Chylothorax Differential Diagnosis: A Comprehensive Guide for Clinicians

Introduction

Chylothorax is characterized by the abnormal accumulation of chyle, a milky fluid rich in triglycerides, within the pleural cavity. This condition arises from the disruption of the thoracic duct or its tributary lymphatic vessels. The etiology of chylothorax is diverse, ranging from traumatic injuries, frequently postoperative complications, to nontraumatic causes, with malignancy being a prominent factor. The leakage of chyle into the pleural space can precipitate significant clinical challenges, including respiratory compromise, nutritional deficiencies, and immunological impairment due to lymphocyte depletion. Diagnosis hinges on a combination of imaging modalities and pleural fluid analysis to confirm the presence of chyle.

Management strategies for chylothorax are tailored to the underlying cause and the severity of the condition. Therapeutic options span from conservative dietary interventions aimed at reducing chyle production, pharmacological agents like somatostatin/octreotide, midodrine, and sirolimus, to more invasive surgical procedures. A staged treatment approach, escalating from minimally invasive to surgical interventions, is often adopted to optimize patient outcomes. This article provides an in-depth review of current diagnostic modalities and treatment strategies for chylothorax, encompassing both conservative and surgical approaches. It emphasizes the critical role of an interprofessional healthcare team in effectively managing chylothorax, enhancing patient care, and improving clinical outcomes. Furthermore, this review aims to equip healthcare professionals with a thorough understanding of chylothorax, including its pathogenesis, etiology, diagnostic workup, and comprehensive management strategies, with a particular focus on Chylothorax Differential Diagnosis.

Objectives:

• Recognize the salient clinical signs and symptoms of chylothorax to facilitate prompt diagnosis and intervention.
• Employ dietary modifications and pharmacological treatments, such as medium-chain triglycerides and somatostatin analogs, to effectively manage chylothorax.
• Implement a staged care plan, progressing from conservative management to surgical interventions, based on individual patient response and the severity of chylothorax.
• Foster collaboration within an interprofessional healthcare team to deliver holistic care for patients with chylothorax, prevent potential complications, and adapt treatment strategies as necessary.

Etiology of Chylothorax

The causes of chylothorax are broadly classified into three categories: nontraumatic (spontaneous), traumatic, and idiopathic. Historically, nontraumatic causes were more prevalent; however, contemporary data indicates that traumatic chylothorax, especially postoperative chylothorax, now constitutes over half of reported cases.

Nontraumatic Chylothorax

Nontraumatic chylothorax may stem from various underlying conditions:

• Congenital Chylothorax: This can occur as an isolated anomaly or in conjunction with other lymphatic system disorders, such as lymphangiectasis, lymphangiomatosis, tuberous sclerosis, congenital heart defects, or chromosomal abnormalities like trisomy 21 (Down syndrome) or Turner syndrome.

• Neoplastic Chylothorax: Malignancy is the most frequent cause of nontraumatic chylothorax. A range of cancers, including lymphoma, chronic lymphocytic leukemia, lung cancer, esophageal cancer, and metastatic carcinomas, have been implicated. The decreased incidence of chylothorax in lymphoma patients is likely attributable to earlier diagnosis and treatment of lymphoma, preventing late-stage complications like chylothorax.

• Infectious Chylothorax: Primarily observed in developing nations, infectious chylothorax is often a consequence of tuberculous lymphadenitis. Other infections associated with chylothorax include aortitis, histoplasmosis, and filariasis.

• Rare Causes: Less common etiologies reported in literature include Castleman disease, sarcoidosis, Kaposi sarcoma, yellow nail syndrome, Noonan syndrome, Waldenström macroglobulinemia, amyloidosis, venous thrombosis, thoracic radiation, and goiter. These diverse conditions can lead to thoracic duct obstruction or damage, resulting in chylothorax.

Traumatic Chylothorax

Traumatic chylothorax results from physical disruption of the thoracic duct anywhere along its mediastinal course. This can be a consequence of surgical interventions or blunt or penetrating chest trauma.

