Chylothorax: Surgical Ligation of the Thoracic Duct Through Thoracotomy

Chylothorax is the common manifestation of injury to the thoracic duct secondary to non-surgical trauma, surgical trauma, or malignancy, and associated with a 10% mortality rate. Approximately half of patients with chylothorax respond to non-surgical management typically entailing a combination of pleural drainage, NPO, TPN, diuresis and antisecretory agent administration. Failure to resolve with dietary modification usually necessitates surgical intervention. This is achieved by thoracic duct ligation via right thoracotomy. Anatomy of the thoracic duct is variable with only 50% of patients having a dominant right-sided thoracic duct ascending the posterior mediastinum, crossing over to the left around T5, and terminating into the confluence of the left subclavian and internal jugular veins. The operation entails single lung isolation with access to the thoracic duct via a seventh interspace right lateral thoracotomy. The thoracic duct is isolated low in the chest within soft tissue between the esophagus, aorta and azygous vein overlying the vertebrae. Exposure can be aided by placement of a temporary orogastric tube in the esophagus, and downward retraction of the diaphragm via a suture. This soft tissue is mass ligated at three adjacent positions with nonabsorbable suture. Patients are kept NPO on TPN for five days postoperatively before advancing the diet to confirm resolution of the chyle leak.