Chylopericardium following esophagectomy: a case report and systematic review

BACKGROUND

Chylopericardium is a rare condition characterized by the accumulation of chyle in the pericardial space. It is most commonly caused by thoracic duct injury. Chylopericardium following esophagectomy is extremely rare but can cause life-threatening complications. This report presents a case of chylopericardium post-esophagectomy, resulting in cardiac tamponade and cardiac arrest. A systematic literature review was also conducted to facilitate the understanding of this rare condition.

CASE PRESENTATION

A 41-year-old male was admitted to our hospital with intermediate to highly differentiated squamous cell carcinoma of the mid-thoracic esophagus (clinical T4NxM0). He underwent thoracoscopic-laparoscopic esophagectomy with cervical anastomosis. On postoperative day 1, patient had a cardiac arrest secondary to cardiac tamponade, requiring emergency ultrasound-guided drainage. The drained fluid was initially serous but became chylous after the administration of enteral nutritional emulsion. As a result of significant daily pericardial drainage, patient subsequently underwent thoracic duct ligation. The amount of drainage was substantially reduced post-thoracic duct ligation. Over a period of 2 years and 7 months, patient recovered well and tolerated full oral diet. A comprehensive literature review was conducted and 4 reported cases were identified. Among these cases, three patients developed pericardial tamponade secondary to chylopericardium post-esophagectomy.

CONCLUSION

Chylopericardium is a rare but serious complication post-esophagectomy. Prompt echocardiography and thorough pericardial fluid analysis are crucial for diagnosis. Thoracic duct ligation has been shown to be an effective management approach for this condition.

Primary idiopathic chylopericardium managed by uniportal VATS

Chylopericardium is very rarely encountered in clinical practice. The common causes are post cardiac or thoracic surgery and neoplasms of the mediastinum. Most of the time, no cause is attributed and it is labelled as primary idiopathic chylopericardium. Conservative management is usually not successful and definitive surgery is required. The recommended surgery is creation of a pericardio-pleural window and thoracic duct ligation. We demonstrate that this procedure can be easily accomplished by uniportal video-assisted thoracic surgery (U-VATS).

Chylothorax and chylopericardial tamponade following lobectomy and lymphadenectomy: a rare presentation

BACKGROUND

Although postoperative chylothorax following lung cancer surgery is rare, it is a recognized complication in 0.25-3% of patients. However, cases of cardiac tamponade caused by chylopericardium after lung cancer surgery are extremely rare.

CASE PRESENTATION

We describe hitherto unreported sequelae of chyle leak following lobectomy and systematic mediastinal lymph node dissection (SLND) causing pericardial tamponade and cardiovascular compromise. The patient was successfully treated with minimally invasive surgical repair and ligation. We also discuss the development of chylopericardium as a potential complication of lobectomy and SLND.

CONCLUSIONS

The anatomical characteristics of the thoracic duct warrant special attention in postoperative chyle leak management in patients who undergo definitive mediastinal lymph node dissection. Surgeons should be aware that chylopericardium is a rare but potential complication of lobectomy and SLND as it may help with early diagnosis, management, and prevention of cardiac tamponade.

Challenges to manage primary chylopericardium in children

Primary chylopericardium (PC) is a rare entity in the pediatric population with very few reported cases. Most cases of chylopericardium manifest after trauma or following cardiac surgery. The other etiologies which may lead to chylopericardium are malignancy, tuberculosis, or congenital lymphangiomatosis. We report two cases of PC in the pediatric population with contrasting outcomes. Both failed conservative management with dietary modification and octreotide. Surgery with pleuropericardial and pleuroperitoneal windows was performed in both. The first case had a thoracic duct ligation. The first patient died, and the second survived.

Chylotamponade in Pediatric Primary Mediastinal Large B-Cell Lymphoma

Chylotamponade involves rapid accumulation of chyle in the pericardium elevating the pericardial pressures above normal right heart filling pressures, and is extremely rare. A 12-y-old boy presented to the emergency with complaints of facial puffiness for 1 mo and breathing difficulty for 1 wk. The neck veins were distended, and the heart sounds were muffled. A chest CT demonstrated a large anterior mediastinal mass with pleural and pericardial effusions. Echocardiography confirmed cardiac tamponade. Pericardiocentesis revealed chylopericardium. He was placed on a chyle leak diet, and the drain was removed after 48 h. Biopsy of the mediastinal mass revealed a primary mediastinal B-cell lymphoma. He was successfully managed with chemotherapy. The index case demonstrates how prompt identification and management of chylotamponade and treatment of the underlying cause can lead to good clinical outcomes.

