Tension chylothorax: a rare life threatening entity after pneumonectomy

Tensioned space after pneumonectomy for cancer with mediastinal shift and cardiac tamponade‑causes and treatment (Review)

Regarding the pleural space after pneumonectomy for malignancy, a vast number of studies have assessed early drop in the fluid level, suggesting a broncho-pleural fistula, but only a small number of studies reported on the abnormal increase in the fluid level-a potentially lethal complication. In the present study, the available databases worldwide were screened and 19 cases were retrieved, including 14 chylothorax and 3 hydrothorax cases, 1 pneumothorax and 1 haemothorax case. Tension chylothorax is caused by mediastinal lymph node dissection as an assumed risk in radical cancer surgery. For tensioned haemothorax, the cause has not been elucidated, although lymphatic stasis associated with deep venous thrombosis was suspected. Tensioned pneumothorax was caused by chest wall damage after extrapleural pneumonectomy combined with low aspiration pressure on the chest drain. No cause was determined for none of the tensioned hydrothorax-all 3 cases had the scenario of pericardial resection in addition to pneumonectomy in common. Tensioned space after pneumonectomy for cancer manifests as cardiac tamponade. Initial management is emergent decompression of the heart and mediastinum. Final management depends on the fluid type (chyle, transudate, air, blood) and the medical context of each case. Of the 19 cases, 12 required a major surgical procedure as the definitive management.

Tension chylothorax following pneumonectomy

Post-pneumonectomy chylothorax is an uncommon complication following surgery, with an estimated incidence of less than 0.7%. Post-pneumonectomy tension chylothorax, where rapid accumulation of chyle in the post-pneumonectomy space results in hemodynamic compromise, is exceedingly rare, with just 7 cases previously reported. All prior cases of tension chylothorax were managed operatively with decompressive chest tube placement followed by open thoracic duct repair. Our case is the first reported tension chylothorax to be managed conservatively by thoracostomy drainage coupled with a period of parenteral nutrition followed by a medium chain triglyceride-restricted diet.

Traumatic tension chylothorax: Lessons from a rare complication of thoracic spinal trauma

Injury to the thoracic duct following blunt trauma can rarely result in tension chylothorax. We report a case of traumatic tension chylothorax in a young man with cervical and thoracic spine injuries after he was hit by the open luggage compartment of a passing bus. Diagnosis was made on the fourth day following injury when he became short of breath during physiotherapy, and then deteriorated rapidly with haemodynamic compromise. The tension chylothorax was treated with intercostal drainage leading to immediate resolution of cardiorespiratory function. No further surgical intervention was required. This case highlights three important learning points: pleural fluid, not just air, can cause tension; seriously injured patients should have a multidisciplinary trauma team assessment on arrival to hospital and when reviewing radiographs, all the structures should be carefully examined, not just those that the study was performed to examine.