was made for percutaneous direct transhepatic cisterna chyle puncture for embolization or cisterna chyle disruption. In the rare instance where patients continued to have a high output chest tube drainage, patients underwent a more extensive lymphangiogram to diagnose aberrant intraabdominal chylous drainage for consideration of a subdiaphragmatic surgical approach. Statistical Analysis For the demographic and treatment data, categorical variables are summarized with frequency and percentage, and continuous variables are presented as mean with standard deviation and range. We used the Wilcoxon rank-sum test to compare quantitative variables and Fisher’s exact test for categorical variables between patient groups, based on their treatment and outcome. For quantitative outcomes including chest tubes days in place and the length of hospital stay, multivariable linear regression analysis was performed adjusting for covariates. p-values were two-sided; a significance level of p < 0.05 was used. RESULTS Clinical Characteristics In the 11-year period between May 1, 2005 and June 30, 2016, 17 patients underwent esophageal resections (7 robotic-assisted and 10 open) who had a postoperative significant chylothorax, which is 1.3% of the total 1324 esophageal surgical resections performed during the same time period, similar to the 2% rate in the literature.( 2 , 3 ) In the 17-year period, January 1, 2004 and June 30, 2021, 52 patients underwent lung resections (25 robotic-assisted and 27 open) who had a postoperative significant chylothorax, which represents 1.7% of the total 3058 lung resection performed, similar to the 2.3% rate in the literature.( 2 , 3 ) The time periods and cut-off dates were chosen in order to obtain all patient data and long-term follow-up data. The clinical characteristics of these two patient populations is shown in Table 1 . 94% of esophageal surgery patients underwent neoadjuvant chemoradiotherapy, 70% were current or former smokers, and 53% of tumors were adenocarcinomas. 83% of lung resection patients were current or former smokers, 60% of patients had an adenocarcinoma, and 48% of patients had a robotic-assisted approach. Of the total 1382 lung resection patients during that time period who had a robotic assisted approach, 1.5% had a chylothorax versus 1.6% for the 1676 open cases, which is contrary to the higher incidence of chylothorax after a robotic-assisted lung resection.( 3 ) Table 1 Chylothorax Patient Characteristics (N = 69) Patient Characteristics Value Esophageal Surgery, N = 17 -- Age at Surgery, years, mean ± SD, (range) 61 ± 11.3 (48–75) Gender -- Female 3 (17.6%) Male 14 (82.4) Race -- White 17 (100%) African American 0 Asian, Indian, Pakistani 0 Other 0 Diabetes, yes (%) 2 BMI, kg/m 2 , mean ± SD, (range) 23.1 ± 5.1 (15-31.4) Smoking Status -- Current 8 (47.1%) Former 4 (23.5%) Never-smoker 5 (29.4%) Pack-years (current or former smokers), mean ± SD, range 42.8 ± 36.3 (10–150) Ethanol Intake Daily (%) 14 (82.4%) Neoadjuvant Therapy 16 (94.1%) Esophageal Surgery Type -- Open 10 (58.8%) Robotic/VATS 7 (41.2%) Cancer Cell Type -- Adenocarcinoma, No. (%) 9 (52.9%) Squamous Cell Carcinoma, No. (%) 8 (47.1%) Lung Surgery, N = 52 -- Age at Surgery, years, mean ± SD, range 66 ± 12.8 (29–92) Gender (%) -- Female 28 (53.8%) Male 24 (464.2%) Race (%) -- White 46 (88.%) African American 2 (3.8) Asian, Indian, Pakistani 4 (7.7%) Other 0 Diabetes, yes (%) 2 (3.8%) Smoking Status (%) -- Current 13 (25%) Former 30 (57.7%) Never 9 (17.3) Pack-years (current or former smokers), mean ± SD, (range) 45.9 ± 32.4 (1.5–150) Neoadjuvant Therapy 10 (19.2%) Ethanol Intake Daily 13 (25%) Lung Surgery Type (%) -- Right upper lobectomy 22 (42.3%) Right middle lobectomy 1 (1.9%) Right lower lobectomy 6 (11.5%) Left upper lobectomy 8 (15.4%) Left lower lobectomy 3 (5.8%) Bilobectomy 2 (3.8%) Pneumonectomy 1 (1.9%) Segmentectomy 4 (7.7%) Wedge 5 (9.6%) *Superior sulcus tumor (Pancoast tumor) 8 (15.4%) Surgical Approach (%) -- Open thoracotomy 27 (51.9%) Robotic/VATS 25 (48.1%) Cell Type (%) -- Adenocarcinoma 31 (59.6%) Squamous Cell 8 (15.4%) Other 11 (21.2%) Benign 2 (3.8%) Abbreviations: SD: Standard deviation; VATS: Video assisted thoracic surgery. *Case number larger since Pancoast patients had a lobectomy or segmentectomy. Positive Treatment Outcome A positive treatment outcome ( Table 2 ) in the esophageal surgery group appeared numerically related to using TPN (18%), MCT enteral tube diet (18%), or in performing a surgical ligation of the thoracic duct (35%). For the lung surgery patients, the numerically most effective treatment was octreotide/midodrine (29%), surgical ligation of the thoracic duct (23%) and the performance of a lymphangiogram with embolization combined with octreotide (19%). All esophageal and lung resection patients had a complete chylothorax resolution before hospital discharge with the single or combination treatments listed in Table 3 . Seven patients (10%) had an in-hospital recurrence of their chylothorax after the first postoperative treatment and required a completely different procedure for control. There were no chylothorax recurrences after hospital discharge, followed for at least one year. Table 2. Chylothorax Treatment with an Ultimate Positive Outcome (N=69) Intervention No. Patients (%) Esophageal Surgery N=17 -- Total Parenteral Nutrition (TPN) 3 (17.6%) TPN (and Octreotide) 1 (5.9%) TPN (and Lymphangiogram with Embolization) 1 (5.9%) Medium chain triglyceride diet (Tube or oral) -- Tube 3 (17.6%) Oral 0 Octreotide and MCT diet 1 (5.9%) Octreotide 1 (5.9%) Surgical Ligation of Thoracic Duct 6 (35%) Thoracentesis (and Medium Chain Triglyceride Diet) 1 (5.9%) Lung Surgery N=52 -- Total Parenteral Nutrition (TPN) 0 Octreotide/Midodrine 15 (28.8%) Medium chain Triglyceride (MCT) diet (Tube or oral) -- Tube 0 Oral 8 (15.4%) Surgical Ligation of Thoracic Duct 12 (23.1%) Thoracic Duct Ligation (and Talc Pleurodesis) 1 (1.9%) Talc Pleurodesis 3 (5.8%) Medium Chain Triglyceride Diet (and Talc Pleurodesis) 2 (3.8%) Intra-abdominal Procedure (Thoracic Duct Ligation) 1 (1.9%) Lymphangiogram with Embolization 8 (15.4%) Lymphangiogram (and Thoracic Duct Ligation) 2 (3.8%) Abbreviations: MCT=Medium chain triglyceride; TPN= Total parenteral nutrition. Treatment in parentheses were considered an adjunct to the primary therapy. Chylothorax Presentation For the esophageal patients, all chyle leaks were on the right side and began on the mean 7 th postoperative day. (Table 3) The chyle drainage was high, more than 2-3 liters per day. Most chest drainage tubes remained in place a mean 3 weeks and the mean hospital stay was 24 days. There was one operative mortality from respiratory failure. Table 3. Chylothorax Presentation and Outcome (N=69) Value No. Patients (%) Esophageal Surgery N=17 -- Location of Chyle Leak -- Left chest 0 Right chest (%) 17 (100%) Onset with Beginning Oral Intake (yes) 2 (12%) Postoperative Day of Onset, mean±SD, (range) 7±3 (4-15) Maximum Daily Chest Tube Drainage, ml±SD, (range) 2634±2633 (129-10700) Days Chest Drainage Tubes in Place, mean±SD, (range) 21±22 (8-45) Total Hospital Days, mean±SD, (range) 24±11 (8-45) Hospital Mortality 1 (6%) Lung Surgery, N=52 -- Location of Chyle Leak -- Left chest 12 (23.1%) Right chest 40 (76.9%) Onset with Beginning Oral Intake (yes) 11 (21.2%) Postoperative Day of Onset, mean±SD, (range) 5.3±11.2 (1-59) Maximum Daily Chest Tube Drainage, mean±SD, (range) 1179±1238 (26-6800) Days Chest Drainage Tubes in Place, mean±SD, (range) 11.2±13.9 (2-95) Total Hospital Days, mean±SD, (range) 12.1±14.1 (3-95) Mortality (%) 1 (1.9%) For the lung resection patients, 77% of the chyle leaks were from the right side of the chest and started on the mean 5 th postoperative day. The daily drainage was less than esophageal patients with a mean 1100 ml/day and the drainage tubes remained in place for less time (mean 11 days). Likewise, the hospital stays were shorter (mean 12 days). There was one hospital mortality from acute respiratory distress syndrome in a right pneumonectomy patient. Association of Treatment with Outcomes We compared the outcomes of the major treatment modalities (surgical thoracic duct ligation, octreotide, midodrine, TPN, MCT diet and lymphangiogram) and operative factors on chylothorax recurrence, chest tube duration and hospital stays with a multivariable analysis. Chylothorax recurrence : there was no significant difference in the initial treatments or the demographic characteristics between the 7 patients with chylothorax recurrence and the 62 patients without it. ( Supplementary Table 1 ). Chest Tube Days: Robotic surgery and midodrine use significantly reduced the number of chest tube days while surgical duct ligation and TPN significantly increased the number of chest tube days (Wilcoxon rank sum test p < 0.05). Univariable linear regression analysis showed patients treated by surgical duct ligation have a significantly longer duration of chest tubes in place. However, midodrine treated patients had significantly shorter chest tube days (b=-10.37, p=0.009). Nevertheless, by multivariable regression analysis, theses modalities are not significant factors in chest tube duration. ( Supplementary Table 2 ) Hospital Days : Surgical duct ligation, lymphangiogram and TPN significantly increased the hospital stay. While use of midodrine, octreotide and MCT diet are significantly associated with decreased hospital stay by 11, 8.2 and 6.4 days (Wilcoxon rank sum test p < 0.05; Supplementary Figure 1 ). By univariable linear regression analysis, patients who were treated with octreotide and midodrine have a shorter hospital stay than those who were not. However, those treatments are not significant in multivariable analysis adjusted for covariates. An increased BMI is associated with a shorter hospital stay (b=-0.940, p=0.01)( Supplementary Table 3; Supplementary Figure 1). DISCUSSION A postoperative chylothorax is an uncommon but well-characterized complication of intrathoracic surgery, usually from disruption of thoracic lymphatics during a mediastinal dissection. In our series of 17 esophageal resections and 52 lung resections, the patients developed a chyle leak from disruption of the lymphatics and/or thoracic duct, with high triglyceride and an elevated lymphocyte content, requiring an aggressive approach to control the drainage. High volume leaks require prompt treatment to prevent immunosuppression and potential mortality from lymphocyte and protein loss in the fluid. Anatomy Chyle, with its characteristic milky appearance, contains chylomicrons, triglycerides, cholesterol and fat-soluble vitamins derived from the intestinal lacteal system, combined with lymphatic drainage containing immunoglobulins, enzymes and lymphocytes from the intestine, liver, abdominal wall and lower extremities. This high-protein, electrolyte-rich fluid containing up to 6800 white blood cells/milliliter is carried superiorly into the confluence of the lymphatics termed the cisterna chyle, a lymphatic sac arising at the second lumbar vertebra posterior to the right side of the abdominal aorta. Medium-chain fatty acids (which make up medium-chain triglycerides) contain less than 10 carbon atoms in the chain and are directly absorbed into the portal venous system. Therefore, a medium chain triglyceride diet bypasses the cisterna chyle and the thoracic duct.(6) Approximately 2500 ml of chyle daily flows(7) through the cisterna chyle up the 36-45 mm long thoracic duct(2-3 mm diameter) which enters the chest through the median arcuate ligament traveling between the azygous vein and aorta in the right hemithorax, crossing over to the left side at T5, and ascends posterior to the aortic arch and anterior to the left subclavian vein where it enters the venous circulation. This pattern has significant variations in over 40% of people, frequently with bilateral ducts. These variations explain why even meticulous care at surgery may result in thoracic duct interruption with chyle leakage, in the right and left hemithorax. Often the chyle leakage from the thoracic duct injury will not become apparent for 2-7 days as fluid will build up in the posterior mediastinum and only become apparent with parietal pleura rupture. Figure 1 illustrates common thoracic duct anatomic variations. Chylothorax Treatment Options A variety of treatment options have been described, listed in Table 4. Table 4. Chylothorax Treatment Options Publication Treatment Schild HH, et. al.(8) NPO (nil per os) plus Total Parenteral Nutrition (TPN) Holm-Webber T, et. al.(9) Al-Zubaury AS, et.al.(10) Kelly, RF, et. al.(11) Octreotide Ur Rehman, K, et. al.(12) Midodrine Hashim SA, et. al.(13) Tedjaatmadja C, et. al.(14) Medium Chain Triglyceride Diet (oral or tube feeding) and Elemental Diet Schild HH, et. al.(8) Thoracentesis McGrath EE, et. al.(5) Talc Pleurodesis Nair S, et. al.(6) McGrath EE, et. al.(5) Pleurectomy Bryant AS, et. al.(3) Nair S, et. al.(6) Surgical Thoracic Duct Ligation Sziklavari, Z, et. al.(16) Radiotherapy Artemiou, O, et. al.(17) Pleurovenous Shunt Kariya, S. et. al.(18) Jardinet, T, et. al.(19) Sheybani A, et. al.(20) Nadolski GL, et. al.(21, 22) Boffa DJ, et. al.(23) Lee, CW, et. al.(28) Lymphangiogram Lipiodol â with thoracic duct embolization Lipiodol â with cisterna chyli maceration Lipiodol â instillation only Mason PF, et. al.(24) Vassallo BC, et. al.(25) Schumacher G, et. al.(26) Robinson LA, et. al.(27) Intraabdominal surgical procedure NPO and TPN Once it becomes obvious that there is a significant leak of chyle with milky drainage with an elevated triglyceride level(>110 mg/dL) which usually peaks 3 hours after eating, the first conservative step is to promptly reduce the lymph flow by stopping oral intake of a fat-containing diet and focusing on adequate fluid, nutrition and electrolyte balance with total parenteral nutrition.(8) Unfortunately, even though the chyle drainage will generally diminish rapidly, these measures rarely are adequate since most lymph leaks will not close up spontaneously. Nevertheless, this TPN-only technique was successful in 3 (17%) of our esophageal resection patients but none of our lung resection patients. Octreotide and Midodrine The preferred pharmacologic approach to a chylothorax is beginning octreotide(a somatostatin analog) subcutaneously 20-40 mcg/kg/day for 3-4 days which acts to decrease chyle production by improving lymphatic fluid transport,(9) reducing the intestinal absorption of fats, mainly triglycerides and increasing fecal fat excretion.(10, 11) This drug is well-tolerated short term and rarely is there hypotension or hyperglycemia although hypoglycemia can occur after octreotide is discontinued and requires treatment with intravenous dextrose. Gastrointestinal side effects of nausea and vomiting, abdominal pain, constipation, headaches, bradycardia and dizziness rarely occur but require monitoring. The other pharmacologic option, usually given along with octreotide, is midodrine. This drug is an alpha-1 adrenergic agonist that stimulates the smooth muscle in lymphatic vessels which then constricts lymphatic vessels and reduces chyle flow.