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Eur J Cardiothorac Surg 2000;18:357-359
© 2000 Elsevier Science NL

Case report

Late presentation of tension chylothorax following blunt chest trauma

Oxford Heart Centre, John Radcliffe Hospital, Headley Way, Headington, Oxford, Oxfordshire OX3 9DY, UK

Received 18 January 2000; received in revised form 19 June 2000; accepted 28 June 2000.

Corresponding author. Tel.: +44-1865-220-442; fax: +44-1865-220-244

	Abstract

Top Abstract 1. Introduction 2. Discussion References

 
We describe the case of tension chylothorax in a 29-year-old man following blunt chest trauma sustained in a road traffic accident. This presented with respiratory and haemodynamic compromise. Conservative treatment was attempted but definitive surgical intervention was required.

Key Words: Chylothorax • Thoracic injury • Thoracic surgery • Case report

	1. Introduction

Top Abstract 1. Introduction 2. Discussion References

 
A 29-year-old male motorcyclist presented to the accident and emergency department following a high-speed collision. He was resuscitated according to Advanced Trauma and Life Support guidelines (ATLS). His injuries comprised of bilateral wrist fractures, abdominal tenderness, paraspinal tenderness at the level of T7–T9, loss of motor power and sensation below T12/L1, and a left sided pneumothorax with rib fractures.

Radiographs confirmed a left pneumothorax and an intercostal chest drain was therefore inserted in the left 5th intercostal space, draining air. Radiographic examination of the spinal column was unremarkable.

A computerized tomogram (CT) scan of the abdomen showed free gas. A laparotomy revealed small bowel serosal tears. His orthopaedic injuries were stabilized.

Post operatively he developed a right-sided pneumothorax requiring intercostal drainage. His unexplained sensorimotor loss was investigated further with magnetic resonance imaging (MRI), which revealed stable wedge fractures of T4 and T10 with spinal cord contusion and haematoma.

After 5 days the pneumothoraces had resolved and both intecostal drains were removed. He recovered from his laparotomy and commenced oral intake.

Three weeks following admission and whilst still recovering in hospital he became acutely unwell. He was tachycardic, peripherally shutdown and hypotensive with a respiratory rate of 30 breaths/min.

Examination of his chest showed tracheal deviation to the left and the right hemithorax was dull to percussion with reduced air entry and bronchial breathing. Saturations on pulse oximetry were reduced and radiography demonstrated complete opacification of the right hemithorax Fig. 1 .

View larger version (114K): [in this window] [in a new window]   Fig. 1. Chest radiograph demonstrating opacification of the right hemithorax with mediastinal shift to the left secondary to tension chylothorax.

Over the following 3 successive days the drainage from the chest amounted to 10, 8 and 6 l and the patient became hypoalbuminaemic despite TPN and fluid restriction. The chylous leak was failing to respond to conservative therapy and after 4 days the decision was made to take the patient to the operating theatre.

He was anaesthetized, a nasogastric tube was passed and 500 ml of cream syringed into his stomach. A right posterolateral thoracotomy through the 6th intercostal space was performed. Findings consisted of 1.5 l of chyle and a hole in the thoracic duct lying on the body of T8 and visibly discharging chyle. This was closed directly and a supradiaphragmatic duct ligation with pledgeted sutures was performed below this. Talc was liberally spread within the pleural cavity and the chest closed conventionally over two drains, which were placed on suction.

Initial postoperative management consisted of total parenteral nutrition, nil by mouth and continuous intercostal drainage. Over the following week the discharge from the chest drains decreased and they were removed. He recommenced oral intake and made an uneventful recovery from his thoracic operation.

	2. Discussion

Top Abstract 1. Introduction 2. Discussion References

 
Between 1.5 and 2.5 l of chyle return to the circulation via the thoracic duct daily [1]. Chylothorax results from damage to the duct and collection of chyle within the chest. As the incidence of thoracic surgery rises, the aetiology of duct trauma is increasingly surgical (0.2–0.5% of cardiac [2] and 1.0–1.5% oesophageal [3] surgical patients develop chylothoraces). Non-surgical thoracic trauma, both penetrating and less often blunt [4] accounts for the majority of the remaining cases. Chylothorax is associated with profound respiratory, nutritional and immunological consequences and can lead to significant patient morbidity and mortality.

