Open transabdominal cisterna chyli ligation for refractory chylothorax: a retrospective case series

Chylothorax is a rare but serious condition that can lead to significant morbidity if not effectively managed. While conservative measures and transthoracic duct ligation remain first-line approaches, these can fail in the setting of altered thoracic anatomy, bilateral effusions, or previous thoracic interventions. In such cases, transabdominal ligation of the cisterna chyli offers a direct route to the main lymphatic outflow tract. This study analyzes the results in patients with refractory chylothorax who underwent cisterna chyli ligation through laparotomy. In this retrospective case series conducted by a single surgical team, fourteen patients with refractory chylothorax (defined as persistent high-output leakage after failed conservative and/or transthoracic surgical therapy) underwent open transabdominal cisterna chyli ligation between 2011 and 2025. Demographics, etiology, effusion laterality, prior interventions, operative details and outcomes were reviewed. Primary endpoint was resolution; secondary endpoints were hospital stay, complications, recurrence, and mortality. Median age was 36 years (range 0.4–90), with 9 males. Etiologies were postoperative in 7 (50%), lymphoproliferative disease in 3 (21.4%), and idiopathic in 4 (28.6%). Effusions were right-sided in 5 (35.8%), left in 1 (7.1%), bilateral in 7 (50%), and 1 was intrapericardial. Median postoperative hospital stay was 9 days and median follow-up was 75 months. Nine patients (64.2%) had prior transthoracic surgery. Resolution was achieved in 11 patients (78.6%). Five patients (35.8%) were already intubated in the ICU and remained intubated postoperatively, while the remaining nine were extubated at the end of surgery and returned directly to the ward. Complications included ARDS in one patient and one late recurrence managed successfully with embolization. Three patients had persistent leaks, two due to lymphoma progression and one after esophagectomy. Transabdominal cisterna chyli ligation appears to be a feasible and effective salvage option for refractory chylothorax, particularly in patients with altered thoracic anatomy or after failed transthoracic interventions. However, conclusions are limited by the small retrospective case series.