• Postoperative Chylothorax: This is the most common form of chylothorax in modern medical practice. The risk varies with the surgical procedure. Esophagectomy carries the highest risk, with a 5% to 10% incidence, followed by lung resection with mediastinal lymph node dissection (3% to 7% risk). Other surgeries, such as mediastinal tumor resection, thoracic aneurysm repair, sympathectomy, and procedures in the lower neck and mediastinum, also pose a risk.

• Nonsurgical Posttraumatic Chylothorax: Procedures like central line placement, pacemaker implantation, and embolization of pulmonary arteriovenous malformations can also lead to chylothorax.

• Penetrating Chest Injuries: Gunshot and stab wounds can directly injure the thoracic duct, causing chylothorax.

• Blunt Trauma: Blunt chest or thoracic spine trauma can disrupt the thoracic duct even without overt damage to surrounding structures.

• Uncommon Traumatic Causes: Chylothorax has also been reported after blast injuries and even seemingly minor events like severe coughing or sneezing.

Idiopathic Chylothorax

Idiopathic chylothorax, where the cause remains undetermined, accounts for approximately 10% of all cases. While esophageal resection is a common iatrogenic cause, idiopathic chylothorax has also been documented in pregnancy, sometimes triggered by labor.

Epidemiology of Chylothorax

Chylothorax, regardless of etiology, is a rare condition, accounting for up to 3% of all pleural effusions. Traumatic cases are now more frequently encountered than nontraumatic ones. Iatrogenic chylothorax often arises from thoracic surgeries, particularly esophageal procedures, due to the anatomical proximity and variability of the thoracic duct. The incidence of iatrogenic chylothorax in esophageal resections can be as high as 4%.

Among nontraumatic causes, malignancy is the most prevalent, representing nearly one-third of all chylothorax cases. Lymphoma accounts for 70% to 75% of malignant chylothorax, with non-Hodgkin lymphoma being the most common subtype. Metastatic epithelial tumors can also cause chylothorax, though less frequently. Other nontraumatic causes collectively contribute to about one-fifth of all cases.

Pathophysiology of Chylothorax

Lymphatic System Anatomy

A thorough understanding of the lymphatic system’s anatomy is essential for comprehending chylothorax. The lymphatic system comprises lymphatic vessels, lymph nodes, and the cisterna chyli. The thoracic duct is the primary lymphatic vessel, draining approximately three-quarters of the body’s lymph into the venous circulation.

Lymphatic drainage from the lower extremities converges at the para-aortic nodes, merging with lymph from the pelvic viscera to form bilateral lumbar trunks. Intestinal trunks, large lymphatic vessels, collect lymph from the stomach, intestines, pancreas, and spleen.

The cisterna chyli, a dilated lymphatic sac, is located in the retroperitoneum near the second lumbar vertebra. The thoracic duct originates from the cisterna chyli, ascending through the aortic hiatus of the diaphragm into the posterior mediastinum. It courses between the descending thoracic aorta and the azygos vein. At the level of the fifth thoracic vertebra, the duct veers leftward into the superior mediastinum, ascending behind the aortic arch and left subclavian artery, between the esophagus and left pleura, towards the thoracic inlet.

The thoracic duct typically terminates at the junction of the left subclavian and jugular veins, although variations exist. In adults, it measures 38 to 45 cm in length and 3 to 5 mm in diameter at its origin, narrowing mid-thorax and slightly dilating before termination. Disruption of the thoracic duct at any point in its mediastinal path results in chyle leakage into the pleural cavity, leading to chylothorax.

Chyle Composition

Chyle is composed of chylomicrons, aggregates of long-chain triglycerides, cholesterol esters, and phospholipids. It is also rich in lymphocytes, predominantly T lymphocytes, with concentrations ranging from 400 to 6800 cells/µL. Chyle’s electrolyte composition is similar to plasma, but it is enriched with immunoglobulins and fat-soluble vitamins.

