Chylothorax. Clinical experience in nine cases

An unusual case of chylothorax

Pleural effusions occur in up to 70% of cases of malignant pleural mesothelioma (MPM). However, MPM rarely presents as a chylous effusion making it a diagnostic challenge. There are only six reported cases to date. Most cases of chylothoraces due to malignancy are due to lymphoma or bronchogenic carcinoma. We report an interesting case of MPM in a 75-year-old man who presented with recurrent chylothorax. He reported a four-month history of dyspnea and chest discomfort. Chest x-ray revealed a pleural effusion. Pleural fluid analysis was consistent with a chylothorax. Pleural fluid cytology was negative for malignancy. Computed tomography of the chest showed pleural calcifications, mediastinal adenopathy and left lung infiltrate. A fine needle aspirate of the lymph node and transbronchial biopsy specimen (TBBX) of the left lung infiltrate showed extensive reactive appearing mesothelial cells but none that appeared malignant. A video assisted thoracoscopic surgery was suggested but the patient declined. He returned 3 months later with recurrent pleural effusion and worsening airspace disease. Thoracentesis revealed a chylothorax again. Repeat analysis of TBBX and lymph node specimens showed extensive reactive appearing mesothelial cells. Due to concern for MPM, ancillary testing was obtained - loss of BRCA1 associated protein (BAP-1) and CDKN2A/p16 gene deletion. BAP1 staining was lost in the mesothelial cells supporting MPM. This case highlights a rare cause of MPM presenting as a chylous effusion. In a patient with an unknown etiology of chylothorax, MPM must remain in the differential.

Chest pain and recurrent chylothorax: an unusual presentation of malignant pleural mesothelioma

Malignant mesothelioma presenting with recurrent chylous effusion is rare. We describe the case of a 34‐year‐old female Macedonian immigrant who presented with central chest pain and subsequently a left‐sided chylous pleural effusion. The diagnosis was made on pleural biopsy via video‐assisted thoracoscopic surgery (VATS). Our case demonstrates the utility of thoracic magnetic resonance imaging (MRI) and the difficulties associated with pleural cytology and cervical lymph node biopsy in the establishment of a diagnosis of mesothelioma. It is a reminder that mesothelioma can metastasize to mediastinal and cervical lymph nodes, can occur in young people, and may present as a chylothorax.

Chylothorax complicating pulmonary resection

BACKGROUND

Chylothorax complicating pulmonary resection (CCPR) is infrequent and surgical treatment is for the most part avoided. The purpose of this study is to analyze the clinical and therapeutic characteristics of this complication.

METHODS

From March 1981 to June 2001, 26 cases of CCPR (24 men and 2 women; mean age 57 years) were treated in two departments of thoracic surgery. Twenty-five cases complicated lung resection for lung cancer (lobectomy n = 14, bilobectomy n = 3, pneumonectomy n = 8) and 1 case followed lobectomy for a benign lesion. Medical history, location, and characteristics of the chylothorax, lymphography, and clinical evolution after medical or surgical therapy were studied.

RESULTS

Medical history was never predictive of CCPR. Chylothorax was right sided in 18 cases and left sided in 8 cases. The total amount of chyle ranged from 1.9 L to 27.9 L per patient with a mean of 7.9 L (pneumonectomy 12.3 L and lobectomy 6.3 L). In 15 patients (pneumonectomy n = 2 and lobectomy n = 13) mean quantity of daily chyle was 0.3 L. All these patients recovered with conservative therapy except for 2 patients who underwent drainage and talc slurry (n = 1) and video-assisted lysis of adhesions (n = 1). In the remaining 11 patients (pneumonectomy n = 6 and lobectomy n = 5) mean quantity of daily chyle was 1 L. The chylous leak was seen at lymphography (n = 4), during reoperation (n = 2), or at lymphography and reoperation (n = 3). The location was clearly identified at the level of thoracic duct tributaries in all cases. In 4 postlobectomy cases (4 of 7), surgery was not performed because of the therapeutic usefulness of lymphography. Reoperation was necessary in 6 cases (postpneumonectomy n = 5, postlobectomy n = 1) and consisted of duct ligation (n = 2), leak/suture (n = 3), and fibrin glue (n = 1).

CONCLUSIONS

CCPR is rare and appears to respond well to medical treatment owing to the fact that the thoracic duct is generally patent as the leak is due to injury of its tributaries. When surgery is considered, lymphography may help to select cases in which conservative medical therapy should be continued. However, in a small number of cases, usually after pneumonectomy, surgery remains mandatory.

Early thoracic duct ligation for postoperative chylothorax

Four cases of postoperative chylothorax occurring at this institution over the past 5 years, as well as an extensive review of the world literature, are presented. Of the four cases, three occurred after resection of carcinoma of the lung and one after resection of recurrent chondrosarcoma of the chest wall. These patients were treated nonoperatively for varying periods of time ranging from 2 days to nearly 3 weeks. Subsequently, all patients underwent ligation of the thoracic duct. Early reoperation for ligation of the thoracic duct resulted in no morbidity or mortality. In one case of delayed thoracic duct ligation, after an attempt at ligation of minor lymphatic vessels, the single mortality occurred. In view of the experience with these patients and that reported in the literature, we propose that not only is thoracic duct ligation superior to nonoperative management, but that it should be undertaken without delay.

Chylothorax after endoscopic sympathectomy: case report

Endoscopic sympathectomy is a new trend for the treatment of hyperhidrosis palmaris. It is a simple and effective technique; however, it carries some recognized risks such as Horner's syndrome and pneumohemothorax. We recently encountered a case complicated by the development of a chylothorax. The patient was a 23-year-old healthy women with profuse palmar sweating. She developed an intractable dry cough after a transthoracic endoscopic sympathectomy. A chest x-ray revealed a left pleural effusion. A chylous effusion was found after thoracentesis and fluid analysis. The pleural effusion resolved after chest tube drainage and diet control. Although endoscopic sympathectomy is a simple and quick procedure, unusual complications, such as chylothorax, may occur. Appropriate early recognition and treatment can prevent a disastrous result.

Nutritional management of thoracic duct fistulas. A comparative study of parenteral versus enteral nutrition

Thoracic duct fistulas represent one of the serious technical complications of head and neck surgery, and reoperation for control of the leakage involves considerable morbidity and mortality. In an attempt to define the possibilities of both enteral and parenteral nutrition in the treatment of this problem, two comparable groups of patients were given, respectively, one or the other of these modalities. Significant advantages for parenteral nutrition could be demonstrated regarding duration of therapy (p less than 0.05), closure rate (p less than 0.05), and nutritional response (p less than 0.05). These results strongly recommended the utilization of parenteral nutrition in the primary therapy of thoracic duct fistulas.