Pulmonary Medicine

Chylothorax and Cholesterol Effusion

What every physician needs to know:

Chylothorax and cholesterol effusions, also known as chyliform effusions or pseudochylothorax, are lipid-rich pleural effusions. The lipid content consists of chylomicrons/triglycerides (TG) in a chylothorax or cholesterol in cholesterol effusions. In both conditions, pleural fluid often has an opalescent, whitish or milky appearance because of its high fat concentration (Figure 1).

Figure 1.

Typical appearance of chylothorax

Chylothorax implies a chyle leak that is due to the disruption or blockade of the thoracic duct or its tributaries. Cholesterol effusions have no relationship with lymphatic vessels but are connected with long-standing pleural effusions with or without thickened pleural membranes.

Chylothorax represents about 2-3 percent of all pleural effusions, while cholesterol effusions are rare conditions, with fewer than two hundred cases reported.


Causes of chylothorax can be divided into four major categories: (Table I)

Table I.

Causes of Chylothorax.
Etiologies Incidence Comments
Surgery ~40% Congenital heart and diaphragmatic hernia repair surgeries in children, esophagectomy, lung or mediastinal mass resection, coronary artery bypass grafting, radical neck dissection and descending thoracic aortic aneurism repair in adults
Tumors ~30% Lymphoma (70%), metastatic carcinoma
Miscellaneous ~20% Cirrhosis, congenital or acquired lymphatic disorders (e.g., LAM, yellow-nail syndrome), superior vena cava syndrome, innominate or left subclavian vein thromboses, penetrating and blunt trauma, drugs (dasatinib), radiation injury
Idiopathic ~10% Includes congenital chylothorax. In adults, rule out an occult neoplasm or trivial trauma (coughing, hiccupping, sneezing, stretching while yawning and childbirth delivery) before considering a chylothorax as idiopathic

The most common etiology of cholesterol effusions is tuberculosis (> 50%), particularly in the context of previous collapse therapy and residual effusions following anti-tuberculosis therapy. The second most common cause is chronic rheumatoid pleurisy. Rare causes include paragonimiasis, chronic hemothorax, and coronary-artery bypass surgery.

Are you sure your patient has chylothorax or cholesterol effusion? What should you expect to find?

Consider chylothorax in patients with pleural effusion under the following circumstances:

  • Milky-white fluid is aspirated.

  • There are predisposing factors (e.g., recent cardiothoracic surgery, suspected lymphoma, cirrhosis, and LAM).

  • There is continuous pleural fluid drainage thorough a chest tube in the postoperative period (> 400 mL/d).

  • The cause of a persistent or recurrent effusion is uncertain.

Patients with chylothorax may manifest dyspnea (> 50%) and/or nonproductive cough (< 10%), or no respiratory symptoms (37%) when effusions are small or moderate in size. The onset of symptoms may be acute/subacute in postsurgical chylothorax or gradual in nontraumatic chylothorax.

Given the noninflammatory nature of chyle, you should not expect pleuritic chest pain or fever, with lymphoma being an exception (fever is a “B” symptom). The absence of a milky appearance occurs in half of the patients, especially if they are fasting (e.g., in the postoperative period) or malnourished.

Anatomical reasons explain the preferential lateralization of chylothoraces depending on the level of thoracic duct injury or obstruction: If the duct is damaged below the fifth or sixth thoracic vertebrae, the effusion will be right-sided, which is the most common situation. An injury above this level results in a left chylothorax, whereas bilateral chylothorax (20%) results from disruption at the level of the fifth thoracic vertebrae or from the transdiaphragmatic movement of chylous ascites.

Consider cholesterol effusions when the patient is asymptomatic (1/3) or symptomatic with a unilateral, chronic pleural effusion (> 5 years in 90% of the cases) of unknown etiology, and when the patient has lung entrapment or loculated effusions, whether or not the pleural surfaces are thickened or calcified.

Beware: there are other diseases that can mimic chylothorax or cholesterol effusion:

A milky fluid can be caused by chylothorax, cholesterol effusion, empyema, and extravasation of lipid-containing parenteral nutrition from a central line that has accidentally migrated into the pleural space. In addition, the differential diagnosis of a non-whitish-appearing chylothorax includes other types of postoperative effusions.

