Bilateral spontaneous chylothorax presenting as a neck mass

Chylothorax is a relatively rare condition. Bilateral chylothorax is even more unusual with the majority resulting from trauma or in association with a neoplasm. We describe a case of bilateral spontaneous chylothorax which presented as a sudden neck mass in a 45 year old, healthy female. A complete evaluation failed to reveal any cause. Successful management included thoracentesis and a medium chain triglyceride diet. The patient remains well with a normal chest x-ray and CAT scan of the thorax and abdomen at one year. Spontaneous bilateral chylothorax presenting as a neck mass with no evidence of trauma or tumor has, to our knowledge, not previously been reported in the literature.

Residua of thoracic trauma

While most residua of thoracic trauma are obvious, tracheal stenosis, aneurysm of the aortic arch and diaphragmatic hernia are easily overlooked. They may be asymptomatic and may go undetected until the occurrence of life-threatening consequences. Therefore, these three conditions must be thought of and ruled out during the management and follow-up observation of all patients who have trauma to the chest. Surgeons participating in the management of thoracic trauma must anticipate, prevent when possible, diagnose early and treat any of the residua that can, and often do, result.

[Prenatal diagnosis and therapy of hydro-/chylothorax with fetal hydrops]

The prenatal diagnosis of a massive bilateral hydro-/chylothorax at 34 weeks of gestation is presented. It was associated with a marked hydrops which probably had resulted from protein depletion into the pleural cavity and/or elevation of intrathoracic pressure with subsequent obstruction of venous return. So the hydro-/chylothorax is to be considered a further cause of the congenital hydrops universalis. After induction of lung maturation with dexamethasone the infant was delivered by a primary cesarean section at 36 weeks of pregnancy. The immediately following intensive care guaranteed the circulatory function and ventilation. The pleural effusions were managed successfully by careful continuous intrapleural drainage and intravenous protein substitution. Last not least, the survival of the infant despite the massive findings is to be owed to the close cooperation of pediatricians and obstetricians.

Pleuroperitoneal shunts in the management of neonatal chylothorax

Pleuroperitoneal shunts have been placed in five ventilator-dependent newborns with persistent chylothorax. The etiology of the chylothorax appeared to be secondary to superior vena caval obstruction in three patients and was idiopathic in the remaining two. Despite traditional therapies these infants were on a progressively deteriorating clinical course. Hakim-Cordis low-pressure ventricular-peritoneal shunt catheter systems were used in each infant. Ultrasonography was used to follow the regression of pleural effusions and to determine the need for shunt compression. Shunt patency was confirmed with radionuclide studies. Four of five infants had a complete resolution of their chylothorax and pulmonary insufficiency. Three of these infants were extubated within 28 days following the placement of the shunt. Nutritional and metabolic stability was rapidly achieved. The shunts were removed several weeks later without recurrence of the chylothorax. A fifth infant failed to improve after the placement of the pleuroperitoneal shunt and died of progressive pulmonary insufficiency. The placement of pleuroperitoneal shunts in infants with refractory chylothorax is safe, technically easy to perform, and is associated with few complications.

Chylothorax in a twin pregnancy of 34 weeks--sonographically diagnosed

In a twin pregnancy of 34 gestational weeks sonographic follow-up revealed a rapidly spreading hydrothorax in one twin and slight ascites in the other. Analysis of aspirated fluid by intrauterine needle puncture suggested a chylothorax. Pathogenesis of chylothorax is discussed. Differential diagnosis of hydrothorax is presented. Intrauterine puncture is the only method of achieving prenatal diagnosis and therapy.

Pneumothorax, hemothorax, and other abnormalities of the pleural space

The clinical setting and treatment of various types of pneumothorax are detailed; chylothorax and hemothorax are also discussed. Tube thoracostomy, which can be performed with basic surgical skills if attention is paid to potential complications and optimal technique, is described.

Chylothorax following cardiac surgery in children

Eleven cases of chylothorax following cardiac surgery in children are described. Conservative treatment was carried out with success in all patients but one, who died because of the underlying cardiac pathology, with the chylothorax still present. Our results indicate that conservative treatment is effective in children, although surgery has been previously considered by some authors as the treatment of choice in this age group.

[Chylothorax and the pathology of the lymphatic pleura]

The diagnosis of chylous effusions of the pleura hardly poses any problems if one carefully differentiates the true chylothorax rich in triglycerides from chylous effusions rich in cholesterol and poor in triglycerides. The pathology of chylothorax requires a double breach of both thoracic duct and pleura. The causes are dominated by complications of thoracic surgery direct trauma, closed chest injuries and malignant mediastinal tumours. Other rarer causes raise the difficult problem of the spontaneous chylothorax. Even the idea of an idiopathic chylothorax is controversial and makes one suspect the rupture of a previously fragile thoracic duct, following apparently minimal trauma. Treatment is not yet standardised but requires strict rest, and a medium chain triglyceride diet, correction of fluid and electrolyte balance and careful nutrition. Surgery, generally delayed for a few weeks, may lead to the repair of a lymphatic leak, localised by a biological tracer or a contrast material; sometimes only a ligature at the base of the thoracic duct will dry up the effusion. The prognosis still remains mediocre and is dominated by the cause, notably when this is a tumour and also by the localised or diffuse character of the lymphatic disturbance.