(12) This drug is usually given in doses of 10-20 mg orally 3-4 times daily. The only recommended therapeutic use of midodrine is for chronic hypotension treatment so patients need to be monitored for hypertension as a side effect. In the current series, octreotide was effective in controlling the chylothorax when either used alone or in conjunction with TPN or MCT diet in 3(17.6%) of our esophageal resection patients. Octreotide plus midodrine was quite effective when used together in 15(28.8%) of our lung resection patients. Medium Chain Triglyceride Diet and Elemental Diet Use of a medium chain triglyceride(MCT) diet is an attractive option first described 60 years ago by S. A. Hashim and colleagues whereby nutrition is maintained while the fat portion of the diet, the triglycerides, are absorbed directly into the portal venous system bypassing the cisterna chyle and thoracic duct.(13) A MCT diet almost always is generally superior to TPN since the positive results are usually seen more rapidly, although it still may require weeks for resolution of the chylothorax.(14) The MCT diet is essentially a variant of a ketogenic diet and generally is fairly palatable orally although some may experience gastrointestinal side effects of vomiting, diarrhea, bloating and cramps. However, providing the MCT diet through a feeding tube usually obviates these side effects. An option reserved for tube feeding which provides the same effect as a MCT diet is the elemental diet which consists of pre-digested nutrients such as amino acids, medium chain triglycerides, electrolytes, vitamins, and simple sugars which provides these nutrients in their most basic form. It is more readily tolerated as a tube feeding since nausea is a common side effect if given orally. Our group has found the high calorie elemental diet Peptamen â 1.5 (Nestle Health Science U.S., Bridgewater, NJ) tube feeding supplement to be quite effective in our esophageal tumor patients with 3(17.6%) having a complete response with resolution of the chyle leak. In our lung resection patients, 10 (19.2%) had complete resolution of their chylothorax with an oral MCT diet with minimal side effects. Thoracentesis and Talc Pleurodesis Repeated thoracentesis is generally reserved only for patients where this procedure is needed only short-term for treatment of the underlying chyle leak, and where the buildup of pleural fluid is slow, thereby allowing for ideal pulmonary expansion. In one esophageal resection patient and one lung resection patient with a slow chyle leak, thoracentesis with concomitant MCT diet was effective in controlling the leak. Occasionally repeated thoracentesis plus a talc or doxycycline pleurodesis may be effective, although the pleurodesis is more likely to be effective if the chest remains continuously drained with a chest tube to allow effective pleural symphysis. Surgical Thoracic Duct Ligation and Pleurectomy Since a postoperative chylothorax, especially with high-volume drainage, may result in immunosuppression and malnutrition, a prompt operation with surgical thoracic duct ligation is definitely indicated, performed preferably by a minimally invasive approach although open thoracotomy is quite effective. Administration of cream or olive oil through a nasogastric tube at the start of the procedure may help identify the thoracic duct and/or the area of leak, which is usually at the level of the inferior pulmonary vein. However, since the thoracic duct is only 2-3 mm in diameter, is usually quite thin and white, and difficult to definitely locate, we generally recommend mass ligation of all of the tissue from the azygous vein over to the aorta posteriorly and to the esophagus medially just superior to the diaphragm. While specific identification of the actual duct is feasible, there is a significant chance for inadvertent duct disruption and continued leakage. In our 17 esophageal resections, 5 of the 6 thoracic duct ligations were performed with an open thoracotomy with no recurrent chylothoraces. In our lung resection group, 15(29%) of the total had a thoracic duct ligation with 11 undergoing the procedure by open thoracotomy with no recurrences or complications. And one additional patient had a talc pleurodesis and a pleurectomy performed at the time of thoracic duct ligation with no recurrence. Unless the chylothorax has been present for an extended period of time with inadequate drainage of fluid, a pleurectomy is rarely necessary for lung expansion. Although we had good results with surgical thoracic duct ligation, later in our series we found that our highly-experienced interventional radiologists were also quite adept with the less invasive, lymphangiogram with embolization, which avoided this second surgical approach. Nevertheless, others including J.S. Reisenauer and colleagues found surgical thoracic duct ligation more effective than thoracic duct embolization, although 14% of their surgical duct ligation patients had significant in-hospital morbidity.(15) Radiotherapy Z. Sziklavari and associates reported a series of 7 patients who had a more conservative approach to their chylothorax with pleural fluid tube drainage with full lung expansion to promote adhesion to the area of duct injury and nutritional support followed by “radiotherapy which consisted of opposed isocentric portals to the mediastinum using 15 MV photon beams from a linear accelerator, a single dose of 1–1.5 Gy, and a maximum of five fractions per week. The radiation target area was the anatomical region between TH3 and TH10 depending on the localization of the resected lobe. The mean doses of the ionizing energy was 8.5 Gy ± 3.5 Gy.”(16) They began radiotherapy on the 4 th day after chylothorax diagnosis and radiation was successful in all 7 patients with a median discharge date 3 days after the completion of radiotherapy. Although they had no long-term recurrences of the chylothorax, there are the theoretical complications of pneumonitis and even potential for secondary malignancy or esophageal fibrosis/stricture with this low dose radiotherapy, although they reported no long-term side effects. In our series, anecdotally, we employed this technique of radiotherapy unsuccessfully in a left-sided chylothorax patient with aberrant thoracic duct anatomy. Pleurovenous Shunts Pleurovenous shunts for treatment of refractory chylothoraces and other right-sided pleural effusions have been described using a Denver shunt system (Denver Biomedical, Inc, Denver, CO) in which the system is implanted from the pleural cavity to either subclavian or jugular vein.(17) In this 12-patient series, there was one shunt occlusion at 4 weeks but the rest of the systems were patent over an observation period of 1-40 months with no recurrence. Although the potential complications of the device and the procedure are bleeding, air embolism, infection, or occlusion, there was only one long term occlusion, suggesting that this is an attractive treatment alternative to be considered for non-malignant pleural effusions that requires only an easy, short procedure for use in high-risk patients. Lymphangiogram with Embolization or Cisterna Chyle Disruption An attractive, minimally invasive approach to chylothorax control is offered by experienced interventional radiologists employing percutaneous thoracic duct embolization(TDE). First described in 1999, this technique uses bilateral pedal (inter-digital) lymphangiogram for a high-output chylothorax.(17) This technique is quite time-consuming requiring substantial time for the contrast to travel from the foot to thoracic duct. However, over the last several decades, bilateral pedal lymphangiogram has fallen out of favor, likely due to the technical difficulty involving cannulation of the small lymphatic channels in the feet after a cutdown with high risk of rupture and extravasation, need for suturing the feet afterwards, and risk of post procedural infections. In addition, it is time-consuming as it takes about 3 hours for the contrast to reach the groins from the feet. These problems have been largely solved by the use of the latest ultrasound equipment which allow puncture of non-palpable lymph nodes in the groin for intranodal lymphangiograms(INL) using Lipiodol â which is an iodinated poppy seed oil that allows the visualization of lymphatic vessels and opacification of cisterna chyle usually at the level of L3 vertebra.(18) As opposed to pedal lymphangiography which takes many hours, the visualization of cisterna chyle by intranodal lymphangiography occurs in about an hour. T. Jardinet and associates(19) described their 18-patient experience with refractory postoperative chylothorax using intranodal lymphangiography using only Lipiodol â , where they were successful in 17 of 18 patients. There is a definite higher success rate with just INL, even in lower output chyle leaks. It is felt that the viscous Lipiodol â accumulates at the leakage point leading to an inflammatory reaction with embolic effect. Alternatively, saturation of the central lymphatic system with Lipiodol â may force the lymph to find an alternative route through existing peripheral lymphovenous connections, eventually leading to a reduced thoracic duct flow rate. There are no documented reports of toxic side effects from a maximum dose of 20 ml Lipiodol â . Theoretically, if all the contrast of a larger dose goes to the subclavian vein and ends up in the lung, the patient might get lipid pneumonitis.(20) Thoracic duct and cisterna chyle embolization requires a more invasive procedure with a good technical success rate, generally better than just a lymphangiogram. Once the cisterna chyle and thoracic duct are canulated, platinum embolization coils or N-butylcyanoacrylate glue is used to occlude the thoracic duct. In a series of 50 patients with a chylous leak, G. Nadolski and associates successfully resolved the chylous leak in 49(96%) of patients,(21) using pedal lymphangiography in 28 patients and intranodal lymphangiography in 22 patients. However, “intranodal lymphangiography has been demonstrated to be a superior alternative to traditional pedal lymphangiography for thoracic duct embolization(TDE). In fact, TDE is associated with less morbidity and better clinical success than conservative management or surgical intervention in both traumatic and nontraumatic causes of chylothorax.”(22) The authors emphasize that the results are operator-dependent based on experience, and that results will not necessarily be possible in all practice settings. Likewise, percutaneous access of the cisterna chyle via a transhepatic approach using a 20 cm 22-gauge Chiba needle is another feasible yet rarely used approach to inject coils or glue. But disruption of the cisterna chyle or neighboring retroperitoneal lymphatics although feasible is associated with local extravasation of chyle with potential transdiaphragmatic leakage and is not recommended. Theoretically, creation of a controlled chyle leak into the intact retroperitoneum distal to the thoracic duct leak will divert flow to collaterals, but this mechanism is reported as questionable because the need for reoperation in nearly one-quarter of patients in a series of 36 patients by D. J. Boffa and associates.(23) They report that “percutaneous treatment by thoracic duct embolization or disruption is safe and may obviate reoperation, but embolization of the thoracic duct is preferable to its disruption.”(23) In our surgical series, only one esophageal patient had successful lymphangiogram with embolization. However, we were much more successful with 10 (19%) of lung resection patients having chylothorax control with lymphangiogram techniques. We did have complication of a percutaneous cisterna chyle disruption patient who required reoperation for transdiaphragmatic leakage of massive amounts of chyle into the right thoracic cavity. Intrabdominal Surgical Procedures P. F. Mason and associates first described an intraabdominal surgical approach for treatment of chylothorax involving ligation of the thoracic duct at the level of the diaphragmatic hiatus,(24) with success in 4 of 5 patients and resolution of the leak within 24 hours in all patients. Subsequently B. C. Vassallo and colleagues(25) described laparoscopic thoracic duct ligation from a lithotomy position dividing the gastrohepatic omentum and dissecting the left and right crus to identify the esophagus, to recognize and ligate the thoracic duct along the right side of the aorta. G. Schumacher and colleagues later described their positive experience with 10 patients using transabdominal ligation of the thoracic duct,(26) which they felt was a simple and safe method to treat postoperative chylothorax. However, the most challenging patients who may benefit from a minimally invasive transabdominal approach are those with aberrant thoracic duct anatomy. One of our lung resection patients with a refractory high volume left chylothorax who had failed transthoracic surgical thoracic duct ligation underwent a transnodal CT lymphangiogram which demonstrated an aberrant left thoracic duct in the subdiaphragmatic area to the left of the aorta extending to the anterior vertebral body, similar to the aberrant anatomy in the superior left illustration in Figure 1. Through a very small upper abdominal incision, the anomalous thoracic duct was ligated along the vertebral body with complete control of the chylothorax. Figure 2 shows the lymphangiogram illustrating this aberrant ductal anatomy . This lymphangiogram-directed surgical technique has been described(27) and should be applicable to other patients found to have aberrant thoracic duct anatomy when all other techniques fail. C.W. Lee and colleagues(28) have reported a case adding dynamic magnetic resonance(MR) lymphangiography to provide anatomic information to identify the cisterna chyli and a basic structural assessment of the thoracic duct to help guide conventional thoracic duct lymphangiography with embolization, but they admit that it is difficult with MRI to locate the site of leakage. They felt that a patient with prior major intraabdominal surgery might benefit with initial MR lymphangiography before proceeding with conventional lymphangiography. LIMITATIONS This series has significant limitations in that it is a retrospective study with a small 69-patient sample size and as well there is a certain amount of crossover in treatment decisions. The linear regression analysis of our treatment modalities described in the Results was only minimally helpful likely due to a small sample size. Ideally a randomized trial would overcome the surgeon bias that led to arbitrary management decisions, but no such trials are published. Despite these deficiencies, the therapeutic recommendations are still valid particularly with our 100% in hospital success rate. CONCLUSION The development of an iatrogenic chylothorax in an esophageal or lung resection patient is potentially a life-threatening event(1) if not treated promptly, particularly if there is a high-volume leak. Based on our experience with a series of 69 consecutive chylothorax patients over 17 years and the results in the published literature, we recommend an aggressive approach following the treatment algorithm in Figure 3, which has given us the optimal results and a minimal complication rate. For most patients, we favor obtaining prompt long-term chylothorax control with either a lymphangiogram-based treatment or surgical thoracic duct ligation. Conservative management with a medium chain triglyceride diet, octreotide and midodrine is appropriate initially, if there is a quick response, but we recommend moving promptly to more invasive methods if there is any evidence of progression or a failed treatment response. Abbreviations Gy: Gray INL: Intranodal lymphangiogram MCT: Medium chain triglyceride (diet) MV: Megavolt NPO: Nil per os NSCLC: Non-small cell lung cancer SD: Standard deviation TDE: Thoracic duct embolization TPN: Total parenteral nutrition VATS: Video-assisted thoracic surgery Declarations Human Ethics and Consent to Participate: Not applicable . ( This retrospective study was approved by the Advarra IRB Pro00020692, IRB # 00000971, February 26, 2021, and individual consent was waived by the IRB in this retrospective case review.) Consent for publication: Not applicable. Availability of data and materials: The datasets generated and/or analyzed during the current study are not publicly available due to patient confidentiality but are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests in this section. Funding: This research did not receive any specific grant from funding agencies in the public, commercial or non-profit sectors. Author Contributions: Conceptualization: LR, NR Data curation: LR, NR, YK Formal analysis: LR, NR, YK Funding acquisition: n/a Investigation: LR Methodology: LR, YK Project administration: LR Resources: LR, NR, YK Software: n/a Supervision: LR Validation: LR, YK Visualization: LR Writing – original draft: LR, YK, GH, BK Writing – review & editing: LR, NR, YK, AB, GE, JF, ET, SF, JB, SB, TS, BK Author Information: The first author is L.R., who is a practicing thoracic surgeon for over 40 years. He is Professor of Surgery in the Division of Thoracic Oncology, Director, Lung Cancer Early Detection (LEAD) Center and the Indeterminant Lung Nodule Clinic, Moffitt Cancer Center, Tampa, FL References Porcel JM, Bielsa S, Civit C, Aujayeb A, Janssen J, Bodtger U et al. Clinical characteristics of chylothorax: results from the International Collaborative Effusion database. ERJ Open Res. 2023;9(5). Sarkaria IS, Finley DS, Bains MS. Chylothorax and recuyrrent laryngeal nerve injury associated with robotic video-assisted mediastinal lymph node dissection. Innovations (Philadelphia). 