Differentiate cholesterol effusions from chronic tuberculosis empyema, the latter of which is characterized by a chronic, active mycobacterial infection of the pleural space; a thick, calcific pleural rind and rib thickening surrounding loculated pleural fluid, and a purulent fluid that is smear positive for acid-fast bacilli.

How and/or why did the patient develop chylothorax or cholesterol effusion?

Thoracic duct injury or obstruction leading to the leakage of chyle into the pleural space may result from:

  • accidental damage during cardiothoracic surgery

  • mediastinal lymphadenopathy that impedes lymph drainage from thoracic structures

  • invasion of the thoracic duct by lymphomatous or carcinomatous cells

  • major or minor trauma

  • spontaneous (Behçet disease), catheter-related thrombosis, or external compression (substernal goiter) of great veins

  • the proliferation of abnormal smooth-muscle cells around the lymph vessels (LAM)

  • a drug-induced disorder of the lymphatic network. The anti-leukemic agent dasatinib inhibits the platelet-derived growth factor beta receptor, which is involved in lymphangiogenesis.

In cirrhosis cases, chylothorax appears to be produced by the transdiaphragmatic movement of chylous ascites to the pleural cavity. The origin of the lipids in cholesterol effusions is thought to result from degenerating red and white blood cells in the pleural fluid and trapped cholesterol that changes its lipoprotein-binding characteristics because of local metabolism.

Which individuals are at greatest risk of developing chylothorax or cholesterol effusion?

The prevalence of chylothorax differs based on attendant conditions:

  • Congenital heart surgery: 9 percent

  • Congenital diaphragmatic-hernia repair: 6 percent

  • Esophagectomy: 1 to 3.8 percent

  • Lung resection with thoracic mediastinal lymph node dissection: 1.4 percent

  • Descending thoracic aortic-aneurism repair: 0.4 percent

  • Lymphoproliferative disorders: 2.5 percent

  • Cirrhosis: 5 percent

  • Superior vena cava syndrome: 5 percent

  • LAM: 10-20 percent

  • Congenital: 1 in 8,600 deliveries

Predisposing factors for developing cholesterol effusions include residual tuberculosis pleuritis, chronic rheumatoid pleurisy, and lung entrapment.

What laboratory studies should you order to help make the diagnosis, and how should you interpret the results?

A yellowish or serosanguineous appearance of the fluid is even more common than the typical milky appearance. Moreover, cholesterol effusions often have a satin-sheen or brown appearance.

Aspirate pleural fluid in order to measure:

  • cell count and differential

  • protein

  • lactate dehydrogenase

  • glucose and/or pH

  • cholesterol

  • TG

  • cytology

Obtain serum simultaneously for protein, LDH, glucose, cholesterol and TG levels.

Pleural fluid characteristics in chylothorax are as follows

  • Exudate in 85 percent of the cases. In two-thirds of these cases, the effusion is classified as an exudate by the protein but not by the LDH-concentration criterion (protein-discordant exudate).

  • Transudate in 15 percent of the cases, which should raise suspicions for cirrhosis and, less frequently, heart failure or nephrotic syndrome.

  • Lymphocytes are predominant in 80 percent of the cases, although neutrophilic fluids are not rare in the postoperative period.

  • TG concentration greater than 110 mg/dL in more than 85 percent of cases; a level less than 50 mg/dL strongly argues against this diagnosis, as this level occurs in less than 3 percent of cases.

  • The presence of chylomicrons establishes a definite diagnosis. Measure them only if there are intermediate TG values (50-110 mg/dL).

If a lipoprotein analysis is not available and if there is doubt about the diagnosis, the administration of a high-fat meal will result in a dramatic change in the appearance and TG content of the pleural fluid.

Pleural fluids in cholesterol effusions are (often neutrophil-predominant) exudates that are characterized by:

  • cholesterol levels greater than 200 mg/dL

  • cholesterol/TG ratio greater than 1

  • cholesterol crystals on polarized microscopy (pathognomonic, but not a prerequisite)

  • the absence of chylomicrons

In cholesterol effusions, send the fluid for adenosine deaminase measurement and mycobacterial cultures.

What imaging studies will be helpful in making or excluding the diagnosis of chylothorax or cholesterol effusion?