History and Physical Examination in Chylothorax

Clinical presentations of chylothorax vary based on the underlying etiology. Small chylothoraces may be asymptomatic and discovered incidentally. Larger effusions typically manifest with symptoms due to mechanical compression of the lung, such as progressive dyspnea and reduced exercise tolerance. Chest pressure is a common complaint, while fever and chest pain are usually absent. Patients can tolerate substantial chyle accumulation if it occurs gradually. Posttraumatic chylothorax may present up to 10 days post-injury. In postoperative settings, chylothorax is often initially detected as a pleural effusion or persistent drainage from chest tubes.

Physical examination findings may include decreased breath sounds and dullness to percussion, depending on the fluid volume and location. Approximately 80% of chylothorax cases are unilateral, with the right side affected more often than the left (approximately two-thirds of cases), reflecting the thoracic duct’s anatomy.

Evaluation and Diagnostic Approach to Chylothorax

Further evaluation of chylothorax depends on the suspected cause and available diagnostic resources. A systematic approach is crucial to differentiate chylothorax from other causes of pleural effusion, which is key for chylothorax differential diagnosis.

Chest Radiograph

Chest radiographs are routinely performed for dyspnea, especially in postoperative and trauma patients. They can detect unilateral pleural effusions, appearing as homogeneous densities obliterating costophrenic and cardiophrenic angles. However, chest radiography alone cannot differentiate chylothorax from other pleural effusions.

Thoracic Ultrasound

Thoracic ultrasound is increasingly used for pleural pathology. Chylothorax appears as an isodense echoic region without septations, similar to other effusions. Ultrasound, like radiography, is not specific for chylothorax.

Computed Tomography (CT) of the Chest

CT scanning is more sensitive than radiography and ultrasound. It can visualize the cisterna chyli in about 2% of cases and may show a low-attenuation tubular area in the posterior mediastinum due to chyle’s fat content. CT can also identify underlying causes, such as mediastinal masses, malignancies, or traumatic injuries.

Magnetic Resonance Imaging (MRI) of the Chest

MRI can visualize the cisterna chyli in nearly all cases and offer detailed evaluation of chylothorax. However, it is not the primary imaging modality for thoracic pathology and is rarely used in routine clinical practice.

Lymphangiography

Conventional lymphangiography, using dyes like methylene blue, is a technique to visualize the lymphatic system. It is less common now due to minimally invasive alternatives. Nodal lymphangiography, injecting ethiodized oil into a lymph node, is a more recent modification, considered sensitive and technically easier with fewer complications. Lymphangiography can also be therapeutic in some cases, as the high-density oil may seal leaks.

Nuclear Lymphoscintigraphy

Nuclear lymphoscintigraphy is more frequently used than traditional lymphangiography. It involves injecting Tc99m-labeled human diethylenetriaminepentaacetic acid subcutaneously in the feet and imaging the chest with a gamma camera to identify leaks. SPECT/CT imaging can enhance accuracy. Lymphoscintigraphy findings correlate well with lymphangiography and surgical leak localization.

Laboratory Fluid Analysis

Thoracentesis and pleural fluid analysis are the cornerstone of chylothorax diagnosis. Fluid samples should be analyzed for white blood cell count with differential, glucose, LDH, total protein, cytology, and microbiology. Chyle is lymphocyte-rich (around 80% of cells, predominantly polyclonal T cells). If chylothorax is suspected based on fluid appearance, pH, triglyceride, and cholesterol levels should be measured.

• Color and Appearance: Chyle appearance can vary from milky white to serous or serosanguineous depending on fat content. A non-milky appearance does not exclude chylothorax. Centrifugation of chylous fluid results in an opaque supernatant, unlike the clear supernatant in empyema.

• Lipid Analysis: Pleural fluid triglyceride concentration is crucial. A level >110 mg/dL is highly suggestive of chylothorax. However, up to 15% of cases may have lower levels, influenced by recent meals and dietary fat intake. Lipid electrophoresis is recommended if suspicion remains high, as the presence of chylomicrons confirms chylothorax. Total cholesterol in chylothorax is typically <200 mg/dL.