2015;10:170–3. Bryant AS, Minnich DJ, Wei B, Cerfolio RJ. The incidence and management of postoperative chylothorax after pulmonary resection and thoracic mediastinal lymph node dissection. Ann Thorac Surg. 2014;98:232–7. Takuwa T, Yoshida J, Ono S. Low-fat diet management strategy for chylothorax after pulmopnary resection and lymph node dissection for priomary lung cancer. J Thorac Cardiovasc Surg. 2013;146:571–4. McGrath EE, Blades Z, Anderson P. Chylothorax: Aetiology, diagnosis and therapeutic options. Respir Med. 2009;104:1–8. Nair S, Petko M, Hayward MP. Aetiology and management of chylothorax in adults. Europ J Cariothoracic Surg. 2007;32:362–9. Ilczyszyn A, Ridha H, Durrani AJ. Management of chyle leak post neck dissection: A case report and literature review. J Plast Reconstr Aesthetic Surg. 2011;64:e223–30. Schild HH, Strassburg CP, Welz A, Kalff J. Treatment options in patients with chylothorax. Dtsch Arztebl Int. 2013;110(48):819–26. Holm-Weber T, Skov F, Mohanakumar S, Thorup L, Riis T, Christensen MB et al. Octreotide improves human lymphatic fluid transport a translational trial. Eur J Cardiothorac Surg. 2023;65(1). Al-Zubaury SA, Al-Jazairi AS. Octreotide as a therapeutic option for management of chylothorax. Ann Pharmacother. 2003;37:679–82. Kelly RF, Shumway S. Conservative management of postoperative chylothorax using somatostatin. 2000;69:1944–5. Ur Rehman K, Ahmed L, Sivakumar P. Refractory chylothorax: Midodrine as a novel therapeutic option. Eur Respir J.58(suppl 65):PA3142. Hashim SA, Roholt HB, Babayan VK, Van Itallie TB. Treatment of Chyluria and Chylothorax with Medium-Chain Triglyceride. New Engl J Med. 1964;270:756–61. Tedjaatmadja C, Wulandari Y. Enteral nutrition with medium-chain triglyceride compared to total parenteral nutrition in patient with chylothorax. World Nutr J. 2024;7(2). Reisenauer JS, Puig CA, Reisenauer CJ, Allen MS, Bendel E, Cassivi SD, et al. Treatment of Postsurgical Chylothorax. Ann Thorac Surg. 2018;105(1):254–62. Sziklavari Z, Allgäuer M, Hübner G, Neu R, Ried M, Grosser C, et al. Radiotherapy in the treatment of postoperative chylothorax. J Cardiothorac Surg. 2013;8:72. Artemiou O, Marta GM, Klepetko W, Wolner E, Müller MR. Pleurovenous shunting in the treatment of nonmalignant pleural effusion. Ann Thorac Surg. 2003;76(1):231–3. Kariya S, Komemushi A, Nakatani M, Yoshida R, Kono Y, Tanigawa N. Intranodal lymphangiogram: technical aspects and findings. Cardiovasc Intervent Radiol. 2014;37(6):1606–10. Jardinet T, Veer HV, Nafteux P, Depypere L, Coosemans W, Maleux G. Intranodal Lymphangiography With High-Dose Ethiodized Oil Shows Efficient Results in Patients With Refractory, High-Output Postsurgical Chylothorax: A Retrospective Study. Am J Roentgenol. 2021;217(2):433–8. Sheybani A, Gaba RC, Minocha J. Cerebral Embolization of Ethiodized Oil following Intranodal Lymphangiography. Semin Intervent Radiol. 2015;32(1):10–3. Nadolski GJ, Itkin M. Lymphangiography and thoracic duct embolization following unsuccessful thoracic duct ligation: Imaging findings and outcomes. J Thorac Cardiovasc Surg. 2018;156(2):838–43. Nadolski G, Itkin M. Thoracic duct embolization for the management of chylothoraces. Curr Opin Pulm Med. 2013;19(4):380–6. Boffa DJ, Sands MJ, Rice TW, Murthy SC, Mason DP, Geisinger MA, et al. A critical evaluation of a percutaneous diagnostic and treatment strategy for chylothorax after thoracic surgery. Eur J Cardiothorac Surg. 2008;33(3):435–9. Mason PF, Ragoowansi RH, Thorpe JA. Post-thoracotomy chylothorax–a cure in the abdomen? Eur J Cardiothorac Surg. 1997;11(3):567–70. Vassallo BC, Cavadas D, Beveraggi E, Sivori E. Treatment of postoperative chylothorax through laparoscopic thoracic duct ligation. Eur J Cardiothorac Surg. 2002;21(3):556–7. Schumacher G, Weidemann H, Langrehr JM, Jonas S, Mittler J, Jacob D, et al. Transabdominal ligation of the thoracic duct as treatment of choice for postoperative chylothorax after esophagectomy. Dis Esophagus. 2007;20(1):19–23. Robinson LA, Fontaine J, El-Haddad G, Bryant S, Perez B, Toloza E, et al. Novel Subdiaphragmatic Ligation of Left Thoracic Duct for Refractory Postoperative Left Chylothorax. Ann Thorac Surg. 2022;113(1):e29–31. Lee CW, Koo HJ, Shin JH, Kim MY, Yang DH. Postoperative chylothorax: The use of dynamic magnetic resonance lymphangiography and thoracic duct embolization. Invest Magn Reson Imaging. 2018;22:182–6. Additional Declarations No competing interests reported. Supplementary Files Supp.Figure1.jpg Supplementary Figure 1. Hospital Days Comparing Patients Who Received the Intervention (1) versus Patients Who Didn’t (0), Using Wilcoxon Rank Sum Supp.Table1.docx Supp.Table2.docx Supp.Table3.docx Cite Share Download PDF Status: Published Journal Publication published 20 Apr, 2026 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted Editorial decision: Revision requested 24 Mar, 2026 Reviews received at journal 10 Feb, 2026 Reviewers agreed at journal 29 Jan, 2026 Reviewers agreed at journal 27 Jan, 2026 Reviews received at journal 27 Jan, 2026 Reviews received at journal 23 Jan, 2026 Reviewers agreed at journal 23 Jan, 2026 Reviewers agreed at journal 21 Jan, 2026 Reviewers invited by journal 20 Jan, 2026 Editor assigned by journal 28 Oct, 2025 Submission checks completed at journal 28 Oct, 2025 First submitted to journal 21 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7919123","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":578006713,"identity":"2749302f-244b-4e43-a2a9-ca7468acd1e7","order_by":0,"name":"Lary A. Robinson","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBUlEQVRIiWNgGAWjYBACPiidwAamKhgY2JsPNuDVwoaq5QwDA8+xxMaGA8RoAZOMbSAtCYz4tbCffSbBuMcmj0+6/eHjwnnb5HjYmNsff2CwyZd3wKGFJ91MguFZWjGbzBlj45nbbhvzsDGCHJZmuRGHVWwMaWwSDAcOJ7ZJ5LBJ8267nbhfvhGk5bCBYQMOLfzPYFrSn0nzzrmd2AOxBY8WCbgtCWbSvA1IWuRxeV/iGbNFwgGgXyRyjI15jkH8MuOMQZqBAQ4t/PxpjDc+HLDJk5+R/vAxT81tYIixP/hQUWFjII/DYUDAIpGAKQi0wuAATi3MH7CL47FlFIyCUTAKRhYAAMDrVdDgYLahAAAAAElFTkSuQmCC","orcid":"","institution":"Moffitt Cancer Center","correspondingAuthor":true,"prefix":"","firstName":"Lary","middleName":"A.","lastName":"Robinson","suffix":""},{"id":578006714,"identity":"e2e05cc5-532c-4304-8a32-a1b4b2607977","order_by":1,"name":"Noah A. Robinson","email":"","orcid":"","institution":"Moffitt Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Noah","middleName":"A.","lastName":"Robinson","suffix":""},{"id":578006715,"identity":"07364cc7-cbc9-40c0-82c0-e7976d916295","order_by":2,"name":"Youngchul Kim","email":"","orcid":"","institution":"Moffitt Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Youngchul","middleName":"","lastName":"Kim","suffix":""},{"id":578006716,"identity":"dbeaf748-b859-4efa-b88c-8a28b30d1fc5","order_by":3,"name":"Alexis Bailey","email":"","orcid":"","institution":"Moffitt Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Alexis","middleName":"","lastName":"Bailey","suffix":""},{"id":578006717,"identity":"38b21ca4-8c47-490f-8a89-4f02c8f93f3e","order_by":4,"name":"Ghassan El-Haddad","email":"","orcid":"","institution":"Moffitt Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Ghassan","middleName":"","lastName":"El-Haddad","suffix":""},{"id":578006718,"identity":"e75d4505-426b-4e14-b2f2-710beb0d9ead","order_by":5,"name":"Jacques P. Fontaine","email":"","orcid":"","institution":"Moffitt Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Jacques","middleName":"P.","lastName":"Fontaine","suffix":""},{"id":578006719,"identity":"4e35026c-9994-41f1-8c0f-014f27b5bcbc","order_by":6,"name":"Eric M. Toloza","email":"","orcid":"","institution":"Moffitt Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Eric","middleName":"M.","lastName":"Toloza","suffix":""},{"id":578006720,"identity":"e30f11cd-6be6-4b06-9058-00293f1626b9","order_by":7,"name":"Samuel T. Frealdenhoven","email":"","orcid":"","institution":"Moffitt Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Samuel","middleName":"T.","lastName":"Frealdenhoven","suffix":""},{"id":578006721,"identity":"ba87cc3e-d17e-42a4-bd19-e51cc03df01e","order_by":8,"name":"Jobelle J. A. R. Baldonado","email":"","orcid":"","institution":"Moffitt Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Jobelle","middleName":"J. A. R.","lastName":"Baldonado","suffix":""},{"id":578006722,"identity":"a4697088-fdf4-430f-9fba-f01a47948334","order_by":9,"name":"Sandra Bryant","email":"","orcid":"","institution":"Moffitt Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Sandra","middleName":"","lastName":"Bryant","suffix":""},{"id":578006723,"identity":"14940a86-909e-4b7f-ae43-e1bee1b06e23","order_by":10,"name":"Taylor Schwer","email":"","orcid":"","institution":"Moffitt Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Taylor","middleName":"","lastName":"Schwer","suffix":""},{"id":578006724,"identity":"fc486fdb-d495-4330-a03f-9969d66479e9","order_by":11,"name":"Bela Kis","email":"","orcid":"","institution":"Moffitt Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Bela","middleName":"","lastName":"Kis","suffix":""}],"badges":[],"createdAt":"2025-10-22 08:26:47","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7919123/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7919123/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13019-026-04139-0","type":"published","date":"2026-04-20T16:00:05+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":100949960,"identity":"a5d374fd-7c62-4dc9-86dd-ed8a93e1de3f","added_by":"auto","created_at":"2026-01-23 07:06:32","extension":"tiff","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":1784310,"visible":true,"origin":"","legend":"","description":"","filename":"Figure1ThoracicDuctVariations.tiff","url":"https://assets-eu.researchsquare.com/files/rs-7919123/v1/b3a35f9263b53c6ec3ca288a.tiff"},{"id":101397611,"identity":"63235c11-a69b-4467-9523-f10d592d39f2","added_by":"auto","created_at":"2026-01-29 09:32:26","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":4028903,"visible":true,"origin":"","legend":"","description":"","filename":"102425JCThorSurg.Chylothoraxpaper.docx","url":"https://assets-eu.researchsquare.com/files/rs-7919123/v1/95995f6db0d6899a38dce706.docx"},{"id":100949874,"identity":"c14f82f8-26ad-4f15-a3ec-5ac401edf2ea","added_by":"auto","created_at":"2026-01-23 07:06:08","extension":"tiff","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":32007214,"visible":true,"origin":"","legend":"","description":"","filename":"Figure2Aberrantsubdiaph.tiff","url":"https://assets-eu.researchsquare.com/files/rs-7919123/v1/b9768a475d52ee05ece0436d.tiff"},{"id":102403962,"identity":"4aeb1fd8-ceb5-4128-8b7e-c16f2024841f","added_by":"auto","created_at":"2026-02-11 10:50:31","extension":"jpg","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":334963,"visible":true,"origin":"","legend":"","description":"","filename":"Figure3TreatmentAlgorithm.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7919123/v1/10a6416c84cc5202d82fd2b7.jpg"},{"id":100949853,"identity":"b20a9eb3-90bc-40d1-8ae1-447c418a1d46","added_by":"auto","created_at":"2026-01-23 07:06:02","extension":"json","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":12609,"visible":true,"origin":"","legend":"","description":"","filename":"71cef00940ce43e7943d187f36f88b2a.json","url":"https://assets-eu.researchsquare.com/files/rs-7919123/v1/dca2c8899ebde55205f70e07.json"},{"id":100950295,"identity":"8890cb16-1fc2-43b5-932d-252b65889168","added_by":"auto","created_at":"2026-01-23 07:07:34","extension":"jpg","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":287950,"visible":true,"origin":"","legend":"","description":"","filename":"Supp.Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7919123/v1/09554c703b170e209a2a8f0d.jpg"},{"id":100949473,"identity":"0832d178-5d6c-4e38-a20b-7ac83e9a6d34","added_by":"auto","created_at":"2026-01-23 07:02:54","extension":"docx","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":25573,"visible":true,"origin":"","legend":"","description":"","filename":"Supp.Table1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7919123/v1/e36b4ad83b1cd87d545eab45.docx"},{"id":100949963,"identity":"8719df13-d525-48b0-9998-c304217ac462","added_by":"auto","created_at":"2026-01-23 07:06:33","extension":"docx","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":26899,"visible":true,"origin":"","legend":"","description":"","filename":"Supp.Table2.docx","url":"https://assets-eu.researchsquare.com/files/rs-7919123/v1/92370ea62358e3b3528a5d2f.docx"},{"id":100949885,"identity":"af1b8871-c7eb-48b9-a583-2a6784ba2e48","added_by":"auto","created_at":"2026-01-23 07:06:10","extension":"docx","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":27411,"visible":true,"origin":"","legend":"","description":"","filename":"Supp.Table3.docx","url":"https://assets-eu.researchsquare.com/files/rs-7919123/v1/3cb02939cb6a0ce5dd276285.docx"},{"id":100950296,"identity":"e8941579-4332-4880-aac5-3318836023e6","added_by":"auto","created_at":"2026-01-23 07:07:34","extension":"xml","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":151849,"visible":true,"origin":"","legend":"","description":"","filename":"71cef00940ce43e7943d187f36f88b2a1enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7919123/v1/a35a1a91fed06a770fa8e54b.xml"},{"id":100949898,"identity":"2ddc350c-6632-4392-903d-dc77e8502468","added_by":"auto","created_at":"2026-01-23 07:06:15","extension":"tiff","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":1784310,"visible":true,"origin":"","legend":"","description":"","filename":"Figure1ThoracicDuctVariations.tiff","url":"https://assets-eu.researchsquare.com/files/rs-7919123/v1/9fe2742863e79ce8ae8e233c.tiff"},{"id":100950010,"identity":"5800cda3-35d0-46eb-9012-956ef23dfb2a","added_by":"auto","created_at":"2026-01-23 07:06:41","extension":"tiff","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":32007214,"visible":true,"origin":"","legend":"","description":"","filename":"Figure2Aberrantsubdiaph.tiff","url":"https://assets-eu.researchsquare.com/files/rs-7919123/v1/0bec870fce011efc93c7f5a2.tiff"},{"id":101397685,"identity":"8fffd13e-6ca7-44a3-bb40-c313027a66f8","added_by":"auto","created_at":"2026-01-29 09:35:13","extension":"jpg","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":334963,"visible":true,"origin":"","legend":"","description":"","filename":"Figure3TreatmentAlgorithm.