College Answer

a) Chylothorax secondary to thoracic duct damage.

NB: Both parts needed for whole mark.

b) Conservative management with drainage, octreotide and TPN. Surgical management with pleurodesis or thoracic duct ligation

Discussion

The picture abode is of a drain with chyle in it, which was not part of the original college paper. Indeed, nobody knows what precisely the college depicted in their version.

I have attempted to provide the candidate with a picture which has in it an unambiguously creamy opaque fluid, sitting in some obvious chest drain tubing.

And yes, chylothorax is a frequent complication of oesophagectomy.

Diagnosis of chylothorax:

• Lipoprotein content of pleural drain fluid
• Chylomicron content of pleural fluid
• Fasting test and fat challenge
• CT and lymphangiography may be helpful but practically speaking this could be difficult.

Management of chylothorax

• Low fat diet - or at least a diet rich in medium-chain triglycerides (hoping with reduced chyle flow the defect will close on its own)
• TPN may be required - but is not an essential part of management. If one were to use TPN, one may wish to use medium-chain fatty acids - i.e. anything with a chain length shorter than laurate (12 carbon atoms)
• It seems octreotide is an effective treatment option
• Surgical ligation is always an option, and some say it should be the first option.