The Role of Thoracoscopy for Chylothorax

Typical therapy for chylothorax includes an initial course of medical management; however, prolonged medical management beyond 1 or 2 months may allow significant fibrosing pleuritis to occur. If surgery is an option, prolonged medical management should be avoided. The diagnostic plan for chylothorax is exhaustive and is not altered for thoracoscopy. The typical workup includes CBC, biochemical profile, urinalysis, thoracic radiography following thoracocentesis, pleural fluid analysis, pleural fluid triglyceride level, serum triglyceride level, pleural fluid culture, thoracic ultrasound, abdominal radiographs and ultrasound, cardiac ultrasound, and heartworm testing. Many clinicians include CT or MRI of the thorax prior to surgery or thoracoscopy.

Surgical options for chylothorax include thoracic duct ligation (TDL), pericardectomy, cisterna chyli ablation (CCA), and omentalization. Minimally invasive approaches have been described for TDL, pericardectomy, and CCA and any can be done to treat chylothorax. Thoracoscopic TDL and pericardectomy have been described in clinical patients; however, the author currently performs TDL, pericardectomy, and CCA as an initial treatment for chylothorax. Lateral or sternal recumbency can be used for the procedures; however, only sternal recumbency has been described for endoscopic CCA.  [...]