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7919123/v1/3acaa916a034d24583197a62.jpg"},{"id":100949639,"identity":"c01cdabc-85b8-4c1a-a86d-67d335bf5f92","added_by":"auto","created_at":"2026-01-23 07:04:45","extension":"jpeg","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":98845,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7919123/v1/813684c727bdd8e46fc0d227.jpeg"},{"id":100950302,"identity":"cd1f3fcc-98b8-4e1b-986a-6962803191cc","added_by":"auto","created_at":"2026-01-23 07:07:35","extension":"jpeg","order_by":14,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":1784310,"visible":true,"origin":"","legend":"","description":"","filename":"Figure1ThoracicDuctVariations.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7919123/v1/7cc6d5d8848a7fcf895c26d0.jpeg"},{"id":100949903,"identity":"2aafd64d-ccb2-4b26-a50a-19b1e981eb7d","added_by":"auto","created_at":"2026-01-23 07:06:18","extension":"png","order_by":15,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":1481775,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7919123/v1/fecfb2ae6e6844e39489937e.png"},{"id":100950114,"identity":"19872ca1-9fb1-432f-a3b6-b796f06dfa6f","added_by":"auto","created_at":"2026-01-23 07:06:55","extension":"png","order_by":16,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":652946,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-7919123/v1/f97c1b91f2268f80a7a3ba85.png"},{"id":100866525,"identity":"6f29e912-f45e-4d4b-bd5a-a2777a670d75","added_by":"auto","created_at":"2026-01-22 08:34:27","extension":"png","order_by":17,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":176983,"visible":true,"origin":"","legend":"","description":"","filename":"OnlineFigure1ThoracicDuctVariations.png","url":"https://assets-eu.researchsquare.com/files/rs-7919123/v1/e36d6cfa81979d98123eabd3.png"},{"id":100866526,"identity":"1f30baa2-699e-424c-b838-d7952cf27266","added_by":"auto","created_at":"2026-01-22 08:34:27","extension":"png","order_by":18,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":195258,"visible":true,"origin":"","legend":"","description":"","filename":"OnlineFigure2Aberrantsubdiaph.png","url":"https://assets-eu.researchsquare.com/files/rs-7919123/v1/84099640a2e6984eab80e651.png"},{"id":100949455,"identity":"e1d01823-5594-4e8e-9bdc-562700b7741f","added_by":"auto","created_at":"2026-01-23 07:02:38","extension":"png","order_by":19,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":122529,"visible":true,"origin":"","legend":"","description":"","filename":"OnlineFigure3TreatmentAlgorithm.png","url":"https://assets-eu.researchsquare.com/files/rs-7919123/v1/06764adf6a7f5fb17f2e1073.png"},{"id":100949883,"identity":"1ba9fe5c-ffdd-41b5-bc4d-6df370ce760e","added_by":"auto","created_at":"2026-01-23 07:06:10","extension":"png","order_by":20,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":67553,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7919123/v1/57a32bf84086232266bd109c.png"},{"id":102298513,"identity":"0337c506-20bb-494e-94fc-2fb236fdebfb","added_by":"auto","created_at":"2026-02-10 10:41:41","extension":"png","order_by":21,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":176983,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7919123/v1/3e15e912a86c05d26654c9f1.png"},{"id":100950128,"identity":"af0a60a7-6231-4d50-bb8f-dbf02298d874","added_by":"auto","created_at":"2026-01-23 07:06:56","extension":"png","order_by":22,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":109042,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7919123/v1/3a22eb0626426dad5a3a2bb6.png"},{"id":101202472,"identity":"475dbc84-f54e-40a2-89b4-d4717d3d285f","added_by":"auto","created_at":"2026-01-27 09:34:10","extension":"png","order_by":23,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":104007,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-7919123/v1/6c6f2043efff085d2ef9ea67.png"},{"id":100866524,"identity":"03c2f816-8a2c-4d20-9a96-8918be9671fa","added_by":"auto","created_at":"2026-01-22 08:34:25","extension":"xml","order_by":24,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":148951,"visible":true,"origin":"","legend":"","description":"","filename":"71cef00940ce43e7943d187f36f88b2a1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7919123/v1/749ab40616feac6a17b30493.xml"},{"id":100949955,"identity":"5da75a25-0683-403a-bd1b-436fffa37b20","added_by":"auto","created_at":"2026-01-23 07:06:30","extension":"html","order_by":25,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":166081,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7919123/v1/b1679ecee1aba9fc5b0427a5.html"},{"id":100949881,"identity":"c1e783d3-9d6d-4256-9610-d4a243312e8b","added_by":"auto","created_at":"2026-01-23 07:06:09","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":450853,"visible":true,"origin":"","legend":"\u003cp\u003eAnatomic Variations of the Thoracic Duct.\u003cstrong\u003e \u003c/strong\u003e[Reprinted by permission Elsevier Inc. (Corporate Office) 1600 John F Kennedy Boulevard, Suite 1600 Philadelphia, PA 19103 2398]\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7919123/v1/0ad3f05d8129e401f27136f7.png"},{"id":100866503,"identity":"ddf4d33e-a92c-4455-99da-4ccaffe2e960","added_by":"auto","created_at":"2026-01-22 08:34:24","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":608626,"visible":true,"origin":"","legend":"\u003cp\u003eAberrant left thoracic duct (blue arrows) traveling along the left side of the lumbar vertebrae, shown on a nodal lymphangiogram. The yellow arrow points out the blush of Lipiodol in the subcarinal area.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7919123/v1/55b2ba101e5fa9a39d969899.png"},{"id":100950133,"identity":"0e407a00-eeda-45ea-964c-0787622f7e66","added_by":"auto","created_at":"2026-01-23 07:06:57","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":233666,"visible":true,"origin":"","legend":"\u003cp\u003eChylothorax Treatment Algorithm\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7919123/v1/23f21754e0f5b2d8147f40b5.png"},{"id":107929121,"identity":"81233370-edde-4bbd-b713-8f1f28285d93","added_by":"auto","created_at":"2026-04-27 16:13:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1829936,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7919123/v1/ce5f4152-9438-4f2b-adc1-7a9abaa3cc5e.pdf"},{"id":101397628,"identity":"3a5ada29-8f99-40b0-a4d9-72afb1e97a76","added_by":"auto","created_at":"2026-01-29 09:33:16","extension":"jpg","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":287950,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSupplementary Figure 1. \u003c/strong\u003eHospital Days Comparing Patients Who Received the Intervention (1) versus Patients Who Didn’t (0), Using Wilcoxon Rank Sum\u003c/p\u003e","description":"","filename":"Supp.Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7919123/v1/43040961da1f85c5930d92e1.jpg"},{"id":101942739,"identity":"15a16337-1281-4e8a-8279-5ad4fb5cc1c3","added_by":"auto","created_at":"2026-02-05 09:36:26","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":25573,"visible":true,"origin":"","legend":"","description":"","filename":"Supp.Table1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7919123/v1/1245d9a0e51a49b7ad9677c5.docx"},{"id":100950343,"identity":"e877fca9-1a0b-4d7c-9007-d6b626cfce47","added_by":"auto","created_at":"2026-01-23 07:07:45","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":26899,"visible":true,"origin":"","legend":"","description":"","filename":"Supp.Table2.docx","url":"https://assets-eu.researchsquare.com/files/rs-7919123/v1/2495d1c7a665ecb6df396cea.docx"},{"id":100950195,"identity":"d668d140-253b-4120-87dd-b62543d88126","added_by":"auto","created_at":"2026-01-23 07:07:12","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":27411,"visible":true,"origin":"","legend":"","description":"","filename":"Supp.Table3.docx","url":"https://assets-eu.researchsquare.com/files/rs-7919123/v1/9244cd2ea22d987658ae590c.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003ePractical Therapeutic Options for Postoperative Chylothorax\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eA postoperative chylous effusion after a thoracic surgical procedure is an uncommon but persistent problem that plagues all busy thoracic surgeons 2\u0026ndash;3 times per year. This problem represents a serious and potentially fatal complication with a reported mortality as high as 47%(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) when prolonged due to protein loss, malnutrition, electrolyte abnormalities, immunosuppression and sepsis. Reportedly, a significant chylothorax occurs following a thoracic mediastinal lymph node dissection in up to 2% of esophageal resections(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) and 2.3% of lung resections,(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) with a higher incidence in robotic-assisted resections that is felt related to a more extensive lymphadenectomy performed with the robotic-assisted approach.(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) Although a variety of rarer non-surgical causes of a chylous effusion occur from obstruction or interruption of the thoracic duct, this study will focus only on postoperative iatrogenic causes.(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe optimal management of a significant chylous effusion is somewhat controversial and has been changing over time, especially as minimally invasive techniques improve. We chose to retrospectively review our 17-year experience with postoperative chylothorax after lung and esophageal resections to provide a real-world, single institution experience, not to investigate causation but to compare our treatment results and make management recommendations from our personal experience and the published literature.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Subjects\u003c/h2\u003e \u003cp\u003eWe conducted a retrospective cohort study of consecutive esophageal and lung resection patients from May 1, 2005 and June 30, 2016 and lung resection patients from January 1, 2004 and June 30, 2021 at Moffitt Cancer Center, collecting the clinical data on all patients who developed a postoperative chylothorax. We chose these 2 slightly different periods of time where we had complete inpatient and follow-up data on all of the patients for both surgical types. A chylothorax was diagnosed based on pleural fluid drainage containing an elevated triglyceride level\u0026thinsp;\u0026gt;\u0026thinsp;110 mg/dL and the typical milky fluid appearance, generally draining\u0026thinsp;\u0026gt;\u0026thinsp;400 mL per day. All patients underwent a mediastinal lymph node dissection. This retrospective study was approved by the Advarra IRB Pro00020692, IRB # 00000971, February 26, 2021. Individual consent was waived by the IRB in this retrospective case review.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eClinical Data\u003c/h3\u003e\n\u003cp\u003eWe retrospectively reviewed all clinicopathologic features plus the chylothorax data including amount of pleural fluid draining daily, cause of the chylothorax by consensus of at least two surgeons, initial treatment and response, other treatments including surgical treatment, time to resolution of chylothorax, chest tube duration, total hospital days, complications, in hospital recurrences, and mortality. We also reviewed effectiveness documented by resolution of the effusion. Over the course of the study period, 6 faculty thoracic surgeons performed surgery on patients in this series, and they made the treatment decisions for their patients based on their personal experience, and \u003cb\u003enot\u003c/b\u003e a standard institutional protocol. In all surgical cases, lymph nodes were sampled from at least 3 or more lymph node stations with no attempt to calculate lymph node yields.\u003c/p\u003e\n\u003ch3\u003eManagement\u003c/h3\u003e\n\u003cp\u003eThe initial management of all patients with high volume chylous drainage (\u0026gt;\u0026thinsp;1000ml/day) was making the patient nil per os(NPO) and starting total parenteral nutrition(TPN). Octreotide and midodrine were started in all patients and if responsive with chest tube drainage\u0026thinsp;\u0026lt;\u0026thinsp;1000 mL/day, then they were placed on an elemental MCT diet, either orally or by tube in esophageal cancer patients. Patients continuing to have a high output pleural fluid drainage\u0026thinsp;\u0026gt;\u0026thinsp;1000 mL/day were generally taken back promptly for minimally invasive surgical right thoracic duct ligation or referred to interventional radiology for a lymphangiogram.\u003c/p\u003e \u003cp\u003eBased on their experience, the interventional radiologists at our center have found that the success of the lymphangiogram and transductal embolization relies heavily on patients being NPO for at least 48 hours, in addition to being on octreotide and midodrine. This decreases chyle flow, allowing targeting of the cisterna to either macerate or catheterize it and do an embolization. All lymphangiograms were done with Lipiodol\u003csup\u003e\u0026reg;\u003c/sup\u003e (Guerbet LLC, Princeton, NJ) either intranodal or inter-digital, followed by either the preferred thoracic duct embolization, cisterna chyli maceration (disruption), or lymphangiogram only when embolization or maceration was not possible. Injecting only Lipiodol,\u003csup\u003eⓇ\u003c/sup\u003e which is viscous, may stop small leaks. Rarely an attempt was made for percutaneous direct transhepatic cisterna chyle puncture for embolization or cisterna chyle disruption. In the rare instance where patients continued to have a high output chest tube drainage, patients underwent a more extensive lymphangiogram to diagnose aberrant intraabdominal chylous drainage for consideration of a subdiaphragmatic surgical approach.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eFor the demographic and treatment data, categorical variables are summarized with frequency and percentage, and continuous variables are presented as mean with standard deviation and range. We used the Wilcoxon rank-sum test to compare quantitative variables and Fisher\u0026rsquo;s exact test for categorical variables between patient groups, based on their treatment and outcome. For quantitative outcomes including chest tubes days in place and the length of hospital stay, multivariable linear regression analysis was performed adjusting for covariates. p-values were two-sided; a significance level of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was used.