Blunt Chest Trauma and Chylothorax: A Systematic Review

Abstract Introduction: Although traumatic chylothorax is predominantly associated with penetrating injuries, instances following blunt trauma, as a rare and challenging condition, are being increasingly documented. This study aims to systematically review the reported cases of blunt chest traumatic chylothorax (BCTC) and provide comprehensive insights into the condition. Methods: Related studies published until December 11, 2024, were identified through Google Scholar. All studies documenting instances of BCTC, without restriction on cause or patient demographics, were included. Studies were excluded if they focused on chylothorax caused by penetrating injuries, their content was unretrievable, they were review articles, or they were published in blacklisted journals. Results: Sixty-five eligible studies, encompassing 69 cases of BCTC, were included in the review. It predominantly affected males (73.91%), with patient ages ranging from 11 months to 84 years old. The most common clinical findings were dyspnea (47.83%) and abnormal auscultation or percussion (34.78%), with road traffic accidents as the primary cause (59.42%). Unilateral chylothorax was found in 72.46% of cases, bilateral chylothorax occurred in 27.54%, and pleural effusion was the most frequent radiological finding (55.07% in X-ray and 33.33% in computed tomography). Treatment typically included drainage (94.20%), parenteral nutrition (50.72%), and thoracic duct closure (39.13%). Most patients achieved complete recovery (89.85%), and six cases (8.70%) died. Conclusion: The condition is rare and complex, underscored by the wide variability in patient demographics, clinical presentations, chylothorax onset, and management approaches. Given the challenges posed by limited evidence, the findings emphasize the need for early recognition and individualized management strategies. Introduction Chylothorax is a rare condition characterized by the accumulation of chyle in the pleural cavity caused by a disruption of the thoracic duct [1]. Chyle is an opalescent fluid that consists of triglycerides, chylomicrons, proteins, electrolytes, immunoglobulins, and fat-soluble vitamins, transported from the gastrointestinal system into the bloodstream by the thoracic duct. It makes up about 1-3% of total body weight in adults. Chylothorax was initially described by Bartolet in 1633 and later reported in the literature by Quinke in 1875 [1,2]. It is categorized into congenital, neoplastic, traumatic, and miscellaneous forms. The most common cause is malignancy, which leads to obstruction of the thoracic duct, while traumatic chylothorax is typically iatrogenic, resulting from surgical procedures or catheter placement. Penetrating trauma is the usual cause of traumatic chylothorax, while blunt trauma is considered an infrequent cause [1,2]. It may also develop due to chest compression or changes in intrathoracic pressure, such as during coughing or persistent vomiting [2]. The incidence of chylothorax is about 0.2% following blunt thoracic trauma and 0.9% after penetrating trauma. Bilateral chylothorax resulting from blunt trauma, mainly when no other injuries are evident, is an infrequent but severe complication [3]. Without prompt treatment, chylothorax can lead to serious complications, such as cardiopulmonary distress and significant nutritional deficiencies, with a high mortality rate of up to 15.5% [2-4]. Although traumatic chylothorax is predominantly associated with penetrating injuries, instances following blunt trauma have been increasingly documented, highlighting the need for awareness among healthcare providers regarding this potential complication [5,6]. This study aims to systematically review the reported cases of blunt chest traumatic chylothorax (BCTC) and provide comprehensive insights into the condition. Methods Literature search The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Related studies published until December 11, 2024, were identified through Google Scholar using a search strategy that combined the following keywords with the “allintitle” and “including citation” features: (blunt trauma chylothorax), (blunt thoracic trauma chylothorax), (blunt thoracic injury chylothorax), (blunt chest injury chylothorax), (blunt torso trauma chylothorax), (blunt thoracic duct trauma), (blunt thoracic duct injury) and (traumatic chylothorax). The search was limited to English-language publications. Eligibility criteria All studies or reports documenting instances of BCTC, without restriction on cause or patient demographics, were eligible for inclusion. Studies were excluded if they focused on chylothorax caused by factors other than blunt chest trauma, if their