Chylothorax & Chylous Ascites Rapid Fire: Update Course 2015

For lymph leak over the bare area of the liver without a discrete source, absorbable cellulose with fibrin glue is a preferred management approach.

If a discrete duct is identified, management options include endo loop, vessel sealing device, sutures, or ligature.

Fluorescein can be used with a black light scope to identify the thoracic duct, as described by veterinarian Jeff Runge in animals.

Lymphangiography is being studied by vascular malformation teams in Philadelphia to identify leak sites preoperatively, and the procedure itself can sometimes serve as therapeutic embolization.

For lymphangiography, contrast is now injected into the groin (into a lymph node) rather than toe web spaces.

Octreotide has marginal or no clear benefit for chylothorax management.

Neonatologists are concerned about octreotide use due to a solitary case report linking it to necrotizing enterocolitis.

A Michigan study of nearly 100 post-cardiac surgery chylothorax patients found that early surgical ligation (within 2 weeks for high-output cases) reduced ICU length of stay by half, overall hospital stay from 30 to 23 days, and ventilator days by half, compared to waiting 30 days.

High-output chylothorax in cardiac patients requires expert fluid management due to significant fluid losses, progressive hypoalbuminemia, and underlying cardiac pathology.

The Michigan group's clinical practice guideline recommends surgical ligation within 2 weeks for high-output post-cardiac chylothorax rather than waiting 30 days.