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eClinical Characteristics\u003c/h2\u003e \u003cp\u003eIn the 11-year period between May 1, 2005 and June 30, 2016, 17 patients underwent esophageal resections (7 robotic-assisted and 10 open) who had a postoperative significant chylothorax, which is 1.3% of the total 1324 esophageal surgical resections performed during the same time period, similar to the 2% rate in the literature.(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) In the 17-year period, January 1, 2004 and June 30, 2021, 52 patients underwent lung resections (25 robotic-assisted and 27 open) who had a postoperative significant chylothorax, which represents 1.7% of the total 3058 lung resection performed, similar to the 2.3% rate in the literature.(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) The time periods and cut-off dates were chosen in order to obtain all patient data and long-term follow-up data.\u003c/p\u003e \u003cp\u003eThe clinical characteristics of these two patient populations is shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. 94% of esophageal surgery patients underwent neoadjuvant chemoradiotherapy, 70% were current or former smokers, and 53% of tumors were adenocarcinomas. 83% of lung resection patients were current or former smokers, 60% of patients had an adenocarcinoma, and 48% of patients had a robotic-assisted approach. Of the total 1382 lung resection patients during that time period who had a robotic assisted approach, 1.5% had a chylothorax versus 1.6% for the 1676 open cases, which is contrary to the higher incidence of chylothorax after a robotic-assisted lung resection.(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eChylothorax Patient Characteristics (N\u0026thinsp;=\u0026thinsp;69)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient Characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEsophageal Surgery, N\u0026thinsp;=\u0026thinsp;17\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge at Surgery, years, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61\u0026thinsp;\u0026plusmn;\u0026thinsp;11.3 (48\u0026ndash;75)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (17.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (82.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRace\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (100%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAfrican American\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsian, Indian, Pakistani\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes, yes (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI, kg/m\u003csup\u003e2\u003c/sup\u003e, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.1\u0026thinsp;\u0026plusmn;\u0026thinsp;5.1 (15-31.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoking Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurrent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (47.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFormer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (23.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNever-smoker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (29.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePack-years (current or former smokers), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, range\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42.8\u0026thinsp;\u0026plusmn;\u0026thinsp;36.3 (10\u0026ndash;150)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEthanol Intake Daily (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (82.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeoadjuvant Therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (94.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEsophageal Surgery Type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e--\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOpen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (58.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRobotic/VATS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (41.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCancer Cell Type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdenocarcinoma, No. (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (52.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSquamous Cell Carcinoma, No. (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (47.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLung Surgery, N\u0026thinsp;=\u0026thinsp;52\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge at Surgery, years, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, range\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66\u0026thinsp;\u0026plusmn;\u0026thinsp;12.8 (29\u0026ndash;92)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (53.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (464.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRace (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46 (88.%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAfrican American\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (3.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsian, Indian, Pakistani\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (7.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes, yes (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (3.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoking Status (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurrent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (25%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFormer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (57.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (17.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePack-years (current or former smokers), mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45.9\u0026thinsp;\u0026plusmn;\u0026thinsp;32.4 (1.5\u0026ndash;150)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeoadjuvant Therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (19.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEthanol Intake Daily\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (25%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLung Surgery Type (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e--\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight upper lobectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (42.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight middle lobectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight lower lobectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (11.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft upper lobectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (15.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft lower lobectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (5.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBilobectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (3.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePneumonectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSegmentectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (7.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWedge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (9.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e*Superior sulcus tumor (Pancoast tumor)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (15.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical Approach (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOpen thoracotomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (51.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRobotic/VATS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (48.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCell Type (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdenocarcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (59.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSquamous Cell\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (15.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (21.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBenign\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (3.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\u003cp\u003eAbbreviations: SD: Standard deviation; VATS: Video assisted thoracic surgery. *Case number larger since Pancoast patients had a lobectomy or segmentectomy.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePositive Treatment Outcome\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA positive treatment outcome (\u003cstrong\u003eTable 2\u003c/strong\u003e) in the esophageal surgery group appeared numerically related to using TPN (18%), MCT enteral tube diet (18%), or in performing a surgical ligation of the thoracic duct (35%). For the lung surgery patients, the numerically most effective treatment was octreotide/midodrine (29%), surgical ligation of the thoracic duct (23%) and the performance of a lymphangiogram with embolization combined with octreotide (19%). All esophageal and lung resection patients had a complete chylothorax resolution before hospital discharge with the single or combination treatments listed in \u003cstrong\u003eTable 3\u003c/strong\u003e. Seven patients (10%) had an in-hospital recurrence of their chylothorax after the first postoperative treatment and required a completely different procedure for control. There were no chylothorax recurrences after hospital discharge, followed for at least one year.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Chylothorax Treatment with an Ultimate Positive Outcome (N=69)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"478\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 346px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntervention\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo. Patients (%)\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 346px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEsophageal Surgery N=17\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 346px;\"\u003e\n \u003cp\u003e\u0026nbsp; Total Parenteral Nutrition (TPN)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e3 (17.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 346px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;TPN (and Octreotide)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e1 (5.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 346px;\"\u003e\n \u003cp\u003e\u0026nbsp; TPN (and Lymphangiogram with Embolization)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e1 (5.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 346px;\"\u003e\n \u003cp\u003e\u0026nbsp; Medium chain triglyceride diet (Tube or oral)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 346px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Tube\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e3 (17.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 346px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Oral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 346px;\"\u003e\n \u003cp\u003e\u0026nbsp; Octreotide and MCT diet\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e1 (5.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 346px;\"\u003e\n \u003cp\u003e\u0026nbsp; Octreotide\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e1 (5.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 346px;\"\u003e\n \u003cp\u003e\u0026nbsp; Surgical Ligation of Thoracic Duct\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e6 (35%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 346px;\"\u003e\n \u003cp\u003e\u0026nbsp; Thoracentesis (and Medium Chain Triglyceride Diet)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e1 (5.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 346px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLung Surgery N=52\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 346px;\"\u003e\n \u003cp\u003e\u0026nbsp; Total Parenteral Nutrition (TPN)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 346px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Octreotide/Midodrine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e15 (28.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 346px;\"\u003e\n \u003cp\u003e\u0026nbsp; Medium chain Triglyceride (MCT) diet (Tube or oral)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 346px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Tube\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 346px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Oral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e8 (15.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 346px;\"\u003e\n \u003cp\u003e\u0026nbsp;Surgical Ligation of Thoracic Duct\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e12 (23.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 346px;\"\u003e\n \u003cp\u003e\u0026nbsp;Thoracic Duct Ligation (and Talc Pleurodesis)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e1 (1.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 346px;\"\u003e\n \u003cp\u003e\u0026nbsp;Talc Pleurodesis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e3 (5.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 346px;\"\u003e\n \u003cp\u003e\u0026nbsp;Medium Chain Triglyceride Diet (and Talc Pleurodesis)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e2 (3.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 346px;\"\u003e\n \u003cp\u003e\u0026nbsp;Intra-abdominal Procedure (Thoracic Duct Ligation)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e1 (1.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 346px;\"\u003e\n \u003cp\u003e\u0026nbsp;Lymphangiogram with Embolization\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e8 (15.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 346px;\"\u003e\n \u003cp\u003e\u0026nbsp;Lymphangiogram (and Thoracic Duct Ligation)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e2 (3.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations: MCT=Medium chain triglyceride; TPN= Total parenteral nutrition.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTreatment in parentheses were considered an adjunct to the primary therapy.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eChylothorax Presentation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor the esophageal patients, all chyle leaks were on the right side and began on the mean 7\u003csup\u003eth\u003c/sup\u003e postoperative day. \u003cstrong\u003e(Table 3)\u003c/strong\u003e The chyle drainage was high, more than 2-3 liters per day. Most chest drainage tubes remained in place a mean 3 weeks and the mean hospital stay was 24 days. There was one operative mortality from respiratory failure.