The management of chylotho-rax, defined as the accumula-tion of lymph in the pleural

space usually because of a leak fromthe thoracic duct or one of its majorbranches, presents a challenge to sur-geons. Although most cases of chy-lothorax are related to previoussurgery or a malignant condition, over100 cases of traumatic chylothoraxhave been reported in the world liter-ature since 1965.1 The cause of mostcases associated with blunt chesttrauma has been attributed to a sud-den hyperextension of the spine caus-ing stretching and rupture of the tho-racic duct.2,3 In only a small subset ofthese patients is the rupture associated

with a thoracic vertebral fracture- dislocation.We report 2 cases of chylothorax

due to blunt trauma, 1 of which wasassociated with a thoracic vertebralfracture.

CASE REPORTS

Case 1

A 17-year-old boy was involved in ahigh-speed automobile crash in whichhe was the unbelted driver. Initial as-sessment at the Sunnybrook RegionalTrauma Unit identified a number ofinjuries, including a minor closed headinjury, a fracture of the left condylar

neck of the mandible and an open frac-ture of the right patella. A chest radi-ograph demonstrated a pneumomedi-astinum and bilateral pulmonarycontusions. The vertebral column ap-peared normal radiographically.The respiratory status of the patient

quickly deteriorated, necessitatingorotracheal intubation. A hematomaof the trachea and right main-stembronchus was visualized on bron-choscopy. Bilateral chest tubes wereinserted, and these immediatelydrained milky fluid. The patient un-derwent surgical repair of the openpatellar fracture.The diagnosis of chylothorax was

confirmed with the measurement of a

Case ReportÉtude de cas

CHYLOTHORAX AFTER BLUNT CHEST TRAUMA: A REPORT OF 2 CASES

John S. Ikonomidis, MD, PhD; Bernard R. Boulanger, MD; Frederick D. Brenneman, MD

From the Department of Surgery and the Trauma Program, Sunnybrook Health Science Centre, University of Toronto, Toronto, Ont.

Accepted for publication May 9, 1996

Correspondence and reprint requests to: Dr. Bernard R. Boulanger, Sunnybrook Health Science Centre, Room H-170, 2075 Bayview Ave., North York ON M4N 3M5

© 1997 Canadian Medical Association (text and abstract/résumé)

Chylothorax is a rare complication of blunt chest trauma and is associated with fracture-dislocation of thethoracic spine in only 20% of these cases. Two cases of chylothorax after blunt chest injury are described inthis paper; 1 was related to a fracture of the third thoracic vertebra. Closed chest drainage and total par-enteral nutrition led to resolution of the condition within 3 weeks in both cases. In general, traumatic chy-lothorax should be managed conservatively for at least 4 weeks before surgical intervention isconsidered.

Complication rare découlant d’un traumatisme contondant au thorax, le chylothorax est associé à des dis-locations et fractures de la colonne thoracique dans 20 % seulement de ces cas. On décrit dans cette com-munication deux cas de chylothorax après un traumatisme contondant au thorax. Dans un des deux cas, ily avait fracture de la troisième vertèbre thoracique. Un drainage thoracique fermé et une nutrition paren-térale totale ont permis de régler le problème en moins de trois semaines dans les deux cas. En général, ilfaudrait traiter le chylothorax d’origine traumatique de façon conservatrice pendant au moins quatre se-maines avant d’envisager une intervention chirurgicale.

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high triglyceride count in the pleuralfluid, and the boy was treated with to-tal parenteral nutrition and bowel rest.The chylous fluid drainage diminishedgradually from 140 mL/d initially toscant drainage by day 17. The boy re-sumed a normal diet, the chest tubewas removed and he was dischargedhome. A follow-up chest radiograph2 weeks later showed complete reso-lution of the chylothorax and pul-monary contusions.

