Ann Thorac Surg 2003;75:285-286
© 2003 The Society of Thoracic Surgeons
Case report
Late-onset chylothorax after heart–lung transplantation
David Shitrit, MDa,
Gabriel Izbicki, MDa,
Daniel Starobin, MDa,
Dan Aravot, MDb,
Mordechai R. Kramer, MDa*
a Pulmonary Institute, Rabin Medical Center, Beilinson Campus, Petah Tiqva, Israel
b Cardiothoracic Unit, Rabin Medical Center, Beilinson Campus, Petah Tiqva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
Accepted for publication August 5, 2002.
* Address reprint requests to Dr Kramer, Pulmonary Institute, Rabin Medical Center, Beilinson Campus, Petah Tiqva 49100, Israel
e-mail: pulm{at}netvision.net.il
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Abstract
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Chylothorax has rarely been reported after heart and lung transplantation. We describe a case of a bilateral chylothorax that occurred in a 53-year-old man 4 months after heart–lung transplantation and review the three additional reports in the literature of chylothorax after heart transplantation. Chyle drainage may cause compromise of the transplant patient. The good nutritional status of our recipient, however, allowed conservative therapy with chest tube drainage and enteral low-fat diet, without the need for surgical intervention. We concluded that chylothorax can presents late after lung transplantation and that conservative treatment should be considered in patients with good nutritional status.
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Introduction
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Laceration of the main thoracic duct can occur during any thoracic procedure, causing chylothorax. The reported rate of this complication is less than 1%. Of the 11,315 patients after thoracic surgery included in the study by Cerfolio and colleagues [1], only 47 (0.42%) were found to have postoperative chylothorax. The reported prevalence ranges from 0.5% to 2%. Chylothorax is even more rarely associated with heart and lung transplantation. In their review of the pleural complications of lung transplantation, Herridge and associates [2] reported that chylothorax developed in only 1 of 91 double lung transplant recipients and in none of the 53 single lung transplant recipients. To the best of our knowledge, only three instances of chylothorax after heart transplantation have been reported [3–5], all of which occurred early in the postoperative course.
We describe a heart–lung transplant recipient who developed bilateral chylothorax 4 months after transplantation. Conservative therapy with chest tube drainage and enteral low-fat diet led to complete resolution, without the need for surgical intervention. The three additional reports of chylothorax after heart transplantation are reviewed.
A 53-year-old man presented at our pulmonary day-care unit with progressive dyspnea without fever or cough 4 months after undergoing heart–lung transplantation. Primary pulmonary hypertension had been diagnosed 2 years previously and was treated for 17 months with continuous intravenous prostacyclin. Thereafter, the patient’s condition deteriorated, and transplantation was performed. The immediate postoperative period was uneventful.
On admission, pulmonary function testing revealed a moderate restrictive ventilatory defect, and chest roentgenogram film showed a moderate-sized bilateral pleural effusion (Fig 1).
A left chest tube was inserted, and 550 mL of milky fluid was drained. Analysis showed a lymphocyte-predominant exudative fluid, with pleural triglyceride (465 mg/dL; plasma level, 126 mg/dL), pleural cholesterol (103 mg/dL; plasma level, 233 mg/dL), and pleural lactic dehydrogenase (1,115 U/L; plasma level, 395 mg/dL). Total blood lymphocyte count was 1,200/mm3. Cyclosporine level measured 235 ng/mL. Staining was negative for bacteria, mycobacteria, and fungi. Bronchoscopy showed an intact, well-healed bronchial anastomosis with normal airway. Histologic examination of the transbronchial biopsy specimen showed no evidence of acute lung rejection. A right chest tube was inserted a few hours after the left one, and 150 mL of fluid was drained. Both chest tubes were then removed, and the patient was placed on an enteral low-fat diet. His condition gradually improved over the next 2 weeks with no additional treatment. Repeated pulmonary function results improved as well, and all pleural and bronchoscopic stains and cultures were negative. Serial chest roentgenogram films showed resolution of the pleural effusions. At the 1-year follow-up, the patient felt well, and there was no recurrence of chylothorax.
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Fig 1. Chest roentgenogram showing bilateral pleural effusion. The ring is the Hickmann catheter of the transplant patient. The patient was treated before the transplantation with i.v. prosthacyclin for severe pulmonary hypertension.