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Chylothorax Presentation and Outcome (N=69)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"478\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 346px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eValue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo. Patients (%)\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 346px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEsophageal Surgery N=17\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 346px;\"\u003e\n \u003cp\u003e\u0026nbsp; Location of Chyle Leak\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 346px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Left chest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 346px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Right chest (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e17 (100%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 346px;\"\u003e\n \u003cp\u003e\u0026nbsp; Onset with Beginning Oral Intake (yes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e2 (12%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 346px;\"\u003e\n \u003cp\u003e\u0026nbsp; Postoperative Day of Onset, \u0026nbsp;mean\u0026plusmn;SD, (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e7\u0026plusmn;3 (4-15)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 346px;\"\u003e\n \u003cp\u003e\u0026nbsp; Maximum Daily Chest Tube Drainage, ml\u0026plusmn;SD, (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e2634\u0026plusmn;2633 (129-10700)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 346px;\"\u003e\n \u003cp\u003e\u0026nbsp; Days Chest Drainage Tubes in Place, mean\u0026plusmn;SD, (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e21\u0026plusmn;22 (8-45)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 346px;\"\u003e\n \u003cp\u003e\u0026nbsp; Total Hospital Days, mean\u0026plusmn;SD, (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e24\u0026plusmn;11 (8-45)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 346px;\"\u003e\n \u003cp\u003e\u0026nbsp; Hospital Mortality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e1 (6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 346px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLung Surgery, N=52\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 346px;\"\u003e\n \u003cp\u003e\u0026nbsp; Location of Chyle Leak\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 346px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Left chest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e12 (23.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 346px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Right chest\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e40 (76.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 346px;\"\u003e\n \u003cp\u003e\u0026nbsp; Onset with Beginning Oral Intake (yes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e11 (21.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 346px;\"\u003e\n \u003cp\u003e\u0026nbsp; Postoperative Day of Onset, \u0026nbsp;mean\u0026plusmn;SD, (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e5.3\u0026plusmn;11.2 (1-59)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 346px;\"\u003e\n \u003cp\u003e\u0026nbsp; Maximum Daily Chest Tube Drainage, mean\u0026plusmn;SD, (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e1179\u0026plusmn;1238 (26-6800)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 346px;\"\u003e\n \u003cp\u003e\u0026nbsp; Days Chest Drainage Tubes in Place, mean\u0026plusmn;SD, (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e11.2\u0026plusmn;13.9 (2-95)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 346px;\"\u003e\n \u003cp\u003e\u0026nbsp; Total Hospital Days, mean\u0026plusmn;SD, (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e12.1\u0026plusmn;14.1 (3-95)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 346px;\"\u003e\n \u003cp\u003e\u0026nbsp; Mortality (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e1 (1.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eFor the lung resection patients, 77% of the chyle leaks were from the right side of the chest and started on the mean 5\u003csup\u003eth\u003c/sup\u003e postoperative day. The daily drainage was less than esophageal patients with a mean 1100 ml/day and the drainage tubes remained in place for less time (mean 11 days). Likewise, the hospital stays were shorter (mean 12 days). There was one hospital mortality from acute respiratory distress syndrome in a right pneumonectomy patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAssociation of Treatment with Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe compared the outcomes of the major treatment modalities (surgical thoracic duct ligation, octreotide, midodrine, TPN, MCT diet and lymphangiogram) and operative factors on chylothorax recurrence, chest tube duration and hospital stays with a multivariable analysis.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eChylothorax recurrence\u003c/em\u003e: there was no significant difference in the initial treatments or the demographic characteristics between the 7 patients with chylothorax recurrence and the 62 patients without it. (\u003cstrong\u003eSupplementary Table 1\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eChest Tube Days:\u0026nbsp;\u003c/em\u003eRobotic surgery and midodrine use significantly reduced the number of chest tube days while surgical duct ligation and TPN significantly increased the number of chest tube days (Wilcoxon rank sum test p \u0026lt; 0.05).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eUnivariable linear regression analysis showed patients treated by surgical duct ligation have a significantly longer duration of chest tubes in place. However, midodrine treated patients had significantly shorter chest tube days (b=-10.37, p=0.009). Nevertheless, by multivariable regression analysis, theses modalities are not significant factors in chest tube duration. (\u003cstrong\u003eSupplementary Table 2\u003c/strong\u003e)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eHospital Days\u003c/em\u003e: Surgical duct ligation, lymphangiogram and TPN significantly increased the hospital stay. While use of midodrine, octreotide and MCT diet are significantly associated with decreased hospital stay by 11, 8.2 and 6.4 days (Wilcoxon rank sum test p \u0026lt; 0.05; \u003cstrong\u003eSupplementary Figure 1\u003c/strong\u003e). By univariable linear regression analysis, patients who were treated with octreotide and midodrine have a shorter hospital stay than those who were not. However, those treatments are not significant in multivariable analysis adjusted for covariates. An increased BMI is associated with a shorter hospital stay (b=-0.940, p=0.01)(\u003cstrong\u003eSupplementary Table 3; Supplementary Figure 1). \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n"},{"header":"DISCUSSION","content":"\u003cp\u003eA postoperative chylothorax is an uncommon but well-characterized complication of intrathoracic surgery, usually from disruption of thoracic lymphatics during a mediastinal dissection. In our series of 17 esophageal resections and 52 lung resections, the patients developed a chyle leak from disruption of the lymphatics and/or thoracic duct, with high triglyceride and an elevated lymphocyte content, requiring an aggressive approach to control the drainage. High volume leaks require prompt treatment to prevent immunosuppression and potential mortality from lymphocyte and protein loss in the fluid.\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnatomy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eChyle, with its characteristic milky appearance, contains chylomicrons, triglycerides, cholesterol and fat-soluble vitamins derived from the intestinal lacteal system, combined with lymphatic drainage containing immunoglobulins, enzymes and lymphocytes from the intestine, liver, abdominal wall and lower extremities. This high-protein, electrolyte-rich fluid containing up to 6800 white blood cells/milliliter is carried superiorly into the confluence of the lymphatics termed the cisterna chyle, a lymphatic sac arising at the second lumbar vertebra posterior to the right side of the abdominal aorta. Medium-chain fatty acids (which make up medium-chain triglycerides) contain less than 10 carbon atoms in the chain and are directly absorbed into the portal venous system. Therefore, a medium chain triglyceride diet bypasses the cisterna chyle and the thoracic duct.(6) \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eApproximately 2500 ml of chyle daily flows(7) through the cisterna chyle up the 36-45 mm long thoracic duct(2-3 mm diameter) which enters the chest through the median arcuate ligament traveling between the azygous vein and aorta in the right hemithorax, crossing over to the left side at T5, and ascends posterior to the aortic arch and anterior to the left subclavian vein where it enters the venous circulation. This pattern has significant variations in over 40% of people, frequently with bilateral ducts. These variations explain why even meticulous care at surgery may result in thoracic duct interruption with chyle leakage, in the right and left hemithorax. Often the chyle leakage from the thoracic duct injury will not become apparent for 2-7 days as fluid will build up in the posterior mediastinum and only become apparent with parietal pleura rupture. \u003cstrong\u003eFigure 1\u003c/strong\u003e illustrates common thoracic duct anatomic variations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eChylothorax Treatment Options\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA variety of treatment options have been described, listed in \u003cstrong\u003eTable 4.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4. Chylothorax Treatment Options\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"587\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 214px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePublication\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 373px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTreatment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 214px;\"\u003e\n \u003cp\u003eSchild HH, et. al.(8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 373px;\"\u003e\n \u003cp\u003eNPO (nil per os) plus Total Parenteral Nutrition (TPN)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 214px;\"\u003e\n \u003cp\u003eHolm-Webber T, et. al.(9)\u003c/p\u003e\n \u003cp\u003eAl-Zubaury AS, et.al.(10)\u003c/p\u003e\n \u003cp\u003eKelly, RF, et. al.(11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 373px;\"\u003e\n \u003cp\u003eOctreotide\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 214px;\"\u003e\n \u003cp\u003eUr Rehman, K, et. al.(12)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 373px;\"\u003e\n \u003cp\u003eMidodrine\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 214px;\"\u003e\n \u003cp\u003eHashim SA, et. al.(13)\u003c/p\u003e\n \u003cp\u003eTedjaatmadja C, et. al.(14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 373px;\"\u003e\n \u003cp\u003eMedium Chain Triglyceride Diet (oral or tube feeding)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;and Elemental Diet\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 214px;\"\u003e\n \u003cp\u003eSchild HH, et. al.(8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 373px;\"\u003e\n \u003cp\u003eThoracentesis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 214px;\"\u003e\n \u003cp\u003eMcGrath EE, et. al.(5)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 373px;\"\u003e\n \u003cp\u003eTalc Pleurodesis\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 214px;\"\u003e\n \u003cp\u003eNair S, et. al.(6)\u003c/p\u003e\n \u003cp\u003eMcGrath EE, et. al.(5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 373px;\"\u003e\n \u003cp\u003ePleurectomy\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 214px;\"\u003e\n \u003cp\u003eBryant AS, et. al.(3)\u003c/p\u003e\n \u003cp\u003eNair S, et. al.(6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 373px;\"\u003e\n \u003cp\u003eSurgical Thoracic Duct Ligation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 214px;\"\u003e\n \u003cp\u003eSziklavari, Z, et. al.(16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 373px;\"\u003e\n \u003cp\u003eRadiotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 214px;\"\u003e\n \u003cp\u003eArtemiou, O, et. al.(17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 373px;\"\u003e\n \u003cp\u003ePleurovenous Shunt\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 214px;\"\u003e\n \u003cp\u003eKariya, S. et. al.(18)\u003c/p\u003e\n \u003cp\u003eJardinet, T, et. al.(19)\u003c/p\u003e\n \u003cp\u003eSheybani A, et. al.(20)\u003c/p\u003e\n \u003cp\u003eNadolski GL, et. al.(21, 22)\u003c/p\u003e\n \u003cp\u003eBoffa DJ, et. al.(23)\u003c/p\u003e\n \u003cp\u003eLee, CW, et. al.(28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 373px;\"\u003e\n \u003cp\u003eLymphangiogram\u003c/p\u003e\n \u003col style=\"list-style-type: lower-alpha;\"\u003e\n \u003cli\u003eLipiodol\u003csup\u003e\u0026acirc;\u003c/sup\u003e with thoracic duct embolization\u003c/li\u003e\n \u003cli\u003eLipiodol\u003csup\u003e\u0026acirc;\u003c/sup\u003e with cisterna chyli maceration\u003c/li\u003e\n \u003cli\u003eLipiodol\u003csup\u003e\u0026acirc;\u003c/sup\u003e instillation only\u003c/li\u003e\n \u003c/ol\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 214px;\"\u003e\n \u003cp\u003eMason PF, et. al.(24)\u003c/p\u003e\n \u003cp\u003eVassallo BC, et. al.(25)\u003c/p\u003e\n \u003cp\u003eSchumacher G, et. al.(26)\u003c/p\u003e\n \u003cp\u003eRobinson LA, et. al.(27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 373px;\"\u003e\n \u003cp\u003eIntraabdominal surgical procedure\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNPO and TPN\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOnce it becomes obvious that there is a significant leak of chyle with milky drainage with an elevated triglyceride level(\u0026gt;110 mg/dL) which usually peaks 3 hours after eating, the first conservative step is to promptly reduce the lymph flow by stopping oral intake of a fat-containing diet and focusing on adequate fluid, nutrition and electrolyte balance with total parenteral nutrition.(8) Unfortunately, even though the chyle drainage will generally diminish rapidly, these measures rarely are adequate since most lymph leaks will not close up spontaneously. Nevertheless, this TPN-only technique was successful in 3 (17%) of our esophageal resection patients but none of our lung resection patients.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eOctreotide and Midodrine\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe preferred pharmacologic approach to a chylothorax is beginning octreotide(a somatostatin analog) subcutaneously 20-40 mcg/kg/day for 3-4 days which acts to decrease chyle production by improving lymphatic fluid transport,(9) reducing the intestinal absorption of fats, mainly triglycerides and increasing fecal fat excretion.(10, 11) This drug is well-tolerated short term and rarely is there hypotension or hyperglycemia although hypoglycemia can occur after octreotide is discontinued and requires treatment with intravenous dextrose. Gastrointestinal side effects of nausea and vomiting, abdominal pain, constipation, headaches, bradycardia and dizziness rarely occur but require monitoring.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe other pharmacologic option, usually given along with octreotide, is midodrine. This drug is an alpha-1 adrenergic agonist that stimulates the smooth muscle in lymphatic vessels which then constricts lymphatic vessels and reduces chyle flow.(12) This drug is usually given in doses of 10-20 mg orally 3-4 times daily. The only recommended therapeutic use of midodrine is for chronic hypotension treatment so patients need to be monitored for hypertension as a side effect.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the current series, octreotide was effective in controlling the chylothorax when either used alone or in conjunction with TPN or MCT diet in 3(17.6%) of our esophageal resection patients. Octreotide plus midodrine was quite effective when used together in 15(28.8%) of our lung resection patients.