Chylothorax secondary to superior vena caval obstruction

Bilateral lethal chylothoraces developed in a premature infant secondary to superior vena caval obstruction related to central venous catheterization for total parenteral nutrition. The accumulation of chyle in the lungs was preceded radiographically by the typical lymphatic pattern in the lungs, usually associated with lymphangiectasia. A nuclear medicine lymphangiogram showed abnormal accumulation of the isotope in the lungs secondary to the lymphatic obstruction.

Chylothorax after myocardial revascularization with internal mammary graft

Chylothorax following an intrapericardial cardiac operation is rare, and we are aware of only 12 reported cases. Nine followed median sternotomy for treatment of congenital heart disorders or acquired valvular disease; more than expected were reoperations (23%). This report documents that this complication may also occur following myocardial revascularization with internal mammary graft and describes the anatomy that makes this possible. This rare complication is important because of the high morbidity of prolonged tube drainage and the fact that nearly half of the affected patients underwent reoperation (5 of 13). Dilated lymphatics exuding chyle have been found at operations undertaken to control lymph fistulas and were located in anterior thymic tissue previously divided by electrocautery. Awareness of the significance of lymph encountered during cardiac operations, particularly during reoperation and near the origin of the internal mammary artery, may alert the surgeon that the stage is set for a disabling complication. Electrocautery may be an unreliable means of control as lymph contains little coagulable material; suture is recommended instead.

Supradiaphragmatic ligation of the thoracic duct in intractable chylous fistula

Spontaneous closure of a chylous fistula is usual, but the rare intractable fistula may lead to disastrous nutritional and immunological consequences. We report the surgical management of 5 patients with intractable fistulas with daily drainage averaging 2,060 ml. Conservative therapy failing, the 5 patients underwent 6 ligations of the thoracic duct. A limited posterolateral thoracotomy was used in 3, full right thoracotomy in 2, and left thoracotomy in 1. Ligations were carried out immediately above the diaphragm, and not at the fistula site, by a mass ligature technique encircling all tissue between the azygos vein and aorta. The ligation achieved immediate cessation of drainage in four of five initial procedures and in the fifth patient, at a second operation. High-output thoracic duct fistulas may be handled by supradiphragmatic ligation of the thoracic duct. Identification of the fistula site or the dissection of the thoracic duct itself is avoided by this technique.

[Diagnosis of subpulmonary effusion in children (author's transl)]

If an elevation of the right or left base of the lung is found on a chest x-ray film, differential diagnosis will have to consider the follwoing possibilities: 1. Elevation of the diaphragm, 2. Subpulmonary effusion and 3. Hernia of abdominal organs through the diaphragm. Suspicion of a subpulmonary effusion is prompted by the following x-ray findings: 1. Flattening of the costophrenic angle and elevation of the base of the lung. 2. Increased distance between "magenblase" (stomach bubble) and base of the lung. 3. Elevation of the lower margins of the lung, the apex being in the region of the lateral hemithorax. 4. Translucency of the margins of the diaphragm below the elevated base of the lung. 5. Absence of vascular shadoes behind the diaphragm on a wellexposed x-ray film. If one or several of these symptoms is seen, proof should be obtained by provoking issuing of the effusion by placing the patient in supine position or in lateral position on the affected side, and by trying to achieve visualization of the resulting condition.

[Diagnostic problems in chest injuries (angiography) (author's transl)]

Roentgenography is the simplest and most reliable means to arrive at the diagnosis of chest injury. General roentgenograms are difficult to interpret as they tend to be technically imperfect. Fractures, emphysema, pneumothorax, accumulation of fluid can usually be ascertained directly; but the traumatic origin of changes in the pulmonary parenchyma or of an enlarged heart shadow cannot be reliably deduced from the X-ray appearance. It may provide some differential-diagnostic information but the correct interpretation of the findings depends on further observation. In 6-7% of severe chest trauma with vascular injuries and rupture of the diaphragm angiography is indicated. The evidence to be obtained from chest radiography should not be overestimated: fractures of ribs are sometimes overlocked, even by the expert; parenchymatous lesions may manifest themselves as shadows but their nature remains obscure until they have been related to the clinical and subsequent radiological findings. The same applies to rupture of the diaphragm, bronchi or vessels, if only the immediate posttraumatic roentgenographs are examined. A tent-shaped heart shadow is considered characteristic of the presence of fluid in the pericardium; this is valid only for chronic hydropericardium, but not for the potentially fatal cardiac tamponade; if the pericardium has lost its elasticity a haemorrhage of not more than 150 ml may prove fatal. Nor does the roentgenogram provide information about pulmonary function. Especially in cases of pulmonary shock minor changes in the chest roentgenogram may give a false sense of security when, in fact, blood gas analyses show that a life-endangering situation has developed. The radiologist who is aware of the limititations of the method will derive maximum diagnostic benefit from a chest angiography. No other method is capable of supplying information of such great importance in such a short time.