• Other Composition: Chyle is typically alkaline (pH 7.4-7.8) and similar to plasma in electrolyte composition.

Pseudochylothorax (Chyliform Effusion)

Pseudochylothorax, or chyliform effusion, presents with a milky appearance similar to chylothorax but is a long-standing exudative effusion. It is characterized by high cholesterol levels, giving it a milky appearance, but lacks chylomicrons and long-chain fatty acids. Cholesterol in pseudochylothorax originates from cell membranes in long-standing effusions.

Pseudochylothorax is often associated with tuberculosis and chronic rheumatoid pleural effusion due to high cell concentrations. Other causes include yellow nail syndrome and paragonimiasis. In pseudochylothorax, cholesterol levels are typically >200 mg/dL, triglycerides <110 mg/dL, and the cholesterol-to-triglyceride ratio is >1. Cholesterol crystals may be visible under polarized light in dried fluid slides, appearing as notched rectangular plates, virtually diagnostic of pseudochylothorax. Distinguishing pseudochylothorax is a key aspect of chylothorax differential diagnosis.

Treatment and Management of Chylothorax

Chylothorax management depends on the etiology and may include dietary modification, pleurodesis, thoracic duct ligation, and thoracic duct embolization. Somatostatin/octreotide, midodrine, and sirolimus are also used to reduce chyle formation. A staged care plan, starting with less invasive approaches, is generally preferred.

Dietary Therapy

Reducing or eliminating long-chain fatty acids in the diet can decrease chyle production and promote spontaneous leak closure. A diet with <5 g fat per meal is recommended to minimize chyle formation. Medium-chain and small-chain fatty acids can be included, while long-chain fatty acids may be supplemented intravenously to prevent fat deficiency and malnutrition.

Thoracentesis

Therapeutic thoracentesis or indwelling catheters are used initially to relieve dyspnea in nontraumatic and nonsurgical traumatic effusions. Chest tubes are often used for postoperative chylothorax. Prolonged pleural fluid drainage can lead to malnutrition and immunoglobulin loss. Continuous drainage should ideally be limited to <2 weeks, and surgical intervention considered if drainage exceeds 1.5 L daily.

Pleurodesis

Pleurodesis is indicated for persistent fluid re-accumulation despite dietary changes and repeated thoracenteses. VATS with talc insufflation is effective in up to 80% of cases. Thoracic duct ligation during surgical pleurodesis can further improve success.

Thoracic Duct Ligation

Thoracic duct ligation via VATS is considered for patients unresponsive to dietary modifications and pleurodesis. Lymphedema, a potential complication, usually resolves over time with collateral lymphatic-venous communication development.

Thoracic Duct Embolization and Disruption

Percutaneous catheterization and embolization, involving needle disruption of the thoracic duct and cisterna chyli, are increasingly used for both traumatic and nontraumatic chylothorax. Pedal lymphangiography and fluoroscopic visualization guide transabdominal needle cannulation of retroperitoneal lymphatics. After cannulating the cisterna chyli and localizing the leak, the affected thoracic duct segment is embolized using coils and surgical glues.

Emerging Therapies

• Somatostatin and Octreotide: These agents reduce gastric, pancreatic, and biliary secretions, decreasing lymphatic flow and promoting spontaneous closure of thoracic duct leaks. Effective in spontaneous, congenital, postoperative, and malignancy-related chylothorax, optimal dosing and duration remain undefined.

• Sirolimus: Used for lymphangiomyomatosis, sirolimus is known to reduce chylothorax incidence in these patients.

• Shunting: Pleurovenous or pleuroperitoneal shunts can recycle chyle back into the body, effectively resolving chylothorax. Pleuroperitoneal shunts include active (Denver shunt) and passive (Le Veen shunt) types. Pleural venous shunting, draining chyle to the subclavian or jugular vein, has been successful in yellow nail syndrome and postoperative chylothorax.