Case 2

A 24-year-old man suffered a mi-nor closed head injury, a fracture ofthe left seventh rib and a left hemoth-orax in a snowboarding accident. He

also had fractures of C2, T3 and thetransverse processes of L1–5, with noneurologic deficits. A chest radi-ograph demonstrated an abnormalmediastinum (Fig. 1), and a chesttube was inserted for a left hemotho-rax. A chest CT scan revealed a smallleft posterior mediastinal hematomaassociated with the fracture of T3(Fig. 2). A thoracic aortogram wasnormal.On the second day of admission,

the chest tube drained 240 mL ofmilky fluid identified as chyle, with atriglyceride level of 8.91 mM. Abipedal lymphangiogram demon-strated an interruption of the thoracicduct at T3 (Fig. 3).The patient was treated with total

parenteral nutrition and bowel rest,and the chylous drainage consistentlydecreased until day 19 when it wasclear and minimal. He resumed a reg-ular diet and the chest tube was re-moved. A chest radiograph 1 monthafter discharge showed resolution ofthe abnormal mediastinum with nopleural effusion.

DISCUSSION

Traumatic injury to the thoracicduct may occur after cervical, thoracicor abdominal surgical procedures oras a result of penetrating or blunttrauma. Chylothorax is a rare compli-cation of blunt chest trauma, as thethoracic duct is generally well pro-tected by the spine posteriorly andmediastinal contents anteriorly. Al-though thoracic or lumbar spinal in-jury is a common occurrence afterblunt chest trauma, very few patientswill have an associated chylothorax.Gartside and Hebert4 identified only 1case of chylothorax out of 925 traumapatients who had sustained fracturesof the thoracic or lumbar spine over a12-year period. Despite this rare oc-currence, the association of spinal frac-ture with thoracic duct injury is seenin approximately 20% of cases of trau-matic chylothorax.3 The first reportedcase of chylothorax associated withthoracic vertebral trauma was de-scribed by Hahn in 1899 in a patientwho had been run over by a wagon.2

Including our second case, only 18such patients have been reported inthe literature since then.2,3

The most common mechanism ofinjury to the thoracic duct after blunttrauma appears to be sudden hyperex-tension of the spine.2,3 This results inrupture of the duct, due to stretchingover the vertebral bodies, or a shear-ing of the duct by the right crus of thediaphragm.5 The most common sitefor the development of a traumatic

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FIG. 1. Chest radiograph showing an abnormal mediastinum (arrows) after blunt chest injury.

chylothorax appears to be at the levelof the lower thoracic vertebral seg-ments.5

The management of chylothoraxafter trauma differs from that relatedto other causes. For example, whennontraumatic chylothorax is associ-ated with lymphatic or venous ob-struction, specific treatment of the un-derlying process is required forsuccess. If widespread malignant dis-ease is present, chemical pleurodesismay be a reasonable choice before op-erative intervention is considered.6 Inaddition, when a chylothorax devel-ops in association with trauma, the pa-tient often has a variety of other in-juries that may influence treatment.Based on our limited experience

and the current literature, we recom-mend an algorithm for the manage-ment of blunt traumatic chylothorax(Fig. 4). The diagnosis is usually madeclinically, based on the appearance ofthe pleural fluid — either milky fluidor fat droplets floating in bloody fluidobserved during closed chest drainage.The diagnosis is confirmed by the find-ing of free microscopic fat with posi-tive Sudan III staining and a triglyc-eride count greater than 1.24 mM.6 If

the patient requires a thoracotomy forrepair of other injuries such as spinalinstability, concomitant surgery for thetorn thoracic duct may also be consid-ered. Otherwise, these patients shouldbe managed conservatively with closedchest drainage to enable full expansionof the lung and apposition of the vis-ceral pleura.6 An important aspect inmanagement includes nutritional sup-port and correction of any fluid andelectrolyte imbalances. Although a dietconsisting of medium-chain triglyc-erides has been advocated,7 total par-enteral nutrition and bowel rest maybe most effective because oral intakeof any kind may increase lymph flowand perpetuate the leak.In general, if the chest tube

drainage persists and is greater than500 mL/d after 2 weeks of conserva-tive therapy, operative interventionshould be planned. However, there isno consensus on the length of timebefore surgical therapy should be con-sidered in the patient whose drainagehas significantly decreased. Although4 further weeks of chest drainage hasbeen suggested empirically,4 somehave favoured a more aggressive ap-proach, with immediate thoracotomy