Review of chylopericardium

Chylopericardium is a rare pathologic condition consisting of the accumulation of excess amounts of chylous fluid within the pericardial cavity. Most patients are asymptomatic at presentation; however, chest pressure, chest pain and lightheadedness have been reported, and the most common presenting symptom is shortness of breath. Patients are noted to have enlargement of the cardiac silhouette on routine chest radiograph, and evidence of a pericardial effusion on echocardiography. The diagnosis is only definitively confirmed with pericardiocentesis and fluid analysis. The fluid is typically turbid white or milky in appearance, with a triglyceride level in excess of 500 mg/dL. The mechanism by which chyle accumulates within the pericardium is believed to be secondary to abnormal or damaged lymphatics or due to elevated pressure within the thoracic duct that results in chyle reflux into the pericardium. Following drainage with a pericardiocentesis or pericardial drain, attempts at conservative therapy with nothing by mouth and parental nutrition can be made, but have a high rate of failure and subsequent reaccumulation of chyle. Surgical treatment provides the most definitive management and consists of ligation of the thoracic duct just above the level of the diaphragm and creation of a pericardial window. With this treatment, risk of recurrence is incredibly low (<5%).

Post-medistinoscopy chylopericardium

Isolated Chylopericardium (without chylothorax) is a rare clinical disorder that may happen idiopathically or secondary to trauma, radiotherapy, lymphatic anomalies, infections or mediastinal neoplasm. We present a case of middle-aged male with no past medical history of note prior to developing heavy sweating, loss of weight and cough. A series of investigations were done including chest computed tomography which showed enlarged mediastinal lymph nodes leading to uncomplicated mediastinoscopy and lymph node biopsy. Six days after being discharged, he developed dyspnoea and chest pain. Echocardiography revealed massive pericardial effusion. Pericardiocentesis was done and surprisingly revealed milky white chylous fluid. The patient was then successfully managed without the need for further intervention.

Spontaneous chylopericardium in an adult due to mediastinal cystic hygroma

Chylopericardium is a rare and benign condition. Apart from common causes like non-surgical trauma, tuberculosis, malignancy, radiation, and postoperative, mediastinal cystic hygroma presenting as chylopericardium is an extremely rare entity. Primary or idiopathic chylopericardium is diagnosed when the precise cause is not known. It is a diagnosis of exclusion. We report a 27-year-old lady with mediastinal cystic hygroma, presenting as spontaneous chylopericardium, who was managed surgically with no recurrence on 18 months follow-up. She was evaluated for complaints of discomfort in the upper abdomen region and breathing difficulty in left lateral position for 4 days, and was found to have a large pericardial effusion with impending tamponade. She underwent pericardiocentesis, and on fluid analysis, it was confirmed as chylous pericardial effusion. She was evaluated thoroughly and was taken up for right video-assisted thoracoscopy. The thoracic duct was clipped and a window was created in the pericardium, the cystic hygroma was excised, and pleurodesis was done. The postoperative period was uneventful. Histopathology of the pericardial window showed chronic inflammatory pathology and cystic lesion was confirmed as a chylous cyst.

A case report of generalized lymphangiomatosis with chylopericardium: the crucial role of magnetic resonance lymphangiography

Background

Chylopericardium due to generalized lymphangiomatosis is a rare clinical entity. Its aetiology and treatment remain unclear.

Case summary

We report one case of a 51-year-old man who was diagnosed with generalized lymphangiomatosis with idiopathic chylopericardium by bilateral inguinal intranodal contrast-enhanced magnetic resonance lymphangiography. Magnetic resonance lymphangiography demonstrated abnormal communications between the pericardial sac and the thoracic duct. The patient with idiopathic chylopericardium was therefore successfully treated by exclusive surgical ligation of the abnormal communications and partial pericardiectomy by thoracotomy. The patient’s postoperative recovery was uneventful, and no recurrence of pericardial effusion occurred during the 13-month follow-up.

Discussion

Magnetic resonance lymphangiography showed a good capability for evaluating the extent of generalized lymphangiomatosis and therefore is helpful for delineating the anatomy of the thoracic duct and identifying chyle leakage and abnormal communications between the thoracic duct and the pericardial sac. This makes a simple ligature of the abnormal communications, instead of thoracic duct mass ligation possible in the treatment of chylopericardium.

Steroids as a possible effective therapy in the management of large isolated chylopericardium following open heart surgery

BACKGROUND

Chylopericardium is the collection of lymph fluid inside the pericardial cavity. The incidence of chylopericardium is very low, as this diagnosis is rarely reported following cardiac procedures in children. While some reports were published worldwide on isolated chylopericardium after cardiac surgeries for diverse reasons, it has never been reported after repair for partial anomalous pulmonary venous return. In addition, management of this diagnosis ends up being surgical with minimal concentration on medical treatment which proved unsuccessful. We present a medical approach with corticosteroids as an effective method to treat isolated chylopericardium.

