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Chylothorax as a Complication of Radical Nephrectomy
002:2-534/ /93/1506-1895$03.(JO/O Vol. 150,
THE JOCRNAL OF UROLOGY 1993 by AMERICAN UROLOGICAL ASSOC!AT!ON, INC.
Copyright
CHYLOTHORAX AS A COMPLICATION OF RADICAL NEPHRECTOMY R. DUANE CESPEDES, SAMUEL J. PERETSMAN AND MICHAEL J. HARRIS From the Department of Urology, Wilford Hall Medical Center, San Antonio, Texas
ABSTRACT
We report a case of chylo-retroperitoneum and chylothorax following an uneventful left radical nephrectomy for renal cell carcinoma, and propose the mechanism of an infradiaphragmatic lymphatic injury with fistulous connection into the chest. Treatment with oral medium chain triglycerides was unsuccessful. Subsequently, total parenteral nutrition in conjunction with chest drainage, retroperitoneal drainage and sclerotherapy successfully treated the chylothorax. To our knowledge chylothorax following radical nephrectomy has not been reported previously in the literature. KEY WORDS:
chylothorax, kidney neoplasms, nephrectomy
To our knowledge chylothorax is a previously unreported complication of radical nephrectomy. We report a case in which left radical nephrectomy for renal cell carcinoma, completed through a flank incision, was complicated by chylo-retroperitoneum and subsequently chylothorax. We discuss the possible etiology, pathophysiology, diagnosis and treatment. CASE REPORT
A healthy 69-year-old white woman complained of vague abdominal pain after minor trauma. Abdominal computerized tomography (CT) revealed a 3 cm. solid mass in the left kidney, suggesting renal cell carcinoma (fig. 1). There was no evidence of local or metastatic spread, and left radical nephrectomy was done through an eleventh rib approach. Formal lymphadenectomy was not performed. The diaphragm was released laterally but no perforations or lacerations were noted. A small incidental pleurotomy was closed. The patient was discharged home on postoperative day 6 with a chest x-ray showing only minimal left base atelectasis. Pathological diagnosis was stage A clear cell carcinoma. Con-
valescence was uneventful until 3 weeks postoperatively, when she complained of sudden onset of shortness of breath. Chest x-ray demonstrated a large left pleural effusion (fig. 2). Thoracentesis yielded 1,200 cc milky fluid high in triglycerides. Pleural fluid amylase was normal. Cytological evaluation revealed 400 mononuclear cells per mm., no bacteria and no neutrophils. Urine culture yielded no growth. With a working diagnosis of chylothorax the patient was started on a complete enteral product that uses medium chain triglycerides as the source of fats. Serial chest x-rays showed a re-accumulation of fluid and repeat thoracentesis was per-
Accepted for publication May 21, 1993. The opinions or assertions contained herein are the private views of the authors and are not to be construed as reflecting the views of the Department of the Air Force or the Department of Defense.