and thoracic duct ligation if the leakhas not resolved after 2 weeks of ob-servation.3 It has been suggested thatthis more expedient algorithm may bemore appropriate for cases of chy-lothorax associated with thoracic ver-tebral trauma or penetrating thoracictrauma. Whereas most cases of chy-lothorax will resolve spontaneously af-ter 2 weeks of conservative manage-ment,6 a recent review suggests that aduct closure rate of only 50% can beexpected for cases of chylothorax oc-curring in conjunction with injuries ofthe thoracic spine.3 Further, Wor-thington and colleagues8 reported auniform failure of conservative man-agement in 8 patients with thoracicduct injuries as a result of penetratingtrauma, all of whom were successfullytreated with surgery. However, in thesetting of blunt thoracic trauma, wegenerally recommend up to 4 moreweeks of conservative management ifnecessary. If the chest tube drainagehas not markedly decreased by then,surgical treatment should be consid-ered. The site of the thoracic duct in-terruption should be identified bylymphangiography. A post-lymphan-giography chest CT scan may betterdelineate the relationship of the tear

TRAUMATIC CHYLOTHORAX

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FIG. 2. CT scan showing a left posterior mediastinal hematoma (arrow) in association with a fractureof T3. A thoracic aortogram was normal.

FIG. 3. Bipedal lymphangiogram showing the siteof interruption of the thoracic duct with resul-tant chyloma (arrow) adjacent to a thoracic ver-tebral fracture.

to other structures in the medi-astinum. The surgical techniquescommonly used are either direct liga-tion of the thoracic duct leak or massligation of the duct just above the di-aphragm. Van Pernis9 reported thatthe thoracic duct is a duplicate struc-ture from T12 to T8 in 40% of pa-tients; therefore, mass ligation may bethe most effective method to avoidmissing a major channel.10,11 Mass liga-tion may be performed through aright lateral thoracotomy or by thora-coscopic techniques.12

In the present report, complete res-

olution of a traumatic chylothorax in2 patients with different blunt chestinjuries was observed after 3 weeks ofconservative management. The out-come in these two patients suggeststhat as long as consistent reductionand clearing of chest drainage occurs,observation of these patients is safeand appropriate.

References

1. Laaveg SJ, Sprague BL. Traumaticchylothorax, a complication of frac-

ture dislocation of the spine. J BoneJoint Surg [Am] 1978;60:708-9.

2. MacNab DS, Scarlett EP. Traumaticchylothorax due to intrathoracic rup-ture of the thoracic duct. Can MedAssoc J 1932;27:29-36.

3. Silen ML, Weber TR. Managementof thoracic duct injury associatedwith fracture dislocation of the spinefollowing blunt trauma. J Trauma1995;39:1185-7.

4. Gartside R, Hebert JC. Chylothoraxfollowing fracture of the thoracolum-bar spine. Injury 1988;19:363-4.

5. Birt AB, Conolly NK. Traumatic chy-lothorax: a report of a case and a sur-vey of the literature. Br J Surg 1951;39:564-8.

6. Malthaner RA, McKneally MF.Anatomy of the thoracic duct and chy-lothorax. In: Pearson FG, DeslauriersJ, Ginsberg RJ, Hiebert CA, McK-neally MF, Urschel HC Jr, editors.Thoracic surgery, Toronto: ChurchillLivingstone, 1995:1069-81.

7. Kaul TK, Bain WH, Turner MA,Taylor KM: Chylothorax: report of acase complicating ductus ligationthrough a median sternotomy, andreview. Thorax 1976;31(5):610-6.

8. Worthington MG, deGroot M, Gun-ning AJ, von Oppell UO. Isolatedthoracic duct injury after penetratingchest trauma. Ann Thorac Surg 1995;60:272-4.

9. Van Pernis PA. Variation of the tho-racic duct. Surgery 1949;26:308-12.

10. Patterson GA, Todd TRJ, DelarueNC, Ilves R, Pearson FG, Cooper JD.Supradiaphragmatic ligation of thethoracic duct in intractable chylousfistula. Ann Thorac Surg 1981; 32(1):44-9.

11. Milsom JW, Kron IL, Rheuban KS,Rodgers BM. Chylothorax: an assess-ment of current surgical manage-ment. J Thorac Cardiovasc Surg1985; 89(2):221-7.

12. Graham DD, McGahren ED, TribbleCG, Daniel TM, Rodgers BM. Useof video-assisted thoracic surgery inthe treatment of chylothorax. AnnThorac Surg 1994;57:1507-12.

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FIG. 4. Treatment algorithm for chylothorax after blunt trauma.