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMedium Chain Triglyceride Diet and Elemental Diet\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eUse of a medium chain triglyceride(MCT) diet is an attractive option first described 60 years ago by S. A. Hashim and colleagues whereby nutrition is maintained while the fat portion of the diet, the triglycerides, are absorbed directly into the portal venous system bypassing the cisterna chyle and thoracic duct.(13) A MCT diet almost always is generally superior to TPN since the positive results are usually seen more rapidly, although it still may require weeks for resolution of the chylothorax.(14) The MCT diet is essentially a variant of a ketogenic diet and generally is fairly palatable orally although some may experience gastrointestinal side effects of vomiting, diarrhea, bloating and cramps. However, providing the MCT diet through a feeding tube usually obviates these side effects. An option reserved for tube feeding which provides the same effect as a MCT diet is the elemental diet which consists of pre-digested nutrients such as amino acids, medium chain triglycerides, electrolytes, vitamins, and simple sugars which provides these nutrients in their most basic form. It is more readily tolerated as a tube feeding since nausea is a common side effect if given orally.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur group has found the high calorie elemental diet Peptamen\u003csup\u003e\u0026acirc;\u003c/sup\u003e 1.5 (Nestle Health Science U.S., Bridgewater, NJ) \u0026nbsp;tube feeding supplement to be quite effective in our esophageal tumor patients with 3(17.6%) having a complete response with resolution of the chyle leak. In our lung resection patients, 10 (19.2%) had complete resolution of their chylothorax with an oral MCT diet with minimal side effects.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThoracentesis and Talc Pleurodesis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eRepeated thoracentesis is generally reserved only for patients where this procedure is needed only short-term for treatment of the underlying chyle leak, and where the buildup of pleural fluid is slow, thereby allowing for ideal pulmonary expansion. In one esophageal resection patient and one lung resection patient with a slow chyle leak, thoracentesis with concomitant MCT diet was effective in controlling the leak. Occasionally repeated thoracentesis plus a talc or doxycycline pleurodesis may be effective, although the pleurodesis is more likely to be effective if the chest remains continuously drained with a chest tube to allow effective pleural symphysis.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSurgical Thoracic Duct Ligation and Pleurectomy \u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSince a postoperative chylothorax, especially with high-volume drainage, may result in immunosuppression and malnutrition, a prompt operation with surgical thoracic duct ligation is definitely indicated, performed preferably by a minimally invasive approach although open thoracotomy is quite effective. Administration of cream or olive oil through a nasogastric tube at the start of the procedure may help identify the thoracic duct and/or the area of leak, which is usually at the level of the inferior pulmonary vein. However, since the thoracic duct is only 2-3 mm in diameter, is usually quite thin and white, and difficult to definitely locate, we generally recommend mass ligation of all of the tissue from the azygous vein over to the aorta posteriorly and to the esophagus medially just superior to the diaphragm. While specific identification of the actual duct is feasible, there is a significant chance for inadvertent duct disruption and continued leakage.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn our 17 esophageal resections, 5 of the 6 thoracic duct ligations were performed with an open thoracotomy with no recurrent chylothoraces. In our lung resection group, 15(29%) of the total had a thoracic duct ligation with 11 undergoing the procedure by open thoracotomy with no recurrences or complications. And one additional patient had a talc pleurodesis and a pleurectomy performed at the time of thoracic duct ligation with no recurrence. Unless the chylothorax has been present for an extended period of time with inadequate drainage of fluid, a pleurectomy is rarely necessary for lung expansion.\u003c/p\u003e\n\u003cp\u003eAlthough we had good results with surgical thoracic duct ligation, later in our series we found that our highly-experienced interventional radiologists were also quite adept with the less invasive, lymphangiogram with embolization, which avoided this second surgical approach. Nevertheless, others including J.S. Reisenauer and colleagues found surgical thoracic duct ligation more effective than thoracic duct embolization, although 14% of their surgical duct ligation patients had significant in-hospital morbidity.(15)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eRadiotherapy\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eZ. Sziklavari and associates reported a series of 7 patients who had a more conservative approach to their chylothorax with pleural fluid tube drainage with full lung expansion to promote adhesion to the area of duct injury and nutritional support followed by \u0026ldquo;radiotherapy which consisted of opposed isocentric portals to the mediastinum using 15 MV photon beams from a linear accelerator, a single dose of 1\u0026ndash;1.5 Gy, and a maximum of five fractions per week. The radiation target area was the anatomical region between TH3 and TH10 depending on the localization of the resected lobe. The mean doses of the ionizing energy was 8.5 Gy \u0026plusmn; 3.5 Gy.\u0026rdquo;(16) They began radiotherapy on the 4\u003csup\u003eth\u003c/sup\u003e day after chylothorax diagnosis and radiation was successful in all 7 patients with a median discharge date 3 days after the completion of radiotherapy.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAlthough they had no long-term recurrences of the chylothorax, there are the theoretical complications of pneumonitis and even potential for secondary malignancy or esophageal fibrosis/stricture with this low dose radiotherapy, although they reported no long-term side effects. In our series, anecdotally, we employed this technique of radiotherapy unsuccessfully in a left-sided chylothorax patient with aberrant thoracic duct anatomy.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePleurovenous Shunts\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePleurovenous shunts for treatment of refractory chylothoraces and other right-sided pleural effusions have been described using a Denver shunt system (Denver Biomedical, Inc, Denver, CO) in which the system is implanted from the pleural cavity to either subclavian or jugular vein.(17) In this 12-patient series, there was one shunt occlusion at 4 weeks but the rest of the systems were patent over an observation period of 1-40 months with no recurrence. Although the potential complications of the device and the procedure are bleeding, air embolism, infection, or occlusion, there was only one long term occlusion, suggesting that this is an attractive treatment alternative to be considered for non-malignant pleural effusions that requires only an easy, short procedure for use in high-risk patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLymphangiogram with Embolization or Cisterna Chyle Disruption\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAn attractive, minimally invasive approach to chylothorax control is offered by experienced interventional radiologists employing percutaneous thoracic duct embolization(TDE). First described in 1999, this technique uses bilateral pedal (inter-digital) lymphangiogram for a high-output chylothorax.(17) This technique is quite time-consuming requiring substantial time for the contrast to travel from the foot to thoracic duct. \u0026nbsp;However, over the last several decades, bilateral pedal lymphangiogram has fallen out of favor, likely due to the technical difficulty involving cannulation of the small lymphatic channels in the feet after a cutdown with high risk of rupture and extravasation, need for suturing the feet afterwards, and risk of post procedural infections. In addition, it is time-consuming as it takes about 3 hours for the contrast to reach the groins from the feet. These problems have been largely solved by the use of the latest ultrasound equipment which allow puncture of non-palpable lymph nodes in the groin for intranodal lymphangiograms(INL) using Lipiodol\u003csup\u003e\u0026acirc;\u003c/sup\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003ewhich is an iodinated poppy seed oil that allows the visualization of lymphatic vessels and opacification of cisterna chyle usually at the level of L3 vertebra.(18)\u0026nbsp;As opposed to pedal lymphangiography which takes many hours, the visualization of cisterna chyle by intranodal lymphangiography occurs in about an hour.\u003c/p\u003e\n\u003cp\u003eT. Jardinet and associates(19) described their 18-patient experience with refractory postoperative chylothorax using intranodal lymphangiography using only Lipiodol\u003csup\u003e\u0026acirc;\u003c/sup\u003e, where they were successful in 17 of 18 patients. There is a definite higher success rate with just INL, even in lower output chyle leaks. It is felt that the viscous Lipiodol\u003csup\u003e\u0026acirc;\u003c/sup\u003e accumulates at the leakage point leading to an inflammatory reaction with embolic effect. Alternatively, saturation of the central lymphatic system with Lipiodol\u003csup\u003e\u0026acirc;\u003c/sup\u003e may force the lymph to find an alternative route through existing peripheral lymphovenous connections, eventually leading to a reduced thoracic duct flow rate. There are no documented reports of toxic side effects from a maximum dose of 20 ml Lipiodol\u003csup\u003e\u0026acirc;\u003c/sup\u003e. Theoretically,\u0026nbsp;if all the contrast\u0026nbsp;of a larger dose\u0026nbsp;goes to the subclavian vein and ends up in the lung,\u0026nbsp;the patient\u0026nbsp;might get lipid pneumonitis.(20)\u003c/p\u003e\n\u003cp\u003eThoracic duct and cisterna chyle embolization requires a more invasive procedure with a good technical success rate, generally better than just a lymphangiogram. \u0026nbsp;Once the cisterna chyle and thoracic duct are canulated, platinum embolization coils or N-butylcyanoacrylate glue is used to occlude the thoracic duct. In a series of 50 patients with a chylous leak, G. Nadolski and associates successfully resolved the chylous leak in 49(96%) of patients,(21) using pedal lymphangiography in 28 patients and intranodal lymphangiography in 22 patients. However, \u0026ldquo;intranodal lymphangiography has been demonstrated to be a superior alternative to traditional pedal lymphangiography for thoracic duct embolization(TDE). In fact, TDE is associated with less morbidity and better clinical success than conservative management or surgical intervention in both traumatic and nontraumatic causes of chylothorax.\u0026rdquo;(22) The authors emphasize that the results are \u003cem\u003eoperator-dependent\u0026nbsp;\u003c/em\u003ebased on experience, and that results will not necessarily be possible in all practice settings.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLikewise, percutaneous access of the cisterna chyle via a transhepatic approach using a 20 cm 22-gauge Chiba needle is another feasible yet rarely used approach to inject coils or glue. \u0026nbsp;But disruption of the cisterna chyle or neighboring retroperitoneal lymphatics although feasible is associated with local extravasation of chyle with potential transdiaphragmatic leakage and is not recommended. Theoretically, creation of a controlled chyle leak into the intact retroperitoneum distal to the thoracic duct leak will divert flow to collaterals, but this mechanism is reported as questionable because the need for reoperation in nearly one-quarter of patients in a series of 36 patients by D. J. Boffa and associates.(23) They report that \u0026ldquo;percutaneous treatment by thoracic duct embolization or disruption is safe and may obviate reoperation, but embolization of the thoracic duct is preferable to its disruption.\u0026rdquo;(23)\u003c/p\u003e\n\u003cp\u003eIn our surgical series, only one esophageal patient had successful lymphangiogram with embolization. However, we were much more successful with 10 (19%) of lung resection patients having chylothorax control with lymphangiogram techniques. We did have complication of a percutaneous cisterna chyle disruption patient who required reoperation for transdiaphragmatic leakage of massive amounts of chyle into the right thoracic cavity.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eIntrabdominal Surgical Procedures\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eP. F. Mason and associates first described an intraabdominal surgical approach for treatment of chylothorax involving ligation of the thoracic duct at the level of the diaphragmatic hiatus,(24) with success in 4 of 5 patients and resolution of the leak within 24 hours in all patients. Subsequently B. C. Vassallo and colleagues(25) described laparoscopic thoracic duct ligation from a lithotomy position dividing the gastrohepatic omentum and dissecting the left and right crus to identify the esophagus, to recognize and ligate the thoracic duct along the right side of the aorta. G. Schumacher and colleagues later described their positive experience with 10 patients using transabdominal ligation of the thoracic duct,(26) which they felt was a simple and safe method to treat postoperative chylothorax.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHowever, the most challenging patients who may benefit from a minimally invasive transabdominal approach are those with aberrant thoracic duct anatomy. One of our lung resection patients with a refractory high volume left chylothorax who had failed transthoracic surgical thoracic duct ligation underwent a transnodal CT lymphangiogram which demonstrated an aberrant left thoracic duct in the subdiaphragmatic area to the left of the aorta extending to the anterior vertebral body, similar to the aberrant anatomy in the superior left illustration in \u003cstrong\u003eFigure 1.\u003c/strong\u003e Through a very small upper abdominal incision, the anomalous thoracic duct was ligated along the vertebral body with complete control of the chylothorax. \u003cstrong\u003eFigure 2\u0026nbsp;\u003c/strong\u003eshows the lymphangiogram illustrating this aberrant ductal anatomy\u003cstrong\u003e.\u003c/strong\u003e This lymphangiogram-directed surgical technique has been described(27) and should be applicable to other patients found to have aberrant thoracic duct anatomy when all other techniques fail.