CASE PRESENTATION

In this manuscript, we present an approach to treat isolated post-operative chylopericardium in a child following repair of partial anomalous pulmonary venous return. Chylous drainage responded to corticosteroids and completely ceased. There was no need for surgical intervention.

CONCLUSION

Until now, isolated chylopericardium has never been reported to occur with partial anomalous pulmonary venous return repair. A review of the literature showed that most patients follow a conservative approach consisting of diuretics and non-steroidal anti-inflammatory agents with some of them undergoing surgical re-intervention. With future research on the topic still needed, we hope that this will encourage physicians worldwide to consider administering a trial of corticosteroids as an option to treat chylopericardium.

Complete resolution of chylopericardium after chemotherapy for chronic lymphocytic leukemia

Nontraumatic chylous pleural effusions (chylothorax) and pericardial effusions (chylopericardium) are rare. They can, however, accompany intrathoracic malignancies and, most commonly, lymphomas. An association of chronic lymphocytic leukemia (cll) with chylopericardium has rarely been reported. A 68-year-old woman with cll, previously treated with single-agent fludarabine in the community, developed pleuritic chest pain and a new pericardial effusion. Computed tomography (ct) imaging of her chest revealed a large pericardial effusion with progressive lymphadenopathy. Pericardiocentesis identified a chylous effusion, and complete evacuation was achieved by catheter drainage. The cll was not treated. An asymptomatic pericardial effusion subsequently recurred. Pericardiocentesis was not repeated. Lymph node biopsy and flow cytometry revealed no evidence of large-cell lymphoma transformation. The patient was treated with 6 cycles of chlorambucil and obinutuzumab. Imaging of her chest by ct between cycles 2 and 3 revealed a marked resolution of the intrathoracic lymphadenopathy, with complete disappearance of the pericardial effusion. Repeat imaging at 5 months and again at 3 years after completion of chemotherapy demonstrated no recurrence of either the lymphadenopathy or the pericardial effusion. The mechanism of production and the treatment of chylous effusions are poorly defined. In this case, resolution of the pericardial effusion with effective chemotherapy is postulated to have alleviated obstruction of anterograde lymphatic flow facilitating drainage into the systemic venous system and allowing for spontaneous complete resolution of the pericardial effusion without surgical intervention.

Pigtail saves a twisted redo: successful management of chylopericardium after midline valve surgery

Pericardial effusion after midline cardiac surgery may be transudative or exudative. The exudative infective or haemorrhagic variety requires early surgical intervention. However there are rare cases of collections like chylomediastinum which should be ruled out. Their low incidence prompts to establish protocol for evaluating postoperative pericardial collections, which includes echocardiography and biochemical analysis of aspirate. The same is important from the perspective of management as chylopericardium may be successfully managed without surgical intervention by aspiration, pig tail insertion, dietary and medical management, which we demonstrate through our rare case which occurred after midline double valve replacement.

Pediatric Chylopericardium: Treatment Conundrum

Primary chylopericardium is a rare entity in the pediatric population, which is characterized by chyle accumulation in the pericardial sac. Treatment of this rare problem is a management dilemma as no definitive treatment has been found to be curative. We share our experience of treating chylopericardium with minimally invasive surgery.

Chylopericardium following thoracoscopic resection of a mediastinal cyst: A case report

INTRODUCTION

Thoracic duct cysts are very rare, and diagnosis is often difficult. We report a rare case of chylopericardium following thoracic duct cyst resection. There are no established guidelines on the management of such cases. We reviewed the literature on postoperative complications after thoracic duct cyst resection, and conducted the first thorough review of the etiology and management of chylopericardium in surgical cases.

PRESENTATION OF CASE

A 54-year-old male presented with cardiac tamponade due to chylopericardium. He had undergone resection of a thoracic duct cyst 2 years previously, which was complicated by postoperative chylothorax. Chyle accumulation resolved with conservative treatment.

DISCUSSION

Chylothorax is a frequent complication following thoracic duct cyst resection, especially in cases where no intraoperative diagnosis is reached. Diagnosis may be difficult due to anomalous location of the cyst, as in our case. Chylopericardium is rarely reported, and may have occurred in our case because of prior pleurodesis. Chyle accumulation can reportedly be managed with diet restrictions in over half of reported cases, especially in cases of lung or mediastinal tumor resection.

