Ann Thorac Surg 2004;78:e61-e62
© 2004 The Society of Thoracic Surgeons
Case report
Combined Late Diagnosed Right Main Bronchial Disruption and Chylothorax From Blunt Chest Trauma
Cemal Ozcelik, MD*,a,
Serdar Onat, MDa,
Emin Sirri Bayar, MDa
a Department of Thoracic Surgery, Dicle University School of Medicine, Diyarbakir, Turkey
Accepted for publication August 28, 2003.
* Address reprint requests to Dr Ozcelik, Dicle University School of Medicine, Thoracic Surgery Department, Diyarbakir, Turkey 21280
cozcelik{at}dicle.edu.tr
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Abstract
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Both main bronchial disruption and chylothorax are uncommon injuries associated with blunt thoracic trauma. We report the case of a patient who presented late after traumatic rupture of the right main bronchus who also had a traumatic chylothorax.
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Introduction
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Both main bronchial disruption and chylothorax are uncommon injuries associated with blunt thoracic trauma [1, 2]. Failure to recognize and repair main bronchial disruption ultimately results in stricture formation with secondary atelectasis or bronchiectasis of the distal lung. Chylothorax is a serious and often life threatening clinical entity. Bronchial disruption and chylothorax combined together caused by a blunt thoracic trauma has not been previously reported and herein we report such a case.
The patient was a 15-year-old girl who had three prior hospitalizations. The third and last hospitalization was at our hospital 75 days after she had been rescued from the rubble of her house subsequent to an earthquake (magnitude, 7.8 Richter scale) on August 17, 1999 in Izmit, Turkey.
During this 75-day period she had admissions to two local hospitals; the first hospital was within 24 hours after trauma. She was admitted with respiratory distress, extensive bilateral subcutaneous air emphysema, and bilateral pneumothoraxes. She had neither rib fractures nor extrathoracic injuries. Bilateral chest tubes were inserted and both lungs were fully inflated. She was discharged several days later. She did not have a bronchoscopy performed during this hospitalization.
The second hospitalization was 45 days later at the State Hospital in Diyarbakir, Turkey, because of increasing respiratory distress. A chest roentgenogram taken at this hospital suggested a right-sided pleural effusion, and a chest tube was inserted but no fluid was obtained. The patient then underwent a bronchoscopic examination and an obstructed right main bronchus was noted. She was then transferred to our care 75 days after her original injury.
On admission to our hospital, a new chest roentgenogram showed a small right apical pneumothorax, a consolidated right lung, and a small pleural effusion. A chest computed tomographic scan confirmed these findings (Fig 1). The milky appearance of the pleural drainage suggested chylothorax. Analysis of the pleural fluid revealed a triglyceride level of 629 mg/dL and cholesterol of 8l mg/dL. She underwent a bronchoscopic examination and the previously noted obstruction of the right main bronchus was confirmed; it was completely obstructed with granulation tissue. Diagnoses of a traumatic disruption of the right main bronchus and a traumatic chylothorax were thus established.
The operative plan was to repair the bronchial disruption and to ligate the thoracic duct. Shortly before thoracotomy, l50 mL of olive oil was instilled through a nasogastric tube.
The mediastinal structures were exposed through the right fifth interspace posterolateral thoracotomy utilizing a left-sided double lumen endotracheal tube. There were only loose adhesions between the pleural surfaces and decortication was not required. Dense adhesions made dissection of the distal trachea, right upper lobe bronchus, and bronchus intermedius difficult. The entire length of the right main bronchus from the trachea to the origin of the right upper lobe bronchus was completely fibrotic and was then resected. Thick yellow bronchial secretions filled the distal lung. These were suctioned out and the distal lung was irrigated. Cultures of this material revealed no bacterial growth.
An end-to-end anastomosis was made (using 4-0 Vicryl [Ethicon, Somerville, NJ]) between the tracheal origin of the right main bronchus and its distal end at the origin of the right upper lobe bronchus. A tension-free anastomosis could be achieved by mobilizing the inferior pulmonary ligament and the arterial and venous pericardial attachments of the right lung.
Reinflation of the right lung was surprisingly normal. Neither the thoracic duct nor the precise site of the chyle leak could be identified. Therefore all tissues between the aorta and the azygos vein were mass ligated with a series of mass suture ligatures at the level of the eighth thoracic vertebral body. Fiberoptic broncoscopy on postoperative day 3 showed good repair.
After extubation and beginning oral intake, the pleural drainage increased and became milky. The triglyceride level of the pleural drainage was l05 mg/dL. Oral intake was stopped and the patient was treated with total parenteral nutrition until the chest tubes were removed on postoperative day 20. On postoperative day 4, tetracycline installation through the chest tubes was done at a dosage of 35 mg/kg. A repeat chest computed tomographic scan (Fig 2) and bronchoscopy were performed before discharge and both were unremarkable. Examination at 1-month postdischarge follow-up was likewise unremarkable.
