Ann Thorac Surg 2006;81:1488-1491
© 2006 The Society of Thoracic Surgeons
Case report
Very Unusual Case of Post-Traumatic Chylothorax
Cristiano Benato, MDa,*,
Giovanni Magnanelli, MDb,
Alberto Terzi, MDb,
Paolo Scanagatta, MDa,
Cinzia Bonadiman, MDa,
Francesco Calabrò, MDb
a Scuola di Specializzazione in Chirurgia Toracica, Policlinico GB Rossi, Verona, Italy
b Policlinico GB Rossi, Unità Operativa di Chirurgia Toracica, Ospedale Civile Maggiore, Verona, Italy
Accepted for publication February 28, 2005.
* Address correspondence to Dr Benato, c/o U.O. Chirurgia Toracica, Ospedale Civile Maggiore, Verona, 37126 Italy (Email: bena.c{at}mailcity.com).
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Abstract
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Chylothorax is a rare disease caused by both traumatic and nontraumatic events. Chylothorax can cause cardiopulmonary abnormalities and significant nutritional, metabolic, and immunologic consequences. We present an exceptional case of chylothorax due to penetrating chest trauma. The diagnosis was made by thoracentesis. Conservative management with nothing by mouth and total parenteral nutrition failed; therefore the patient needed surgical closure of the duct leak.
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Introduction
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Post-traumatic chylothorax, either surgical or not, is a well-known clinical entity. When it is not related to surgical trauma, it is most commonly due to hyperextension of the spine. Penetrating chest injury is rarely the cause of post-traumatic chylothorax alone, because the trauma is usually associated with life-threatening damage to vital organs. We report an exceptional case of isolated post-traumatic chylothorax that occurred in a woman after penetrating chest trauma.
A 56-year-old woman suffered from a wound in her left supraclavicular fossa after being violently hit in the rib by a beach umbrella that was pulled up by a gust of wind during a sudden storm on Lake Garda in northern Italy (Fig 1A). After the accident she complained of pain in the supraclavicular fossa and also of a mild pain in the lower posterior part of the right hemithorax. The woman received a wound dressing at the local first aid post and then went home.
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Fig 1. (A) Entry point of the foreign body at the base of the neck (black circle). (B) Air bubble in the left supraclavicular fossa. (C) Chest roentgenogram showing the path followed by the rib-tip (white line).
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A day later she came to our hospital for dyspnea and pain in the right hemithorax. A chest roentgenogram showed a right pleural effusion and an air bubble in the left supraclavicular area (Fig 1B). A thoracentesis was performed and 1,100 mL of milky fluid was aspirated. A repeat chest roentgenogram showed an iron-density cylindrical shadow that resembled an umbrella rib tip at the level of the 11th intercostal space (Fig 1C). A neck and chest computed tomographic scan demonstrated the path of the umbrella rib (ie, from the left supraclavicular fossa behind the external jugular vein, medially between the left common carotid artery and a vertebral body, and then between the posterior wall of the esophagus and a vertebral body). The track crossed the mediastinum from left to right and ended in the posterior costophrenic space where the tip was retained. The attached metal rib exited (Figs 2A–E). An esophagogram by water-soluble contrast ruled out a possible esopahgeal injury.
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Fig 2. (A–E) Computed tomographic scans showing the path followed by the rib-tip from the left supraclavicular fossa through the mediastinum (white circles) to the right costophrenic space (white arrow).
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A day later the patient underwent an operation to remove the foreign body and to identify the source of chylous effusion. A fat meal was ingested before operation and a right video-assisted procedure was performed. The foreign body was identified and removed (Figs 3A,
3B); the chyle leak was not identified. We assumed that a minor lymph channel and not the thoracic duct had been transected. Therefore a chest drain was placed. Postoperative conservative treatment for chylothorax with nothing by mouth and total parenteral nutrition was instituted. The chyle leak continued at an average of 1,100 mL/day. After 5 days, octreotide was started at a dose of 300 mcg/day subcutaneously, and then 2,400 mcg/day by continuous intravenous infusion for a total of 12 days without results. Eventually the patient underwent a second operation through a small lateral thoracotomy. The thoracic duct was identified just above the diaphragm and it was ligated. The chyle leak stopped, and the patient started eating again. She was finally discharged within a few days.