FIG. 2. Chest x-ray demonstrates chylous left pleural effusion
FIG. 1. CT reveals left renal mass 1895
1896
CHYLOTHORAX FOLLOWING RADICAL NEPHRECTOMY
formed 1 week later, which produced 1,200 cc milky fluid high in triglycerides. CT revealed a large left retroperitoneal fluid collection that appeared to track under the left diaphragmatic crus (fig. 3). A retroperitoneal drain was placed, which initially drained 500 cc chylous fluid per day. Contrast medium was injected into the retroperitoneal space but no fistula leading into the chest was demonstrated. The left chylothorax became symptomatic within a few days after the second thoracentesis and a chest tube was placed. The output in both drains decreased quickly to 50 cc serous fluid per day. The patient was slowly progressed to a regular diet; however, after 2 days the chest and retroperitoneal drainage increased substantially and the fluid contained elevated triglycerides. An enteral diet using medium chain triglycerides was again started but the drainage from the retroperitoneum and chest tube did not decrease. Nutritional status deteriorated, with the albumin and lymphocyte count decreasing to abnormal levels. All oral intake was withheld and intravenous total parenteral nutrition was initiated. Within 1 week the output from the chest tube and retroperitoneal drain decreased substantially. The retroperitoneum was sclerosed with 1 gm. tetracycline in 100 cc normal saline. Within a few days the chest tube and retroperitoneal drainage was minimal with decreased triglycerides. Total parenteral nutrition was continued for an additional week. A regular diet was then resumed without change in drainage. The chest tube and later the retroperitoneal drain were removed. The patient was asymptomatic with a normal chest x-ray 6 months later. DISCUSSION
To our knowledge chylothorax is a previously unreported complication of radical nephrectomy. Other chylous complications of urological procedures are also rare. A total of 15 cases of chylous ascites after retroperitoneal lymph node dissection for testis tumor has been reported in the literature with few simultaneous occurrences of chylothorax. In a previous review 4 cases of chylous ascites were reported following radical nephrectomy but all had concomitant regional lymphadenectomy.1 Lymphoceles and chylo-retroperitoneums are probably under-diagnosed, since they are usually self-limiting and rarely become clinically evident. 2 The lumbar lymphatic trunks form at the aortic bifurcation and ascend on either side of the aorta to the Ll-L2 level, where they join to form the cisterna chyli · behind the right diaphragmatic crus. The left lumbar trunk usually receives the drainage from the intestinal lacteals and
Fm. 3. CT shows large left chylo-retroperitoneum tracking under diaphragm.
carries most of the chylous lymph. Flow through the thoracic duct may increase to more than 200 cc per hour after a fatty meal. Chylothoraces have multiple etiologies, including neoplasm, trauma, and iatrogenic and congenital processes, but they are rarely secondary to a primary chylous ascites or chylo-retroperitoneum. The apparent etiology in our case was a primary chylo-retroperitoneum that entered the chest. The cause for the chylo-retroperitoneum was unclear, since lymphadenectomy was not performed; however, medial dissection or retractor placement may have lacerated the left lumbar trunk or mesenteric root. It is unclear how the chyle then entered the chest, especially since chylothorax occurred suddenly 3 weeks postoperatively. One explanation is an iatrogenic diaphragmatic rent that initially sealed but later reopened secondary to increased pressure from the enlarging chylo-retroperitoneum. Another possibility is that the chylo-retroperitoneum slowly dissected into the posterior mediastinum with subsequent rupture into the left chest, which is how some cases of "spontaneous" chylothorax have occurred as described in the literature.3 The diagnosis of chylothorax requires examination of the thoracentesis fluid. The hallmark of chylous fluid is an elevated triglyceride level. If the triglyceride level is greater than 110 mg./dl. there is a 99% chance that the fluid is chylous. The presence of chylomicrons is also diagnostic. It is important to test amylase levels to rule out pancreatic injury. Chylothorax, manifested by dyspnea and shortness of breath, usually occurs by day 4 or 5 after a regular diet is resumed. There are several methods of localizing the source of a chylous leak. In the absence of a chest tube, ethiodized lymphangiography or nuclear lymphangiography with technetium-antimony colloid may show the site of leakage. 4 If an operation to ligate the lymphatics is contemplated cream or olive oil with or without dye (Sudan III or Evans blue) is administered preoperatively to assist in identifying the lymphatic leak during laparotomy, thoracotomy or thorascopy. 