Differential Diagnosis of Chylothorax

A comprehensive chylothorax differential diagnosis is essential to ensure accurate diagnosis and appropriate management. Several conditions can mimic chylothorax, presenting with pleural effusions that require careful differentiation. Key differentials include:

• Pseudochylothorax: As detailed earlier, pseudochylothorax shares a similar milky appearance but is biochemically distinct, lacking chylomicrons and having high cholesterol and low triglyceride levels. Differentiating these conditions relies heavily on pleural fluid lipid analysis.

• Empyema: Thoracic empyema, or pus in the pleural space, can also present as a pleural effusion. However, empyema is typically associated with infection, presenting with fever, chest pain, and elevated white blood cell count in the pleural fluid, unlike chylothorax. Gram stain and culture of the pleural fluid are crucial for diagnosing empyema.

• Hemothorax: Hemothorax, or blood in the pleural space, usually results from trauma or bleeding disorders. The pleural fluid in hemothorax is grossly bloody with a high hematocrit, differentiating it from the milky or serous fluid of chylothorax.

• Parapneumonic Effusion and Complicated Parapneumonic Effusion: These effusions are associated with pneumonia. While they can be exudative, they lack the characteristic milky appearance and lipid profile of chylothorax. Clinical context, along with pleural fluid analysis including glucose, pH, and differential cell count, helps distinguish them.

• Malignant Pleural Effusion: Pleural effusions due to malignancy can sometimes be exudative and may need to be differentiated from chylothorax, especially when malignancy is also considered in the etiology of chylothorax itself. Cytological examination of the pleural fluid is essential to identify malignant cells.

• Congestive Heart Failure (CHF): CHF typically causes transudative pleural effusions, which are clear and straw-colored, with low protein and LDH levels, in contrast to the exudative nature of chylothorax. Clinical history, physical exam findings, and serum BNP levels help in differentiating CHF-related effusions.

• AIDS-related Complex: In patients with AIDS, various pulmonary complications can occur, including pleural effusions. While less common, chylothorax can be associated with AIDS-related conditions like Kaposi sarcoma. However, other causes of pleural effusions in AIDS patients, such as infections and malignancies, are more frequent and need to be considered in the differential.

A thorough clinical evaluation, combined with appropriate pleural fluid analysis focusing on lipid content, cell counts, and microbiology, is crucial in distinguishing chylothorax from these differential diagnoses.

Prognosis of Chylothorax

Chylothorax is a relatively rare complication after cardiothoracic surgery, with an incidence of about 1.8%. Due to its rarity, robust comparative trials for treatment options are limited. Consensus on optimal surgical intervention timing after failed nonoperative management is lacking. However, given the associated morbidity, mortality, prolonged hospital stays, and potential for re-intervention, early surgical consideration post-diagnosis in postoperative cardiothoracic patients is reasonable.

Most patients benefit from a staged care approach, progressing from less to more invasive treatments. Prognosis for chylothorax from benign causes is generally favorable, while malignancy-related chylothorax carries a more guarded prognosis. The Esophagectomy Complications Consensus Group (ECCG) has developed a classification system for chyle leaks post-esophagectomy, categorizing leaks by treatment response and output volume, which is expected to standardize future studies and management approaches. Conservative management is often successful for type I and II leaks (dietary modification and TPN). The effectiveness of TPN versus enteral medium-chain triglycerides, and their sequential use, remains under investigation.

Octreotide’s use is supported by evidence mainly from various chyle leak etiologies. While generally safe and modestly effective, its specific benefit in esophageal resection surgery and in different leak types requires further clarification.

Complications of Chylothorax

Patients with chylothorax can experience significant complications, impacting their health and quality of life. Malnutrition is a primary concern due to chyle loss, rich in fats, proteins, and fat-soluble vitamins, leading to weight loss, muscle wasting, and weakened immunity. Lymphocyte loss can cause immunosuppression, increasing infection susceptibility. Persistent pleural effusions can cause respiratory distress, and prolonged chyle leakage may lead to electrolyte imbalances and fluid depletion. Management involves nutritional support, infection control, and careful monitoring of fluid and electrolyte balance.