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Comment
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Post-traumatic chylothorax due to penetrating injury to the chest is seldom observed alone. Actually when an offending agent damages the deep-well protected thoracic duct, other vital structures are usually damaged. This case is quite exceptional, because a steel beach umbrella rib passed through the entire length of the mediastinum from left to right and exited without damaging any vital organ, but left evidence of its passage (ie, the rib tip). Only the complaint of dyspnea the day after the incident made the patient ask for medical assistance. The presence of a right pleural effusion on chest roentgenogram led to a thoracentesis that was diagnostic of post-traumatic chylothorax, and eventually led to identification of the foreign body and reconstruction of the pathogenesis of the trauma.
Conservative treatment is recommended as the initial treatment for post-traumatic chylothorax. Standard methods include drainage, dietary restriction, and total parenteral nutrition [1–3]. Somatostatin has been used to reduce chyle flow [2, 4]; it can be initially given subcutaneously at a dose of 100 µg BID for the first 2 days and then 100 µg TID for the next 6 days [4]. If this is not effective in reducing the chyle drainage, somatostatin can be given by continuous infusion. The starting dose is 3.5 µg/kg per hour according to the case report of Rimensberg and colleagues [5], and it can be increased every day up to 10 µg/kg per hour. However, because longstanding chylothorax can result in important metabolic derangements and immunodepression, conservative treatment should not continue for more than 2 to 3 weeks. After that time, surgical measures should be considered [3].
Surgical treatment of traumatic chylothorax can be made by oversewing the leakage point if identified or by supradiaphragmatic ligation of the thoracic duct.
Supradiaphragmatic ligation of the thoracic duct as proposed by Patterson and colleagues [6] can be performed either by thoracotomy or by video-assisted thoracic surgery. Thoracoscopic ligature has been reported since the beginning of the 1990s by Kent and Pinson [7]; more recently, thoracoscopic ultrasonic coagulation for division of the thoracic duct has been reported by Ohtsuka and colleagues [8].
In our case, during the first thoracoscopic procedure to remove the foreign body we failed to identify any source of chyle leak even though a preoperative fat meal was given. We supposed a minor lymph channel was involved, so conservative management was established. Unfortunately this was not successful, and in spite of maximal medical and dietary conservative treatment, chyle losses exceeded 1,000 mL/day; therefore the thoracic duct legation was considered mandatory. A second surgical procedure was performed through a small lateral thoracotomy in the 7th intercostal space; the thoracic duct was identified, and it was ligated with complete recovery of the patient. In summary, this is an exceptional and possibly unique case of post-traumatic chylothorax due to the penetrating trauma of the chest.
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References
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- Markham KM, Glover JL, Welsh RJ, Lucas RJ, Bendick PJ. Octreotide in the treatment of thoracic duct injuries Am Surg 2000;66:1165-1167.[Medline]
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- Mikroulis D, Didilis V, Bitzikas G, Bougioukaws G. Octreotide in the treatment of chylothorax Chest 2002;121:2079-2080.[Free Full Text]
- Rimensberger PC, Muller-Schenker B, Kalangos A, Beghetti M. Treatment of persistent postoperative chylothorax with somatostatin Ann Thor Surg 1998;66:253-254.[Abstract/Free Full Text]
- Patterson GA, Todd TRJ, Delarue NC, Ilves R, Pearson FG, Cooper JD. Supradiapragmatic ligation of the thoracic duct in intractable chylous fistula Ann Thorac Surg 1981;32:44-49.[Abstract/Free Full Text]
- Kent RB, Pinson W. Thoracoscopic ligation of the thoracic duct Surg Endosc 1993;7:52-53.[Medline]
- Ohtsuka T, Tanaka M, Nakajima J, Takamoto S. Videoscopic supradiaphragmatic duct division using ultrasonic coagulator Eur J Cardiothorac Surg 2002;22:828-830.[Abstract/Free Full Text]
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Abstract
Introduction