5 The initial therapy for chylous ascites or chylothorax is dietary manipulation with a low fat or elemental diet using medium chain triglycerides, which are absorbed directly into the portal venous system. This treatment decreases flow in the thoracic duct by 70 to 80%, allowing the damaged lymphatic channels to seal. Decompression of the involved chest with repeat thoracentesis or with a chest tube is necessary. Our case is unusual in that the source of chyle was from the retroperitoneum with a fistulous communication into the chest leading to chylothorax. For this reason retroperitoneal drainage was also necessary, since chest drainage alone would maintain patency of the transdiaphragmatic fistula. If the chylous output is not substantially decreased after 2 to 3 weeks of therapy or if the patient fails after starting a regular diet again, as in our case, then the patient should take nothing orally and should be placed on total parenteral nutrition. This regimen will further decrease lymphatic flow, since any oral intake will create some lymphatic flow. While ligation of the supradiaphragmatic thoracic duct is an option in primary intrathoracic chylothorax, in our case the chyle was leaking proximal to the thoracic duct and ligation could have aggravated the problem. Attempts to reinfuse aspirated chylous fluid into the venous system are not recommended, since this approach has been associated with fat emboli. 6 The necessary duration of dietary modification or total par. enteral nutrition to ensure fistula closure is unclear. If the patient receives adequate nutrition and maintains an adequate lymphocyte count there is no definite time frame in which dietary therapy or total parenteral nutrition must yield to surgical therapy. Surgical intervention is usually indicated if average chyle loss is greater than 1,500 cc per day for more than 5 days in adults or greater than 100 cc per year of age per day for more than 5 days in children, chyle flow has not
CHYLO'THORAX FOLLOWING RADICAL NEPHRECTO:MY
diminished after 14 of or total parenteral nutrition therapy, or metabolic or nutritional complications occur. 7 Procedures most likely to control the lymphatic leak in primary chylothorax include direct closure of the leaking lymphatic channel, ligation of the thoracic duct at the diaphragm with closure of the leaking mediastinal pleura, and mass ligature of the tissue found between the azygos vein and the aorta. 8 Since our case involved a secondary chylothorax, for which a paucity ofliterature exists, it is unclear whether any of these procedures would have been more effective than the nonoperative approach taken. Sclerotherapy of the retroperitoneum, which has not been described previously, appeared to be helpful in this case. Pleurodesis using talc and tetracycline has been described previously and appears to be helpful in the treatment of a primary chylothorax. 9 Although there was little reason to suspect obstruction of the lymphatics by cancer cells in our patient, this phenomenon does occur in a small number of cases. These cases are best treated with chemotherapy and/or radiation therapy if the tumor is sensitive to these modalities. 10 In summary, we report a case of chylothorax following radical nephrectomy that was treated successfully with a combination of total parenteral nutrition, chest drainage, retroperitoneal drainage and sclerotherapy.
1897
REFERENCES
Ferrigni, R. G. and Novicki, D. E.: Chylous ascites complicating genitourinary oncological surgery. J. Urn!., 134: 774, 1985. 2. Herz, J., Shapiro, S. R., Konrad, P. and Palmer, J.: Chylous ascites following retroperitoneal lymphadenectomy: report of 2 cases with guidelines for diagnosis and treatment. Cancer, 42: 349, 1.
1978. 3. Ross, J. K.: A review of the surgery of the thoracic duct. Thorax, 16: 12, 1961.
4. Sachs, P. B., Zelch, M. G., Rice, T. W., Geisinger, M. A., Risius, B. and Lammert, G. K.: Diagnosis and localization of laceration
5. 6. 7.
8.
of the thoracic duct: usefulness of lymphangiography and CT. AJR, 157: 703, 1991. Toshizumi, S., Amano, J. and Takabe, K: Thorascopic diagnosis and treatment of chylothorax after pneumonectomy. Ann. Thorac. Surg., 52: 306, 1991. Vasko, J. S. and Tapper, R. I.: The surgical significance of chylous ascites. Arch. Surg., 95: 355, 1967. Selle, J. G., Snyder, W. H., III and Schreiber, J. T.: Chylothorax: indications for surgery. Ann. Surg., 177: 245, 1973. DeMeester, T. R. and Lafontaine, E.: The pleura. In: Gibbon's Surgery of the Chest. Edited by D. C. Sabiston and F. C. Spencer. Philadelphia: W. B. Saunders Co., vol. 1, chapt. 16, pp. 455-458,
1990. 9. Adler, R. H. and Levinsky, L.: Persistent chylothorax. Treatment by talc pleurodesis. J. Thorac. Carcliovasc. Surg., 76: 859, 1978.