Deterrence and Patient Education for Chylothorax

Patients with chylothorax are vulnerable to infections due to malnutrition, underlying illnesses, immunosuppressive therapies, indwelling devices (pleural catheters, chest tubes, central lines), and prolonged hospitalization. An interprofessional team approach is crucial to mitigate these risks.

Patient education is vital. Patients should understand the importance of dietary modifications, like low-fat diets with medium-chain triglycerides, to reduce chyle production. Recognizing early signs of recurrence or complications, such as increased dyspnea or infection signs, and seeking prompt medical attention is crucial. Educating patients about long-term monitoring and follow-up care improves treatment adherence and outcomes.

Pearls and Other Key Considerations in Chylothorax

Chylothorax results from thoracic duct disruption, with trauma and malignancy being leading causes. Diagnosis relies on pleural fluid analysis showing triglyceride levels >110 mg/dL or chylomicrons.

Key management pearls include early diagnosis and intervention, prompt dietary modifications (low-fat, medium-chain triglycerides), and effective pleural effusion drainage. Surgical and nonsurgical approaches exist, with somatostatin analogs showing promise.

A multidisciplinary approach involving pulmonologists, thoracic surgeons, dietitians, and other specialists is essential. Vigilance for complications like malnutrition and immunosuppression is crucial for timely intervention and optimized patient outcomes.

Enhancing Healthcare Team Outcomes in Chylothorax Management

Chylothorax management is complex and multidisciplinary, requiring pulmonologists, thoracic surgeons, dietitians, internists, intensivists, advanced practitioners, nurses, and pharmacists.

Physicians and advanced practitioners need expertise in diagnosis and management. Nurses are crucial for symptom monitoring, drainage system management, and patient education. Pharmacists oversee dietary supplements and medications. A cohesive, integrated care plan is essential.

Initial treatment is often conservative, but surgery may be needed for persistent leaks. Newer techniques like pleurovenous/pleuroperitoneal shunting and thoracic duct embolization are successful. Coordinated care includes timely follow-ups, dietary consultations, and seamless transitions between care settings. Effective interprofessional communication through case discussions and shared documentation enhances patient-centered care, safety, and team performance.

Review Questions

Figure. Chest X-Ray Showing Chylothorax With Homogeneous Density.