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Comment
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A Medline search of the English-speaking literature revealed only one report of chylothorax after lung transplantation. Herridge and colleagues [2] studied the pleural complications in 30 of 138 patients (22%) after single (n = 53) and double (n = 91) lung transplantation. Fourteen developed pleural effusions, and in only one (double lung transplant) was the cause chylothorax. No details were provided about the postoperative course.
In the same MEDLINE search, we found only three case reports of chylothorax after adult heart transplantation [3–5]. The pertinent clinical data are summarized in Table 1.
Patient ages ranged from 32 to 62 years (median, 32 years); all were men. The chylothorax occurred from 7 to 21 days after transplantation. In our patient, it was noted at 4 months after transplantation. This late occurrence might be explained by damage to small lymphatic vessel during the operation. All 3 earlier patients had unilateral cholothorax, whereas in our patient, it was bilateral. All 4 patients underwent chest tube drainage for 1 to 33 days (median, 24 days).
In patients after heart and lung transplantation, the huge loss of calories, fluids, and proteins can cause nutritional deficiency, dehydration, and immunologic dysfunction. Therefore, prompt diagnosis and adequate early treatment of chylothorax are important [6]. There are, however, no recognized guidelines for the management of chylothorax in this group of patients. The traditional treatment consists of nutritional support, reduction of flow in the thoracic duct, and maintenance of lung expansion [6]. Two of the reported patients with chylothorax after transplantation were given total parenteral nutrition, and one received medium-chain triglycerides through a feeding tube. Our patient, whose nutritional status was good, was treated with an oral low-fat diet. All the patients recovered without sequelae.
Lymph consists of 90% small lymphocytes, mostly T cells. Thus, in chylothorax, the immunosuppressive regimen may need to be adjusted in relation to the lymphocyte count and the continued loss of chyle. A total lymphocyte count of less than 500 mm3 may be an indication for operative intervention.
In adjusting the immunosuppressive regimen, clinicians also need to take into account the risk of accumulation of cyclosporine in chylous effusions. Cyclosporine may also increase the lymphatic drainage. One of the four (including ours) patients after transplant presented with a low lymphocyte count and one with a low cyclosporine level. There was, however, no evidence of rejection or infection. No significant changes occurred in the cyclosporine level and in the total lymphocyte count in our patient. We assumed that the cause was his good clinical status.
In summary, chylothorax is an uncommon complication in lung and heart transplant recipients. It should be suspected when unexplained pleural effusion is noted in the absence of evidence of infection or rejection. A pleural fluid triglyceride concentration more than 110 mg/dL is diagnostic [6]. The chylothorax can present late in the post-transplantation period. Conservative therapy may be sufficient for complete resolution. Special considerations include increased risk of infection in the cyclosporine-treated patient and the effect of a decreasing absolute lymphocyte count on cellular rejection.
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References
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- Cerfolio J.R., Allen M.S., Deschamps C., Trastek V.F., Pairolero P.C. Postoperative chylothorax. J Thorac Cardiovasc Surg 1996;112:1361-1366.[Abstract/Free Full Text]
- Herridge M.S., de Hoyos A.L., Chaparro C., Winton T.L., Kesten S., Maurer J.R. Pleural complications in lung transplant recipients. J Thorac Cardiovasc Surg 1995;110:22-26.[Abstract/Free Full Text]
- Conroy J.T., Twomey C., Alpern J.B. Chylothorax after orthotopic heart transplantation in an adult patient: a case complicated by an episode of rejection. J Heart Lung Transplant 1993;12:1071.[Medline]
- Bowerman R.E., Solomon D.A., Bongnolo D., Brauner L.R. Chylothorax: report of a case complicating orthotopic heart transplantation. J Heart Lung Transplant 1993;12:665-668.[Medline]
- Twomey C.R. Chylothorax in the adult heart transplant patient: a case report. Am J Crit Care 1994;3:316-319.
- Fahimi H., Casselman F.P., Mariani M.A., van Boven W.J., Knaepen P.J., van Sweiten H.A. Current management of postoperative chylothorax. Ann Thorac Surg 2001;71:448-451.[Abstract/Free Full Text]
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Abstract
Introduction
