The Addition of the Fat Challenge for a More Individualized Approach to Management of Postoperative Chylothorax

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Objectives Postoperative chylothorax is a common complication of pediatric cardiothoracic surgery, traditionally managed with fat-modified diets (FMD). Emerging evidence suggests that shorter durations of dietary modification may be sufficient for many patients; however, the optimal duration remains undefined, and substantial practice variation persists. We hypothesized that a subset of low-risk patients were overtreated with their FMD and evaluated whether a protocolized reintroduction of a regular diet, or Fat Challenge, would safely shorten FMD duration. Methods We conducted a single-center quality improvement project between 2016–2024, with patients undergoing Fat Challenge over three successive protocol changes. In each protocol era, “low-risk” patients, determined by chest tube (CT) output after FMD initiation, underwent a Fat Challenge and were monitored for increase in chest tube output. If output remained low, patients were continued on their regular diet. Differences in FMD duration were analyzed utilizing run charts and differences between successive protocols were evaluated using Tukey-Kramer post hoc comparisons. Results 43 patients qualified for Fat Challenge across all protocols. Median FMD duration decreased from 28 days (interquartile range [IQR] 12–31) in 2016–2018 to 4 days (IQR 2–5) in 2019–2021 and 3 days (IQR 2–3.5) in 2022–2024 (p < 0.0001). One patient failed Fat Challenge; no patients required chest tube replacement or readmission for recurrence. Conclusion While historic management of postoperative chylothorax has been a standardized duration of a FMD, the Fat Challenge protocol demonstrates that low-risk patients can be safely managed with a short duration of an FMD.