A chest X-ray confirms the presence of pleural effusion. In chylothorax of uncertain origin, a thoracic and abdominal CT scan may reveal lymphadenopathy, thrombosis or compression of the great veins, and/or cystic parenchymal changes suggestive of LAM.

In cholesterol effusions, a chest CT may demonstrate thickened or calcified pleural surfaces, a loculated fluid collection, and/or the presence of a fat-fluid or fat-calcium level.

In patients where thoracic-duct repair or ligation is planned, localizing the leakage site may require non-contrast-enhanced MRI lymphoductography or intranodal lymphangiography (in which an inguinal lymph node is accessed under ultrasound guidance and, subsequently, an oil-based contrast agent is injected), as the the preferred imaging techniques. Less commonly used modalities include lymphoscintigraphy after oral ingestion of 123I-labeled beta-methyl-iodophenyl pentadecanoic acid, or intradermal injection of 99mTc-labeled albumin or colloidal sulfur into the dorsum of the foot or hand; or pedal lymphangiography using lipiodol.

What non-invasive pulmonary diagnostic studies will be helpful in making or excluding the diagnosis of chylothorax or cholesterol effusion?

See imaging studies.

What diagnostic procedures will be helpful in making or excluding the diagnosis of chylothorax or cholesterol effusion?

The diagnosis of chylothorax and cholesterol effusion relies on the pleural fluid analysis (See above.)

After the centrifugation of the pleural fluid, the supernatant is opaque in chylothorax and cholesterol effusions, and clear in empyema (the milkiness is caused by suspended leukocytes and debris). Adding 2mL of ethyl ether will clear the milkiness in chylothorax, but not in a cholesterol effusion.

A pleural fluid-to-serum glucose ratio may assist in differentiating chylothorax (ratio < 1) from the extravascular migration of a central venous catheter in patients receiving total parenteral nutrition (ratio > 1).

CT-guided pleural biopsy or pleuroscopy may be necessary for diagnosing malignancy-related chylothorax if pleural fluid cytological and/or flow cytometrical analyses are inconclusive.

What pathology/cytology/genetic studies will be helpful in making or excluding the diagnosis of chylothorax or cholesterol effusion?

No pathology/cytology/genetic studies are helpful in making or excluding the diagnosis of chylothorax or cholesterol effusion.

If you decide the patient has chylothorax or cholesterol effusion, how should the patient be managed?

Management decisions for chylothorax depend on the underlying cause, the effusion’s size and the severity of the symptoms, the rate of fluid formation or reaccumulation, and the local expertise. When managing a chylothorax, proceed from conservative measures to more invasive treatments.

Treatment strategies are divided into three categories:

  1. Treatment of the underlying condition - chemotherapy, with or without radiation therapy for lymphomas and metastatic tumors; diuretics, or large-volume paracentesis and/or TIPS for cirrhotic ascites; and discontinuation of dasatinib when moderate or large effusions result from it (corticosteroids and/or diuretics may be necessary). The immunosuppressant silorimus (1 to 5 mg/d) may reduce the size of intractable chylous effusions in patients with LAM.

  2. Conservative management - therapeutic thoracentesis or chest-tube drainage for symptomatic relief (Figure 2), a period of total parenteral nutrition or a low-fat diet supplemented with oral medium-chain TG to reduce chyle flow in the thoracic duct, and octreotide (sandostatin), 50-100 mcg/8 h SC to reduce intestinal chyle production.

  3. Surgical and/or palliative options should be considered if conservative measures during a two-week period have been unsuccessful, there are severe nutritional or metabolic complications, or the average daily chyle loss exceeds 1-1.5 L for a 5-7-day period.

Figure 2.

Therapeutic thoracentesis in a patient with chylothorax

In high-output chylothoraces (>1 L/d), the treatment modalities include visualization of the thoracic duct under fluoroscopy by intranodal lymphangiography or percutaneous CT-guided access to the cisterna chyli and injection of a water-soluble iodine contrast, followed by catheterization and embolization of the thoracic duct with multiple radio-opaque micro coils and/or liquid embolic agents (eg., N-butyl cyanoacrylate glue). Conventional lymphangiography itself might reduce or heal chyle leaks in some patients.