Chylothorax: a complication of Dwyer's anterior instrumentation

The authors report the development of an extensive right chylothorax several days after Dwyer's anterior instrumentation in a 6-year-old girl with a severe progressing infantile scoliosis. Instrumentation extended from T11 to L4 with removal of the tenth rib and with splitting of the diaphragm. The postoperative course was initially without any problems. However, respiratory distress on the tenth day after surgery was accompanied by mediastinal shift and the symptoms were relieved with aspiration of 600 ml of chyle from the right pleural cavity. The literature on this complication of chylothorax is reviewed; it has been observed in cardiothoracic surgery. The management of the case is reported in detail and methods of detection and treatment are discussed.

Chylothorax: therapeutic alternatives

Persistent loss of chyle, rich in metabolites, water and electrolytes, can be quickly devastating, particularly in debilitated patients and children. Chylothorax of traumatic origin, especially when loss of chyle is rapid, is most effectively arrested with direct closure of the fistula or ligation of the thoracic duct. Thoracic duct ligation is indicated when a controlled fat diet or parenteral hyperalimentation without oral intake and closed chest drainage are not effective in arresting chylous pleural effusions.

Diagnosis of chylothorax with 131I-triolein: case report

Communication between the thoracic duct and the pleural space can be demonstrated after oral administration of radiolabeled triglycerides or fatty acids of suitable chain length. A case of chylothorax was confirmed in this manner using 131I-triolein. The technique may be most useful in cases where the chylous nature of a pleural effusion is not apparent on inspection of the pleural fluid.

Chylothorax: diagnosis by lipoprotein electrophoresis of serum and pleural fluid

This report describes a 31-year-old woman who underwent a technically difficult left pneumonectomy for tuberculosis and developed thereafter a large left pleural effusion which was milky in colour. A traumatic chylothorax was suspected, and the diagnosis was confirmed by simultaneous fasting pleural and serum lipid studies and lipoprotein electrophoresis. The latter study was especially helpful in confirming the chylous nature of the fluid in that it revealed a marked chylomicron band at the origin; this was not present in the patient's serum nor in the pleural fluid of five patients with other disease states studied as controls.

Chylothorax: report of a case complicating ductus ligation through a median sternotomy, and review

An unusual case of chylothorax is described in a 4-year-old child after repair of a ventricular septal defect and ligation of a patent ductus arteriosus through a median sternotomy. Left chylothorax developed after a latent period of six days and was treated initially with continuous drainage and parenteral supplementation of proteins and lipids. Operative intervention with oversewing of the site of the leak in the anterior mediastinum proved necessary after three weeks. The anatomical variations of the thoracic duct are outlined to explain the occurrence of chylothorax after diverse intrathoracic operations. The physiological effects of a thoracic duct fistula and various aspects of management are reviewed.

[Chylothorax: causes, diagnosis, therapy]

The ductus thoracicus acts as the main vessel of the lymphatic system that flows into the venous system. It has the function of transporting lipis resorbed from the intestinal tract. Diseases of the thoracic duct are very rare and mostly result of injuries, tumors or as in most cases secondary infections. The main symptom in these cases is the presence of chylus outside of the ductus thoracicus, mainly in the thoracal spaces. Depending on the cause chylothorax is defined as traumatic, symptomatic or idiopathic. Therapy consists in drainage or ligature of the ductus thoracicus. The prognosis is good unless the cause is a malignant tumor resp. depends on the disease which is the cause of the chylothorax.

Diffuse lymphangiomyomatosis

A case of diffuse lymphangiomyomatosis with involvement of the large veins of the body is reported. The clinical, pathologoanatomic and especially the roentgenologic findings are described. Interstitial lung thickening, pleural effusions and spontaneous pneumothorax are findings which together with a stasis in the lymphatic system strongly suggest the diagnosis. The extensive involvement of the venous system supports the theory of a hamartomatous nature of the disease.

Experiences of postoperative chylothorax in children

Eight cases of postoperative chylothorax in children are discussed. The age of the patients varied between 5 hours and 18 months. Chylothorax was diagnosed between 3 and 14 days after operation. In 6 cases chylothorax was certainly due to damage to the thoracic duct, or other big lymph vessels in the lungs or mediastinum. These patients had no typical pulmonary changes before chylothorax developed. In 2 cases there was probably no damage to the lymph vessels, but the venous pressure in the upper part of the body was elevated by constriction of the superior caval vein. The anatomical prerequisites for chylothorax in these cases is discussed. In these patients, before chylothorax, pulmonary changes appeared in the radiograph interpreted as widened lymph vessels and caused by altered lymph flow at the periphery. If pulmonary changes of this kind appear in patients with elevation of pressure in the superior caval vein, this may be a sign that chylothorax may develop. The importance of early diagnosis is stressed. Drainage of the pleura with continuous suction has proved to be the therapy of choice. Direct operation has not been necessary in any of our cases.