CONCLUSION

The most important points highlighted by this rare case of chylopericardium secondary to thoracic duct cyst resection are: 1) pedicles should be ligated in cyst resections, regardless of location; 2) careful assessment in the initial surgery may help identify the point of leakage; 3) low-fat diet is the first choice in the initial management of postoperative chylopericardium, but surgical repair may be considered in cases with no response after>2 weeks of conservative treatment.

Chylopericardium presenting as cardiac tamponade secondary to mediastinal lymphangioma

Mediastinal lymphangioma is a rare entity and chylopericardium is a rare form of pericardial effusion. We report a case of acute chylous cardiac tamponade due to a cervicomediastinal lymphangioma in a one-year-old boy. A chest x-ray revealed marked cardiac enlargement and echocardiography showed massive pericardial effusion. Emergency surgery was performed whereby a pericardial window was created, followed by excision of the lymphangioma.

Pulmonary Kaposi's Sarcoma and Its Complications in the HAART Era: A Contemporary Case-Based Review

The early years of the acquired immunodeficiency syndrome (AIDS) epidemic introduced the global medical community to Kaposi's sarcoma (KS), a heretofore seldom encountered angiosarcomatous neoplasm associated with human herpesvirus-8. At that time, clinicians treating these KS patients were routinely exposed to the pulmonary manifestations of this malignancy, including characteristic airway lesions, peribronchovascular opacities, and the typically hemorrhagic pleural effusions. They also witnessed uncommon complications of pulmonary KS such as chylous effusions, diffuse alveolar hemorrhage, and immune reconstitution inflammatory syndrome. Since the advent of highly active antiretroviral therapy, the incidence of KS has steadily declined and with that so has clinician familiarity with this disease. Herein, we present four KS cases recently encountered at our institution that illustrate both typical manifestations of pulmonary KS as well as its thoracic complications. The case descriptions are followed by a review of these clinical entities with the aim of restoring awareness among frontline physicians of what is now a rare but not quite extinct AIDS-defining neoplasm.

Paediatric case report]

BACKGROUND

Chylopericardium is a rare occurrence in children. The most common causes are associated with cardiac surgery, malformations of the lymphatic system, idiopathic reasons, among others.

OBJECTIVE

The case is presented of a patient with traumatic chylopericardium, the diagnostic methodology, and in particular, its successful resolution by surgical means.

CLINICAL CASE

Male patient of 6 years old, previous accident of fall from patient's height. Chest x-ray showed evidence of cardiomegaly. An echocardiogram with pericardial effusion was performed. Pericardial puncture was performed with drainage of milky material, confirming chylous liquid. Treatment included pericardial catheterisation, total parenteral nutrition, octreotide, and diet with medium chain triglycerides, with persistent increased pericardial fluid. Lymphatic abnormalities were ruled out by MRI. He underwent surgical treatment due to failure of prior treatment. A thoracoscopic approach was adopted with a favourable outcome.

CONCLUSIONS

Chylopericardium occurs in children in most cases after cardiovascular surgery. The case presented here was classified as idiopathic. Patients with this condition may present with severe symptoms, such as tamponade, or can be asymptomatic as in the case presented. If medical treatment fails, it should be resolved by surgery; the best choice is minimally invasive treatment with its well-known advantages.

Chylous pericardial effusion as a rare complication after pulmonary endarterectomy

Chylous pericardial effusion is a rare complication of cardiac surgery. We report a case of a patient who underwent pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension and was diagnosed with chylopericardium after the procedure. We present the surgical management of this condition, which included bilateral pedal lymphangiography followed by ligation of injured lymph vessel.

Chylopericardium Secondary to Lymphangiomyoma - A case report -

Chylopericardium is a rare disease entity characterized by the accumulation of chylous fluid in the pericardial sac. It usually arises from mediastinal neoplasms, thrombosis of the subclavian vein, tuberculosis, nonsurgical trauma, thoracic or cardiac surgery. The spectrum of symptoms for chylopericardium varies from an incidental finding of cardiomegaly to dyspnea, upper abdominal discomfort, cough, chest pain, palpitation, fatigue. However, most of the patients are asymptomatic. The main purpose of treatment of chylopericardium is the prevention of cardiac tamponade and prevention of metabolic, nutritional, and immunological compromise due to chyle leak. Here, we report a case of chylopercardium secondary to lymphangiomyoma with review of the literature.

Bilateral chylothorax, chylopericardium and chylous ascitis

Non-Hodgkin's lymphoma (NHL) can commonly present as chylothorax and rarely as chylopericardium. Here we are presenting a case of a 21-years-old female with bilateral chylothorax, chylopericardium and chylous ascites all together finally diagnosed to have NHL as the etiology. To the best of our knowledge, it has been reported very infrequently.