Treatment for high-output chylotoraces can also include video-assisted thoracic surgery (VATS, or thoracotomy) for the surgical repair of the lymphatic disruption and/or ligation of the thoracic duct. Oral cream is administered 24 hours prior to the procedure to facilitate the identification of the point of leakage. If the leak is not identifiable, a mass ligation of all the tissues anterior to the esophagus and between the aorta and the azygos vein should be performed. VATS allows for simultaneous pleurodesis with talc poudrage.

In low-output, persistent chylothoraces or those caused by malignancy, controlling pleural effusion may require bedside pleurodesis with doxycycline or talc slurry, or an indwelling catheter (PleurX) or pleuroperitoneal shunting if there has been failed pleurodesis or a trapped lung.

Management of cholesterol effusions includes treatment of the underlying disease, therapeutic thoracentesis for symptomatic relief (the patient may experience substernal chest pain after large-volume aspiration because of the increase in negative pleural pressure (lung entrapment)), and pleurodesis and/or decortication for recurrent symptomatic effusions.

What is the prognosis for patients managed in the recommended ways?

In chylothorax, conservative treatments have a success rate of about 40 percent. The remainder of the cases need a surgical or palliative intervention.

Nontraumatic chylothorax appears to respond less well to conservative and surgical measures than does traumatic chylothorax. Its prognosis is dictated by the underlying etiology.

Thoracic duct ligation for high-output or recurrent chylothoraces of traumatic origin is successful in up to 95 percent of the cases.

The mortality rate of a high output, post-esophagectomy chylothorax is 10-15 percent with early reoperation and greater than 50 percent with conservative measures.

In most cases, cholesterol effusions follow a benign course.

What other considerations exist for patients with chylothorax or cholesterol effusion?

Lipoprotein analysis of the pleural fluid to demonstrate chylomicrons is rarely performed.

Some chylothoraces are likely undiagnosed because of their non-milky appearance.

In fasting or malnourished patients, reliance on the TG criteria may overlook the diagnosis of chylothorax.

Exclude lymphoma before adopting the diagnosis of idiopathic chylothorax.

Prolonged drainage of a chylothorax may lead to malnutrition, immunosuppression and severe electrolyte abnormalities (hyponatremia and hypocalcemia).

Prophylactic thoracic duct mass ligation can be considered to prevent chylothorax during esophagectomy for cancer.

Persistent, high-output chylothorax requires some form of intervention, thoracic duct embolization being a well-tolerated and efficacious treatment.

Intranodal lymphangiography is a feasible technique to opacify the lymphatic system in order to perform a thoracic duct embolization.

Active tuberculosis should be ruled out in all patients with cholesterol effusions.

What’s the evidence?

Agrawal, V, Doelken, P, Sahn, SA. "Pleural fluid analysis in chylous pleural effusion". Chest. vol. 133. 2008. pp. 1436-41.

(The biochemical analysis of 22 chylous effusions showed fifteen exudates and seven transudates. Among the former, eleven (73%) were protein-discordant exudates (i.e., those where the pleural fluid to serum protein ratio was > 0.5 and the pleural LDH concentration was < 67% of the upper limit of normal serum LDH). In all but two patients, lymphocytes predominated)

Alejandre-Lafont, E, Krompiec, C, Rau, WS, Krombach, GA. "Effectiveness of therapeutic lymphography on lymphatic leakage". Acta Radiol. vol. 52. 2011. pp. 305-11.

(In this study, 43 patients with lymphatic leakage (chylothorax, chylous ascites, lymphocele, lymphatic fistulas) underwent therapeutic lymphography after failure of conservative therapy. The lymphatic leak was completely occluded in 70% and 35% of patients with a volume of lymphatic drainage greater and lower than 500 mL/d, respectively.)

Almoosa, KF, McCormack, FX, Sahn, SA. "Pleural disease in lymphangioleiomyomatosis". Clin Chest Med. vol. 27. 2006. pp. 355-68.

(A narrative review of the incidence and clinical characteristics of pneumothorax and chylothorax in LAM.)

Brixey, AG, Light, RW. "Pleural effusions due to dasatinib". Curr Opin Pulm Med. vol. 16. 2010. pp. 351-6.

(An update of the pleural side effects of the anti-leukemic agent dasatinib, which is associated with the development of pleural effusions, many of them of chylous nature, in 20 percent of the cases.)