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eC.W. Lee and colleagues(28) have reported a case adding dynamic magnetic resonance(MR) lymphangiography to provide anatomic information to identify the cisterna chyli and a basic structural assessment of the thoracic duct to help guide conventional thoracic duct lymphangiography with embolization, but they admit that it is difficult with MRI to locate the site of leakage. They felt that a patient with prior major intraabdominal surgery might benefit with initial MR lymphangiography before proceeding with conventional lymphangiography. \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLIMITATIONS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis series has significant limitations in that it is a retrospective study with a small 69-patient sample size and as well there is a certain amount of crossover in treatment decisions. \u0026nbsp;The linear regression analysis of our treatment modalities described in the Results was only minimally helpful likely due to a small sample size. Ideally a randomized trial would overcome the surgeon bias that led to arbitrary management decisions, but no such trials are published. Despite these deficiencies, the therapeutic recommendations are still valid particularly with our 100% in hospital success rate.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe development of an iatrogenic chylothorax in an esophageal or lung resection patient is potentially a life-threatening event(1) if not treated promptly, particularly if there is a high-volume leak. Based on our experience with a series of 69 consecutive chylothorax patients over 17 years and the results in the published literature, we recommend an aggressive approach following the treatment algorithm in \u003cstrong\u003eFigure 3,\u003c/strong\u003e which has given us the optimal results and a minimal complication rate.\u003c/p\u003e\n\u003cp\u003eFor most patients, we favor obtaining prompt long-term chylothorax control with either a lymphangiogram-based treatment or surgical thoracic duct ligation. Conservative management with a medium chain triglyceride diet, octreotide and midodrine is appropriate initially, if there is a quick response, but we recommend moving promptly to more invasive methods if there is any evidence of progression or a failed treatment response.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eGy:\u0026nbsp;\u003c/strong\u003eGray\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eINL:\u0026nbsp;\u003c/strong\u003eIntranodal lymphangiogram\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMCT:\u0026nbsp;\u003c/strong\u003eMedium chain triglyceride (diet)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMV:\u0026nbsp;\u003c/strong\u003eMegavolt\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNPO:\u003c/strong\u003e Nil per os\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNSCLC:\u0026nbsp;\u003c/strong\u003eNon-small cell lung cancer\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSD:\u0026nbsp;\u003c/strong\u003eStandard deviation\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTDE:\u0026nbsp;\u003c/strong\u003eThoracic duct embolization\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTPN:\u0026nbsp;\u003c/strong\u003eTotal parenteral nutrition\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eVATS:\u0026nbsp;\u003c/strong\u003eVideo-assisted thoracic surgery\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate:\u0026nbsp;\u003c/strong\u003eNot applicable\u003cstrong\u003e. (\u003c/strong\u003eThis retrospective study was approved by the Advarra IRB Pro00020692, IRB # 00000971, February 26, 2021, and individual consent was waived by the IRB in this retrospective case review.)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eThe datasets generated and/or analyzed during the current study are not publicly available due to patient confidentiality but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests in this section.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis research did not receive any specific grant from funding agencies in the public, commercial or non-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization: LR, NR\u003c/p\u003e\n\u003cp\u003eData curation: LR, NR, YK\u003c/p\u003e\n\u003cp\u003eFormal analysis: LR, NR, YK\u003c/p\u003e\n\u003cp\u003eFunding acquisition: n/a\u003c/p\u003e\n\u003cp\u003eInvestigation: LR\u003c/p\u003e\n\u003cp\u003eMethodology: LR, YK\u003c/p\u003e\n\u003cp\u003eProject administration: LR\u003c/p\u003e\n\u003cp\u003eResources: LR, NR, YK\u003c/p\u003e\n\u003cp\u003eSoftware: n/a\u003c/p\u003e\n\u003cp\u003eSupervision: LR\u003c/p\u003e\n\u003cp\u003eValidation: LR, YK\u003c/p\u003e\n\u003cp\u003eVisualization: LR\u003c/p\u003e\n\u003cp\u003eWriting \u0026ndash; original draft: LR, YK, GH, BK\u003c/p\u003e\n\u003cp\u003eWriting \u0026ndash; review \u0026amp; editing: LR, NR, YK, AB, GE, JF, ET, SF, JB, SB, TS, BK\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Information:\u003c/strong\u003e The first author is \u003cstrong\u003eL.R.,\u0026nbsp;\u003c/strong\u003ewho is a practicing thoracic surgeon for over 40 years. He is Professor of Surgery in the Division of Thoracic Oncology, Director, Lung Cancer Early Detection (LEAD) Center and the Indeterminant Lung Nodule Clinic, Moffitt Cancer Center, Tampa, FL\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePorcel JM, Bielsa S, Civit C, Aujayeb A, Janssen J, Bodtger U et al. Clinical characteristics of chylothorax: results from the International Collaborative Effusion database. ERJ Open Res. 2023;9(5).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSarkaria IS, Finley DS, Bains MS. Chylothorax and recuyrrent laryngeal nerve injury associated with robotic video-assisted mediastinal lymph node dissection. Innovations (Philadelphia). 2015;10:170\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBryant AS, Minnich DJ, Wei B, Cerfolio RJ. The incidence and management of postoperative chylothorax after pulmonary resection and thoracic mediastinal lymph node dissection. Ann Thorac Surg. 2014;98:232\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTakuwa T, Yoshida J, Ono S. Low-fat diet management strategy for chylothorax after pulmopnary resection and lymph node dissection for priomary lung cancer. J Thorac Cardiovasc Surg. 2013;146:571\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcGrath EE, Blades Z, Anderson P. Chylothorax: Aetiology, diagnosis and therapeutic options. Respir Med. 2009;104:1\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNair S, Petko M, Hayward MP. Aetiology and management of chylothorax in adults. Europ J Cariothoracic Surg. 2007;32:362\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIlczyszyn A, Ridha H, Durrani AJ. Management of chyle leak post neck dissection: A case report and literature review. J Plast Reconstr Aesthetic Surg. 2011;64:e223\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchild HH, Strassburg CP, Welz A, Kalff J. Treatment options in patients with chylothorax. Dtsch Arztebl Int. 2013;110(48):819\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHolm-Weber T, Skov F, Mohanakumar S, Thorup L, Riis T, Christensen MB et al. Octreotide improves human lymphatic fluid transport a translational trial. Eur J Cardiothorac Surg. 2023;65(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAl-Zubaury SA, Al-Jazairi AS. Octreotide as a therapeutic option for management of chylothorax. Ann Pharmacother. 2003;37:679\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKelly RF, Shumway S. Conservative management of postoperative chylothorax using somatostatin. 2000;69:1944\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUr Rehman K, Ahmed L, Sivakumar P. Refractory chylothorax: Midodrine as a novel therapeutic option. Eur Respir J.58(suppl 65):PA3142.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHashim SA, Roholt HB, Babayan VK, Van Itallie TB. Treatment of Chyluria and Chylothorax with Medium-Chain Triglyceride. New Engl J Med. 1964;270:756\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTedjaatmadja C, Wulandari Y. Enteral nutrition with medium-chain triglyceride compared to total parenteral nutrition in patient with chylothorax. World Nutr J. 2024;7(2).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReisenauer JS, Puig CA, Reisenauer CJ, Allen MS, Bendel E, Cassivi SD, et al. Treatment of Postsurgical Chylothorax. Ann Thorac Surg. 2018;105(1):254\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSziklavari Z, Allg\u0026auml;uer M, H\u0026uuml;bner G, Neu R, Ried M, Grosser C, et al. Radiotherapy in the treatment of postoperative chylothorax. J Cardiothorac Surg. 2013;8:72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArtemiou O, Marta GM, Klepetko W, Wolner E, M\u0026uuml;ller MR. Pleurovenous shunting in the treatment of nonmalignant pleural effusion. Ann Thorac Surg. 2003;76(1):231\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKariya S, Komemushi A, Nakatani M, Yoshida R, Kono Y, Tanigawa N. Intranodal lymphangiogram: technical aspects and findings. Cardiovasc Intervent Radiol. 2014;37(6):1606\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJardinet T, Veer HV, Nafteux P, Depypere L, Coosemans W, Maleux G. Intranodal Lymphangiography With High-Dose Ethiodized Oil Shows Efficient Results in Patients With Refractory, High-Output Postsurgical Chylothorax: A Retrospective Study. Am J Roentgenol. 2021;217(2):433\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSheybani A, Gaba RC, Minocha J. Cerebral Embolization of Ethiodized Oil following Intranodal Lymphangiography. Semin Intervent Radiol. 2015;32(1):10\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNadolski GJ, Itkin M. Lymphangiography and thoracic duct embolization following unsuccessful thoracic duct ligation: Imaging findings and outcomes. J Thorac Cardiovasc Surg. 2018;156(2):838\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNadolski G, Itkin M. Thoracic duct embolization for the management of chylothoraces. Curr Opin Pulm Med. 2013;19(4):380\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoffa DJ, Sands MJ, Rice TW, Murthy SC, Mason DP, Geisinger MA, et al. A critical evaluation of a percutaneous diagnostic and treatment strategy for chylothorax after thoracic surgery. Eur J Cardiothorac Surg. 2008;33(3):435\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMason PF, Ragoowansi RH, Thorpe JA. Post-thoracotomy chylothorax\u0026ndash;a cure in the abdomen? Eur J Cardiothorac Surg. 1997;11(3):567\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVassallo BC, Cavadas D, Beveraggi E, Sivori E. Treatment of postoperative chylothorax through laparoscopic thoracic duct ligation. Eur J Cardiothorac Surg. 2002;21(3):556\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchumacher G, Weidemann H, Langrehr JM, Jonas S, Mittler J, Jacob D, et al. Transabdominal ligation of the thoracic duct as treatment of choice for postoperative chylothorax after esophagectomy. Dis Esophagus. 2007;20(1):19\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRobinson LA, Fontaine J, El-Haddad G, Bryant S, Perez B, Toloza E, et al. Novel Subdiaphragmatic Ligation of Left Thoracic Duct for Refractory Postoperative Left Chylothorax. Ann Thorac Surg. 2022;113(1):e29\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee CW, Koo HJ, Shin JH, Kim MY, Yang DH. Postoperative chylothorax: The use of dynamic magnetic resonance lymphangiography and thoracic duct embolization. Invest Magn Reson Imaging. 2018;22:182\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Chylothorax, Lung Resection, Esophagectomy, Lymphangiogram, Lipiodol, Thoracic Duct Ligation, Midodrine/Octreotide","lastPublishedDoi":"10.21203/rs.3.rs-7919123/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7919123/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eOBJECTIVE\u003c/h2\u003e \u003cp\u003eAn iatrogenic chylothorax following an esophageal or lung resection represents an uncommon complication with a significant morbidity and mortality if not treated promptly. The optimal therapeutic recommendations are not well defined and rely on the results of retrospective clinical series. We reviewed our experience with a consecutive series of patients with major postoperative chylothoraces in addition to published literature to create a rational algorithm for treatment of this frustrating problem.\u003c/p\u003e\u003ch2\u003eMETHODS\u003c/h2\u003e \u003cp\u003e We conducted a retrospective cohort study of consecutive esophageal and lung resection patients from July 1, 2005 through June 30, 2021, collecting clinical data on all patients who developed a postoperative chylothorax with careful evaluation of the results of definitive therapy.\u003c/p\u003e\u003ch2\u003eRESULTS\u003c/h2\u003e \u003cp\u003eBetween July 1, 2005 through June 30, 2021, we reviewed clinical data on 17 esophageal resection patients and 51 lung resection patients over a 17-year interval who underwent definitive treatment for their postoperative chylothorax. The esophageal surgery patients ultimately had curative therapy with total parenteral nutrition (TPN) (18%), medium chain triglyceride (MCT) enteral tube diet(18%), and in performing a surgical ligation of the thoracic duct(35%). For the lung surgery patients, the most effective treatments were octreotide/midodrine(29%), surgical ligation of the thoracic duct(23%) and the performance of a lymphangiogram with embolization or combined with octreotide(15%).\u003c/p\u003e\u003ch2\u003eCONCLUSIONS\u003c/h2\u003e \u003cp\u003eAll patients in our cohort of esophageal and lung resection patients had curative therapy of the chylothorax with aggressive, invasive procedures mostly directed toward interruption or ligation of the thoracic duct while some patients responded well to dietary and drug therapy.\u003c/p\u003e","manuscriptTitle":"Practical Therapeutic Options for Postoperative Chylothorax","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-22 08:34:19","doi":"10.21203/rs.3.rs-7919123/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-24T12:59:13+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-10T11:26:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"136820043877045136466408508077512409965","date":"2026-01-29T12:07:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"82565809363813297238406401737395354917","date":"2026-01-27T06:09:09+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-27T05:29:39+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-23T10:35:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"324059381659511855833709904060835841905","date":"2026-01-23T10:00:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"267941643827079168042814791782291366924","date":"2026-01-21T07:35:17+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-20T16:44:17+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-28T06:03:20+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-28T06:01:30+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cardiothoracic Surgery","date":"2025-10-21T21:37:22+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8e938962-8c76-4d2c-a767-a1130a0932bf","owner":[],"postedDate":"January 22nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-27T16:11:19+00:00","versionOfRecord":{"articleIdentity":"rs-7919123","link":"https://doi.org/10.1186/s13019-026-04139-0","journal":{"identity":"journal-of-cardiothoracic-surgery","isVorOnly":false,"title":"Journal of Cardiothoracic Surgery"},"publishedOn":"2026-04-20 16:00:05","publishedOnDateReadable":"April 20th, 2026"},"versionCreatedAt":"2026-01-22 08:34:19","video":"","vorDoi":"10.1186/s13019-026-04139-0","vorDoiUrl":"https://doi.org/10.1186/s13019-026-04139-0","workflowStages":[]},"version":"v1","identity":"rs-7919123","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7919123","identity":"rs-7919123","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}