Q 66 year old male undergoes TTE. After esophagectomy, ICD output is 1000ml chyle on 5th days post operatively. What should be the next step in management?
a) NPO, TPN
b) Enteral feeding with medium chain fatty acid
c) Re explore and suture the defect
d) Radiographic embolization
Answer c
Once the diagnosis is made, one should ensure the pleural space is completely evacuated; if needed, drainage is done by a chest tube or a radiologically directed catheter placement.
Feedings are stopped and total parenteral nutrition (TPN) is started.
The amount of chest tube output is then monitored for several days in order to make a decision about the possible need for reoperation. Small leaks can seal with nonoperative therapy. Large initial daily outputs (typically greater than 1 L/day) often fail nonoperative therapy and require reoperation. An absolute amount of drainage for prediction of failure is unknown and one should consider also if there is a gradual reduction in daily output to continue with conservative therapy.
If the drainage is less than 500 mL per day and slowly decreasing, continued conservative therapy is frequently successful.
Continued volumes more than 1 L after 2 days of TPN is a good indication of the need for reoperation.
In general, it is better to be more rather than less aggressive in returning to the operation theater with a chylothorax. It was more common after THE and was associated with longer intensive care unit (ICU) and hospital stays. There was no difference in mortality between those with and without a chylothorax.
Patients with initial drainage exceeding 2 L within 2 days of starting conservative treatment all required reoperation.