Bryant, AS, Minnich, DJ, Wei, B, Cefolio, RJ. "The incidence and management of postoperative chylothorax after pulmonary resection and thoracic mediastinal lymph node dissection". Ann Thorac Surg. vol. 98. 2014. pp. 232-7.

(In this retrospective study, 41 (1.4%) of 2828 patients who underwent pulmonary resection with mediastinal lymph node disecction experienced a chylothorax. Pathologic N2 disease and a robotic approach were significantly associated with the development of chylothorax. In 90% of the cases, conservative measures resolved the effusion.)

Doerr, CH, Allen, MS, Nichols, FS. "Etiology of chylothorax in 203 patients". Mayo Clinic Proc. vol. 80. 2005. pp. 867-70.

(The causes of 203 chylothoraces that were retrospectively identified over a 21-year period consisted of surgery or trauma in 101 cases (50%), various medical conditions in 89 cases (44%), and unknown in 13 cases (6%). )

García-Zamalloa, A, Ruiz-Irastorza, G, Aguayo, FJ. "Pseudochylothorax. Report of two cases and review of the literature". Medicine (Baltimore). vol. 78. 1999. pp. 200-7.

(This paper is a review of 174 cases of pseudochylothorax appearing in the literature until1999. Tuberculosis explained 95 (54%) of the cases and rheumatoid arthritis 16 (9%). Sixteen (9%) patients had a pleural effusion of less than a five-year duration.)

Itkin, M, Kucharczuk, JC, Kwak, A. "Nonoperative thoracic duct embolization for traumatic thoracic duct leak: experience in 109 patients". J Thorac Cardiovasc Surg. vol. 139. 2010. pp. 584-9.

(In this retrospective series of 109 patients with chyle leaks (106 with chylothoraces), the success rate of catheter embolization (using endovascular coils or liquid embolic agents) or needle interruption of the thoracic duct was about 85 percent. The latter technique was attempted when the catheterization of the thoracic duct through pedal lymphangiography was unsuccessful (in a third of the cases).)

Jimenez, CA, Mhatre, AD, Martínez, CH. "Use of an indwelling pleural catheter for the management of recurrent chylothorax in patients with cancer". Chest. vol. 132. 2007. pp. 1584-90.

(The insertion of a PleurX catheter led to symptomatic improvement in all ten malignancy-associated chylothoraces. Only one patient required an additional procedure.)

Kalomenidis, I. "Octreotide and chylothorax". Curr Opin Pulm Med. vol. 12. 2006. pp. 264-7.

(A literature review concerning the role of somatostatin and its synthetic analogue, octeotride, in the treatment of chylothorax.)

Kanakis, MA, Misthos, P, Kokotsakis, JN, Lioulias, AG. "Chylothorax complicating aortic thoracic surgery". J Card Surg. vol. 26. 2011. pp. 410-4.

(An English literature review on chylothorax as a complication of thoracic aortic aneurism repair.)

Kranzfelder, M, Gertler, R, Hapfelmeier, A, Friess, H, Feith, M. "Chylothorax after esophagectomy for cancer: impact of the surgical approach and neoadjuvant treatment: systematic review and institutional analysis". Surg Endosc. vol. 27. 2013. pp. 3530-8.

(Postoperative chylothorax ocurred in 2% of 1856 patients who underwent esophagectomy, regardless of the transthoracic or transhiatal surgical approach.)

Lai, FC, Chen, L, Tu, YR, Lin, M, Li, X. "Prevention of chylothorax complicating extensive esophageal resection by mass ligation of thoracic duct: a random control study". Ann Thorac Surg. vol. 91. 2011. pp. 1770-4.

(This randomized study compared 325 patients who underwent prophylactic intraoperative thoracic duct mass ligation during esophagectomy (prevention group) with 328 patients receiving esophagectomy (preservation group) due to esophageal cancer. Postoperative chylothorax developed in 1 patient (0.3%) and 7 patients (2.1%), respectively.)

Lyon, S, Mott, N, Koukounaras, J, Shoobridgde, J, Hudson, PV. "Role of interventional radiology in the management of chylothorax: a review of the current management of high output chylothorax". Cardiovasc Intervent Radiol. vol. 36. 2013. pp. 599-607.

(A comprehensive narrative review on interventional management techniques for high-output chylothoraces.)