Tension chylothorax has rarely been described. Previous cases have been associated with recent pneumonectomy [5]. In these, it presented 5–8 days following surgery with respiratory and haemodynamic compromise. Patients become tachypnoeic, tachycardic and hypotensive with an elevated jugular venous pressure. Their hemithoraces are dull to percussion, with reduced air entry and mediastinal shift. Chest X-ray (CXR) will confirm the presence of fluid, mediastinal shift and flattening/inversion of the hemidiaphragm. This is a result of high flow pressures (up to 50 cmH₂O [1]) within an obstructed, damaged thoracic duct, which continues to pump chyle into the hemithorax.

Management of chylothorax varies between centres. Intercostal drainage is common to all techniques. Some centres advocate 2 weeks total parenteral nutrition with no oral intake [6]. Oral intake will increase chyle flow by up to 20% and nil by mouth will reduce this substantially. Others would continue this regime for 4 weeks [7]. During this time the well being of the patient has to be considered. If drainage exceeds 1.5 l/day [5], the patient is deteriorating or conservative treatment fails after 2–4 weeks then operative treatment results. The thoracic duct is identified and ligated using a thoracotomy or minimally invasive approach. This is often combined with a pleurodesis. Identification of the source is often difficult and some authors have used cream placed in the stomach preoperatively via a nasogastric tube to help delineate the leak [5]. Lymphograms are now rarely used. They are time consuming and are off no real benefit unless repair of the defect is contemplated. In most cases if conservative management fails the duct is tied off at the diaphragm and the information supplied by a lymphogram adds nothing [8]. CT scans can be helpful if neoplasia is thought to be involved. Other methods employed to identify the thoracic duct leak include ‘Evans Blue’ lymphangiography [9].

Our case is a rare example of tension chylothorax resulting from blunt trauma. The mechanism is thought to be hyperextension injury to the spine. Chylothorax has previously been described in a 52-year-old woman following body trunk hyperextension [10] but not associated with the presence of tension. It is interesting that the chylothorax took 3 weeks to present following initial injury. The patient remaining nil by mouth after his laparotomy undoubtedly had a part to play in reducing the flow of chyle through the thoracic duct. His orthopaedic injuries limited his mobility, reducing symptoms secondary to lung compression. This all participated in delaying diagnosis until the time of tension.

	References

Top Abstract 1. Introduction 2. Discussion References

 

1. Watne A.L., Hatiboglu I., Moore G.E. Clinical and autopsy study of tumour cells in thoracic duct lymph. Surg Gynecol Obstet 1960;16:12.
2. Cevese P.G., Vecchioni R., D'Amico D.F., Cordiano C., Biasiato R., Favia G., Farello G.A. Postoperative chylothorax. J Thorac Cardiovasc Surg 1975;69:966.[Abstract]
3. Fekele F., Prandi D., Lortat Jacob J.L. Les chylothorax postoperatories enchirurgie oesophagienne. Ann Chir 1972;26:19.
4. Dulchavsky S.A., Ledgerwood A.M., Lucas C.E. Management of chylothorax after blunt chest trauma. J Trauma 1988;28(9):1400-1401.[Medline]
5. Karwande S.V., Wolcott M.W., Gay W.A., Jr Post pneumonectomy tension chylothorax. Ann Thorac Surg 1986;42(5):585-586.[Abstract]
6. Fogli L., Gorini P., Belcastro S. Conservative management of traumatic chylothorax: a case report. Intens Care Med 1993;19(3):176-177.[Medline]
7. Ikonomidis J.S., Boulanger B.R., Brenneman F.D. Chylothorax after blunt chest trauma – a report of 2 cases. Can J Surg 1997;40(2):135-138.[Medline]
8. Wilson A.G. The pleura and pleural disorders. In: Armstrong P., Wilson A.G., Dee P., eds. Imaging of diseases of the chest. Year Book Medical Publishing, 1990:627-702.
9. Kohnoe S., Takahashi I., Kawanaka H., Mori M., Okadome K., Sugimachi K. Combination of preoperative lymphangiography using lipiodol and intraoperative lymphangiography using Evans Blue facilitates the accurate identification of postoperative chylous fistulas. Surg Today 1993;23:929-931.[Medline]
10. Chauvin O., Dore P., Meurice J.C., Boita F., Patte F. Bilateral chylothorax after mild trauma: apropos of a case. Rev Pneumol Clin 1992;48(2):71-73.[Medline]

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