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Comment
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The possibility of bronchial injury should be entertained with every patient who has a blunt chest trauma regardless of its cause [3–5]. After blunt thoracic trauma, every level of the trachea and almost all of the major bronchi have been reported to be involved. Most injuries occur within 2.5 cm of the carina. Burke [6], in his study of 130 cases of traumatic bronchial rupture, reported that injuries were equally divided between the left and right sides, and 86% of the injuries involved the mainstem bronchi.
In patients with central bronchial disruption there are two distinct clinical patterns depending on whether or not there is free communication between the site of the bronchial disruption and the pleura [7]. In type I there is free communication between the site of the disruption and the pleural cavity. There is a resulting large pneumothorax and a continuous air leak and usually failure of the collapsed lung to re-expand.
In type II, although the bronchial transection is complete, there is little or no communication between the proximal transected bronchus and the pleural cavity. A pneumothorax may be present, and if a chest tube is inserted the lung will usually promptly re-expand.
Air generally escapes into the mediastinum and subcutaneous tissues. The ends of the transected bronchus heal by granulation and epithelialization. Initially the peribronchial tissues are firm enough to maintain an airway.
Sometime between the end of the first to the third week after injury, granulation tissue totally obstructs the bronchus and the lung becomes airless. This delayed occurrence of atelectasis may be mistakenly attributed to retained secretions. Because the granulation tissue excludes the proximal airway from the atelectatic lung, the lung remains uninfected thus allowing late reconstruction of the bronchus [3].
In fact, late diagnosis of bronchial injuries is common. In 1959, Hood and Sloan [7] reviewed the literature and found that only 59% of bronchial injuries were diagnosed early (within 7 days), whereas 41% were diagnosed more than 1 month after the injury.
Traumatic chylothorax is most commonly iatrogenic and has been described as a complication of almost every known thoracic surgical procedure [8]. Blunt chest trauma is a rare and infrequently reported cause of chylothorax. Thoracic duct ligation has been recommended as first line therapy, but may be unsuccessful, and pleurodesis with sclerosing agents should then follow.
In conclusion, we report a patient who presented late after traumatic rupture of the right main bronchus, who also had a traumatic chylothorax. Experience shows that in a large series of patients with bronchial rupture, diagnosis is not made until the stenosis that forms after significant bronchial injuries calls attention to itself through atelectasis or sepsis. This lack of diagnostic accuracy, for the most part, is due to the clinical difficulty in distinguishing patients with bronchial rupture from those patients with thoracic trauma without bronchial rupture. The immediate post injury course is of little diagnostic aid because patients with stabilized bronchial ruptures tend to respond to treatment in the same manner as patients without bronchial rupture. Hemoptysis, subcutaneous or mediastinal emphysema, or pneumothorax without a continuing air leak is too inconstant to be of value in diagnosis. Because the diagnosis cannot be satisfactorily made in a majority of patients by clinical appearance or immediate clinical course, visualization of the trachea and bronchi by bronchoscopy is mandatory. Traumatic chylothorax should respond to thoracic duct ligation, and if not, then pleuodesis with sclerosing agents may follow.
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Acknowledgments
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The authors thank Dr Niles Chapman for language editing their manuscript.
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References
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- Baumgartner F, Sheppard B, de Virgilio C, et al. Tracheal and main bronchial disruptions after blunt chest trauma: presentation and management. Ann Thorac Surg. 1990;50:569–574[Abstract]
- Milsom JW, Kron IL, Rheuban KS, Rodgers BM. Chylothorax: an assessment of current surgical management. J Thorac Cardiovasc Surg. 1985;89:22l–27
- Hood RM. Injury to the trachea and major bronchi. Hood RM, Boyd AD, Culliford AT. Thoracic trauma. Philadelphia: W.B. Saunders Co; 1989. p. 245–266
- Hood RM. Pulmonary and pleural complications of trauma. Hood RM, Boyd AD, Culliford AT. Thoracic trauma. Philadelphia: W.B. Saunders Co; 1989. p. 359–382
- Kirsch MM, Orringer MB, Behrendt DM, Sloan H. Management of tracheobronchial disruption secondary to nonpenetrating trauma. Ann Thoracic Surg. 1976;22:93–101[Abstract]
- Burke JF. Early diagnosis of traumatic rupture of the bronchus. JAMA. 1962;18l:682–686
- Hood RM, Sloan HE. Injuries to the trachea and major bronchi. J Thorac Surg. 1959;38:458–480
- Chinnock BF. Chylothorax: case report and review of the literature. J Emerg Med. 2003;24:259–262[Medline]
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Abstract
Introduction