Maldonado, F, Cartin-Caba, R, Hawkins, FJ, Ryu, JH. "Medical and surgical management of chylothorax and associated outcomes". Am J Med Sci. vol. 339. 2010. pp. 314-8.

(In this retrospective study of 75 patients with chylothorax, a surgical procedure was eventually necessary in 44 cases (59%). The rate of resolution from the initial conservative measures was significantly worse (27%) for nontraumatic than for traumatic chylothoraces (50%). Even after surgical maneuvers, a third of the patients from the former group failed to resolve their pleural effusion.)

Maldonado, F, Hawkins, FJ, Daniels, CE. "Pleural fluid characteristics of chylothorax". Mayo Clin Proc. vol. 84. 2009. pp. 129-33.

(In this retrospective study of 74 patients with chylothorax, the pleural fluid appeared milky in only 44 percent of the cases. Eighty-six percent of the effusions met exudative criteria while 14 percent were transudates. Ten (14%) patients exhibited pleural fluid triglyceride values less than 110 mg/dL, with two of them less than 50 mg/dL.)

Mares, DC, Mathur, PN. "Medical thoracoscopic talc pleurodesis for chylothorax due to lymphoma: a case series". Chest. vol. 114. 1998. pp. 731-5.

(The success rate of talc poudrage pleurodesis in nineteen patients with lymphoma-related chylothorax was 100 percent at three different time points (thirty, sixty, and ninety days following the pleuroscopy).)

Matsumoto, T, Yamagami, T, Kato, T. "The effectiveness of lymphangiography as a treatment method for various chyle leakages". Br J Radiol. vol. 82. 2009. pp. 286-90.

(Pedal lymphangiography with lipiodol led to spontaneous cessation of leakage in eight of nine patients with chyle leaks that were refractory to conservative measures, including five chylothoraces. The authors speculate about a regional inflammatory reaction that is due to lipiodol accumulation, causing the point of leakage to seal.)

McGrath, EE, Blades, Z, Anderson, PB. "Chylothorax: aetiology, diagnosis and therapeutic options". Respir Med. vol. 104. 2010. pp. 1-8.

(A review of the English language publications on chylotorax from 1980 to 2008 that highlights the need for guidelines and randomized controlled studies.)

Nadolski, GJ, Itkin, M. "Thoracic duct embolization for nontraumatic chylous effusion. Experience in 34 patients". Chest. vol. 143. 2013. pp. 158-63.

(In this retrospective study, thoracic duct embolization was technically successful in 71% of 34 patients with nontraumatic chylous effusions, particularly in cases of thoracic duct occlusion or extravasation.)

Orringer, MB, Marshall, B, Chang, AC. "Two thousand transhiatal esophagectomies. Changing trends, lessons learned". Ann Surg. vol. 246. 2007. pp. 363-74.

(Chylothorax complicated 2007 transhiatal esophagectomies in just 1 percent of the cases.)

Paul, S, Altorki, NK, Port, JL. "Surgical management of chylothorax". Thorac Cardiovasc Surg. vol. 57. 2009. pp. 226-8.

(In this series, thoracic duct ligation, performed in most cases during a thoracotomy, was successful in 22 of 23 (95%) patients with high-output or recurrent chylothorax, mainly of traumatic origin. There were no intraoperative complications or deaths within one month. The success rate of talc pleurodesis was 83 percent (five of six additional patients).)

Romero, S, Martín, C, Hernández, L. "Chylothorax in cirrhosis of the liver. Analysis of its frequency and clinical characteristics". Chest. vol. 114. 1998. pp. 154-9.

(Of 809 patients who were submitted to thoracentesis, 24 met the biochemical criteria of chylothorax, of whom 5 (20%) had cirrhosis. All of the cirrhotic chylothoraces were transudates.)

Ryu, JH, Doerr, CH, Fisher, SD. "Chylothorax in lymphangioleiomyomatosis". Chest. vol. 123. 2003. pp. 623-7.

(In this retrospective review, chylothorax was documented in 8 out of 79 (10%) patients with lymphangioleiomyomatosis.)

Ryu, JH, Tomassetti, S, Maldonado, F. "Update on uncommon pleural effusions". Respirology. vol. 16. 2011. pp. 238-243.

(An excellent review of the diagnosis and treatment of uncommon pleural conditions, such as chylothorax, pseudochylothorax, yellow nail syndrome and urinothorax.)