content was unretrievable, if they were review articles, or if they were published in blacklisted journals. The legitimacy of the studies was verified by cross-referencing with widely recognized predatory journal checklists [7]. Study selection First, an author conducted a literature search using the specified keywords and collected the relevant results. The titles and abstracts of the identified studies were then screened to exclude duplicates, non-English studies, and those unrelated to the study objective. Full-text screening was conducted for studies that passed the initial filtration, excluding those with unretrievable content or irrelevant study designs, such as reviews. This step was supervised by two authors, who independently reviewed each study. Finally, the remaining studies underwent legitimacy filtering. Data extraction The collected data encompassed various parameters, including the first author's name, year of publication, patient demographics, clinical manifestations, causes of chylothorax, chyle volume and content, the onset of chyle production, diagnostic methods, ICU admission status, treatment modalities, outcomes, and follow-up. Statistical Analysis The extracted data were organized in an Excel sheet (2019) and analyzed descriptively using the Statistical Package for the Social Sciences (SPSS, v. 27, IBM Co.). The results were presented in frequencies with percentages, means with standard deviation, and ranges. Results Study identification A systematic search yielded 201 studies, all of which were case reports. After removing duplicates (16) and non-English articles (17), 168 titles and abstracts were screened. Fifty-five case reports were excluded due to irrelevance, and full-text evaluation of the remaining 113 case reports led to the exclusion of an additional 42. Furthermore, six articles were excluded for being published in warning-listed journals. Consequently, 65 eligible case reports, encompassing 69 cases of BCTC, were included in the review [1-6,8-66] (Tables 1 and 2). The identification process is outlined in a PRISMA flowchart (Figure 1). Table 1. Demographic, Cause and Chyle Characteristics First author, year [Reference] Country Age (year) Gender CFP Cause SOC Amount of chyle (ml)/day* COAP (day) Biochemical content of chyle Harvey, 2024 [5] USA 60 F Chest pain, multiple rib fractures RTA Left <500 2 Triglycerides Burduniuc, 2023 [2] Czech Republic 70 F Blunt injury Fall on stairs Right >1000-2000 3 Protein, cholesterol, triglycerides Dung, 2023 [14] Vietnam 32 M Thoracic spine injury, paraplegia RTA Right >1000-2000 At once Cholesterol, triglycerides Kim, 2023 [4] South Korea 45 M Hemodynamically unstable, chest discomfort, multiple fractures, hemopneumothorax Crushed by a 2-ton metal frame Left >1000-2000 1.66 Triglycerides Boateng 2023 [33] USA 75 F Respiratory distress Fall from bed Right <500 At once Triglycerides Ruest 2023 [34] USA 15 months M Tenderness over right paraspinal thoracolumbar back, abnormal auscultation Child abuse Right N/A At once N/A Mohanakrishnan 2022 [35] USA 70 F Dyspnea, back pain, abnormal auscultation Violent coughing episode Right >1000-2000 At once Chylomicrons, triglycerides Mazhar, 2021[23] UK 42 F Dyspnea, abnormal auscultation Fall from horse 1 week before presentation Right >1000-2000 7 Triglycerides Waseem, 2021[32] Pakistan 50 M Dyspnea RTA 2 days before presentation Bilateral >1000-2000 2 Triglycerides, cholesterol, fat-rich fluid with few inflammatory cells Din Dar 2021 [36] India 50 M Blunt injury RTA Right >1000-2000 25 Triglyceride, chylomicrons Bacon, 2020 [9] USA 53 M Hemopneumothorax RTA Left <500 5 N/A Champion, 2020 [12] Canada 29 M Dyspnea, flushing, diaphoresis, vomiting, abnormal auscultation RTA Bilateral >1000-2000 At once Cholesterol, triglycerides Jindal 2019 [37] India 35 M Dyspnea, respiratory distress RTA Bilateral >1000-2000 4 Triglyceride, WBC, albumin, glucose, protein, LDH Ahmed, 2018 [1] Iraq 42 M Severe back pain RTA Right 500-1000 2 Triglycerides and lymphocyte Brown, 2018 [10] USA 53 M Thoracoabdominal injuries, subcutaneous emphysema, unstable pelvis RTA Left >1000-2000 N/A Triglycerides and lymphocyte Litzau, 2018 [22] USA 66 F Dyspnea, multiple fractures, abnormal auscultation RTA 7 days before presentation Right >1000-2000 7 Triglycerides Kozul, 2017 [19] Australia 18 M Multiple injuries RTA Bilateral 500-1000 0.46 N/A Lee, 2017 [21] South Korea 70 M Hemothorax, flail chest RTA Right >2000 5 Triglycerides, cholesterol Mohamed, 2017 [3] USA 51 M Dyspnea, chest pain, abnormal auscultation Fall on stairs Bilateral >1000-2000 5 Triglycerides, Leukocytes, RBCs, LDH, protein Spasić, 2017 [6] Serbia 55 F Multiple injuries RTA Rig

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