Chylothorax treatments: What's the evidence? Thoracic Duct ligation with pericardectomy versus Cysterna Chyli ablation

Thoracic duct ligation with subphrenic pericardiectomy w/cisterna chili ablation is up for considerable debate with regard to how to properly choose treatments for chylothorax. Chylothorax is a complex and frustrating syndrome that is characterized by an accumulation of chyle within the chest cavity that ultimately leads to respiratory and metabolic compromise as well as fibrosing pleuritis. In some cases, it is caused by an underlying disease process, but in many cases, the cause it is idiopathic. Although many different surgical procedures have been described for the management of chylothorax, the combination of thoracic duct ligation (TDL), and subphrenic pericardectomy (SPP) has been associated with the highest success rates reported in the veterinary literature. More recently a minimally invasive approach for TDL was shown to eliminate the need for a single or double intercostal thoracotomy (often routinely used when done in the traditional open manner). The minimally invasive approach utilizes video-assisted thoracoscopic surgery (VATS) to TDL which provides excellent visualization and illumination of the thoracic cavity without the morbidity of an open thoracotomy. Recent studies have suggested MIS TDL to be performed in sternal recumbency and combined with a laparoscopic cisterna chili ablation, with the same positioning. Patients would subsequently then be repositioned for a SPP in dorsal recumbency after successful TDL and CCA under the same anesthetic episode. The initial treatment of chylothorax was based on TDL alone and was not associated with very impressive outcomes with complete resolution at approximately 59%. Studies looking at the combination of a TDL and a SPP through two intercostal thoracotomies had resolution rates between 80-100%.   [...]