Shah, RD, Luketich, JD, Schuchert, MJ, Christie, NA. "Postesophagectomy chylothorax: incidence, risk factors, and outcomes". Ann Thorac Surg. vol. 93. 2012. pp. 897-904.

(Chylothorax ocurred in 34 (3.8%) of 892 consecutive patients who underwent esophagectomy. Early postesophagectomy chest tube output exceeding 400 mL/d should raise suspicion of chylothorax and prompt laboratory analysis of pleural fluid to confirm diagnosis. Thoracic duct ligation was performed in 21 (62%) cases at a median of 13 days after esophagectomy. High-ouput chylothoraces (> 11.6 mL/Kg) were more likely to fail medical therapy.)

Schoellnast, H, Maybody, M, Getrajdman, GI. "Computed tomography-guided access to cisterna chyli: introduction of a technique for direct lymphangiography to evaluate and treat chylothorax". Cardiovasc Intervent Radiol. vol. 34. 2011. pp. S240-4.

(This study describes two patients with postoperative chylothorax. These patients were treated using a hybrid imaging system for rapid CT-guided access to the cisterna chyli that allowed for diagnostic and therapeutic maneuvers)

Skouras, V, Kalomenidis, I. "Chylothorax: diagnostic approach". Curr Opin Pulm Med. vol. 16. 2010. pp. 387-393.

(This review proposes a diagnostic algorithm for patients with suspected chylothorax.)

Song, JW, Im, JG, Goo, JM. "Pseudochylous pleural effusion with fat-fluid levels: report of six cases". Radiology. vol. 216. 2000. pp. 478-80.

(The CT scans of six patients with tuberculosis cholesterol effusions showed a fat-fluid or fat-calcium level at the nondependent site.)

Soto-Martínez, M, Massie, J. "Chylothorax: diagnosis and management in children". Paediatr Respir Rev. vol. 10. 2009. pp. 199-207.

(This review article outlines the causes of chylothorax in children, presents a diagnostic algorithm, and describes various management options.)

Taveira-DaSilva, AM, Hathaway, O, Stylianou, M, Moss, J. "Changes in lung function and chylous effusions in patients with lymphangioleiomyomatosis treated with sirolimus". Ann Intern Med. vol. 154. 2011. pp. 797-805.

(In this small observational study, 11 patients with LAM and chylous effusions who had required repeated thoracenteses and/or pleurodesis experienced a complete (9 patients) or partial (2 patients) resolution of their effusions after an average of 2.4 years of sirolimus therapy.)

Teng, CL, Li, KW, Yu, JT, Hsu, SL. "Malignancy-associated chylothorax: a 20-year study of 18 patients from a single institution". Eur J Cancer Care (Engl). vol. 21. 2012. pp. 599-605.

(In this study, 18 patients with malignancy-associated chylothoraces were evaluated, of whom 11 (61%) had lymphomas and 7 had solid malignancies. After chemotherapy, chylothoraces resolved in 6 (55%) lymphoma patients, but in none with solid tumors.)

Valentine, VG, Raffin, TA. "The management of chylothorax". Chest. vol. 102. 1992. pp. 586-91.

(In this early compilation series of 191 patients with chylothorax, 138 (72%) had nontraumatic causes, of which 70 were secondary to lymphoma.)

Wrightson, JM, Stanton, AE, Maskell, NA. "Pseudochylothorax without pleural thickening: time to reconsider pathogenesis". Chest. vol. 136. 2009. pp. 1144-7.

(A series of six patients with arthritis-related pseudochylothorax in the absence of the typical thick pleural peel is reported. The median duration of pleural-related symptoms was fifteen months. Such findings dispute the necessity for chronic pleuritis with significant pleural thickening as a prerequisite for cholesterol effusion development.)

Zabeck, H, Muley, T, Dienemann, H, Hoffmann, H. "Management of chylothorax in adults: when is surgery indicated". Thorac Cardiovasc Surg. vol. 59. 2011. pp. 243-6.

(A retrospective analysis of 82 cases of chylothorax, 45% of which were postsurgical. Half of the postsurgical, but only 13% of nonsurgical chylothoraces, needed surgical intervention. Conservative management was likely unsuccessful in postoperative chylothoraces with a flow leak >900 mL/d)
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