References

1.Schild HH, Pieper C. [Chylothorax: Current Therapeutic Options]. Zentralbl Chir. 2019 Sep;144(S 01):S24-S30. [PubMed: 30795028]
2.Zhang C, Xi MY, Zeng J, Li Y, Yu C. Prognostic Impact of Postoperative Complications on Overall Survival in 287 Patients With Oral Cancer: A Retrospective Single-Institution Study. J Oral Maxillofac Surg. 2019 Jul;77(7):1471-1479. [PubMed: 30790530]
3.Iio K, Soneda K, Shimotakahara A, Hataya H, Kono T. Effective method of evaluating infantile chylothorax. Pediatr Int. 2019 Feb;61(2):203-205. [PubMed: 30767369]
4.Hayashi K, Hanaoka J, Ohshio Y, Igarashi T. Chylothorax secondary to a pleuroperitoneal communication and chylous ascites after pancreatic resection. J Surg Case Rep. 2019 Jan;2019(1):rjy364. [PMC free article: PMC6344917] [PubMed: 30697412]
5.Agrawal A, Chaddha U, Kaul V, Desai A, Gillaspie E, Maldonado F. Multidisciplinary Management of Chylothorax. Chest. 2022 Dec;162(6):1402-1412. [PubMed: 35738344]
6.Cherian S, Umerah OM, Tufail M, Panchal RK. Chylothorax in a patient with HIV-related Kaposi’s sarcoma. BMJ Case Rep. 2019 Jan 22;12(1) [PMC free article: PMC6347950] [PubMed: 30674495]
7.Yamagata Y, Saito K, Hirano K, Oya M. Laparoscopic Transhiatal Thoracic Duct Ligation for Chylothorax after Esophagectomy. Thorac Cardiovasc Surg. 2019 Oct;67(7):606-609. [PubMed: 30669171]
8.Gurevich A, Hur S, Singhal S, DiBardino D, Haas AR, Hansen-Flaschen JH, Nadolski G, Itkin M. Nontraumatic Chylothorax and Chylopericardium: Diagnosis and Treatment Using an Algorithmic Approach Based on Novel Lymphatic Imaging. Ann Am Thorac Soc. 2022 May;19(5):756-762. [PubMed: 34797746]
9.Dar PMUD, Gamanagatti S, Priyadarshini P, Kumar S. Traumatic chylothorax: a dilemma to surgeons and interventionists. BMJ Case Rep. 2021 May 21;14(5) [PMC free article: PMC8144052] [PubMed: 34020985]
10.Martínez Camacho RJ, Martínez Camacho LI, Martínez Camacho D, Martínez Camacho A. Idiopathic Chylothorax During Pregnancy: A Case Report. Cureus. 2023 Oct;15(10):e47841. [PMC free article: PMC10611550] [PubMed: 37899891]
11.Ur Rehman K, Sivakumar P. Non-traumatic chylothorax: diagnostic and therapeutic strategies. Breathe (Sheff). 2022 Jun;18(2):210163. [PMC free article: PMC9584559] [PubMed: 36337134]
12.Bhatnagar M, Fisher A, Ramsaroop S, Carter A, Pippard B. Chylothorax: pathophysiology, diagnosis, and management-a comprehensive review. J Thorac Dis. 2024 Feb 29;16(2):1645-1661. [PMC free article: PMC10944732] [PubMed: 38505027]
13.Papoulidis P, Vidanapathirana P, Dunning J. Chylothorax, new insights in treatment. J Thorac Dis. 2018 Nov;10(Suppl 33):S3976-S3977. [PMC free article: PMC6297462] [PubMed: 30631531]
14.Pospiskova J, Smolej L, Belada D, Simkovic M, Motyckova M, Sykorova A, Stepankova P, Zak P. Experiences in the treatment of refractory chylothorax associated with lymphoproliferative disorders. Orphanet J Rare Dis. 2019 Jan 09;14(1):9. [PMC free article: PMC6327395] [PubMed: 30626415]
15.Yang RF, Liu TT, Wang P, Zhang RQ, Li C, Han B, Gao XX, Zhang L, Jiang ZM. Ligation of thoracic duct during thoracoscopic esophagectomy can lead to decrease of T lymphocyte. J Cancer Res Ther. 2018;14(7):1535-1539. [PubMed: 30589035]
16.Furukawa M, Hara A, Miyazaki R, Yokoyama S, Hayashi M, Tao H, Okabe K. [Assessment of Fat-free Diet for Postoperative Chylothorax]. Kyobu Geka. 2018 Dec;71(13):1063-1065. [PubMed: 30587742]
17.Santos LLD, Santos CLD, Hu NKT, Datrino LN, Tavares G, Tristão LS, Orlandini MF, Serafim MCA, Tustumi F. Outcomes of Chylothorax Nonoperative Management After Cardiothoracic Surgery: A Systematic Review and Meta-Analysis. Braz J Cardiovasc Surg. 2023 Oct 06;38(6):e20220326. [PMC free article: PMC10552558] [PubMed: 37801640]
18.Costa KM, Saxena AK. Surgical chylothorax in neonates: management and outcomes. World J Pediatr. 2018 Apr;14(2):110-115. [PubMed: 29508361]
19.Power R, Smyth P, Donlon NE, Nugent T, Donohoe CL, Reynolds JV. Management of chyle leaks following esophageal resection: a systematic review. Dis Esophagus. 2021 Nov 11;34(11) [PMC free article: PMC8597908] [PubMed: 33723611]