10. Sassoon, C. S. and Light, R. W.: Chylothorax and pseudochylothorax. Clin. Chest Med., 6: 163, 1985.
THE JOCRNAL OF UROLOGY 1993 by AMERICAN UROLOGICAL ASSOC!AT!ON, INC.
Copyright
CHYLOTHORAX AS A COMPLICATION OF RADICAL NEPHRECTOMY R. DUANE CESPEDES, SAMUEL J. PERETSMAN AND MICHAEL J. HARRIS From the Department of Urology, Wilford Hall Medical Center, San Antonio, Texas
ABSTRACT
We report a case of chylo-retroperitoneum and chylothorax following an uneventful left radical nephrectomy for renal cell carcinoma, and propose the mechanism of an infradiaphragmatic lymphatic injury with fistulous connection into the chest. Treatment with oral medium chain triglycerides was unsuccessful. Subsequently, total parenteral nutrition in conjunction with chest drainage, retroperitoneal drainage and sclerotherapy successfully treated the chylothorax. To our knowledge chylothorax following radical nephrectomy has not been reported previously in the literature. KEY WORDS:
chylothorax, kidney neoplasms, nephrectomy
To our knowledge chylothorax is a previously unreported complication of radical nephrectomy. We report a case in which left radical nephrectomy for renal cell carcinoma, completed through a flank incision, was complicated by chylo-retroperitoneum and subsequently chylothorax. We discuss the possible etiology, pathophysiology, diagnosis and treatment. CASE REPORT
A healthy 69-year-old white woman complained of vague abdominal pain after minor trauma. Abdominal computerized tomography (CT) revealed a 3 cm. solid mass in the left kidney, suggesting renal cell carcinoma (fig. 1). There was no evidence of local or metastatic spread, and left radical nephrectomy was done through an eleventh rib approach. Formal lymphadenectomy was not performed. The diaphragm was released laterally but no perforations or lacerations were noted. A small incidental pleurotomy was closed. The patient was discharged home on postoperative day 6 with a chest x-ray showing only minimal left base atelectasis. Pathological diagnosis was stage A clear cell carcinoma. Con-
valescence was uneventful until 3 weeks postoperatively, when she complained of sudden onset of shortness of breath. Chest x-ray demonstrated a large left pleural effusion (fig. 2). Thoracentesis yielded 1,200 cc milky fluid high in triglycerides. Pleural fluid amylase was normal. Cytological evaluation revealed 400 mononuclear cells per mm., no bacteria and no neutrophils. Urine culture yielded no growth. With a working diagnosis of chylothorax the patient was started on a complete enteral product that uses medium chain triglycerides as the source of fats. Serial chest x-rays showed a re-accumulation of fluid and repeat thoracentesis was per-
Accepted for publication May 21, 1993. The opinions or assertions contained herein are the private views of the authors and are not to be construed as reflecting the views of the Department of the Air Force or the Department of Defense.
FIG. 2. Chest x-ray demonstrates chylous left pleural effusion
FIG. 1. CT reveals left renal mass 1895
1896
CHYLOTHORAX FOLLOWING RADICAL NEPHRECTOMY
formed 1 week later, which produced 1,200 cc milky fluid high in triglycerides. CT revealed a large left retroperitoneal fluid collection that appeared to track under the left diaphragmatic crus (fig. 3). A retroperitoneal drain was placed, which initially drained 500 cc chylous fluid per day. Contrast medium was injected into the retroperitoneal space but no fistula leading into the chest was demonstrated. The left chylothorax became symptomatic within a few days after the second thoracentesis and a chest tube was placed. The output in both drains decreased quickly to 50 cc serous fluid per day. The patient was slowly progressed to a regular diet; however, after 2 days the chest and retroperitoneal drainage increased substantially and the fluid contained elevated triglycerides. An enteral diet using medium chain triglycerides was again started but the drainage from the retroperitoneum and chest tube did not decrease. Nutritional status deteriorated, with the albumin and lymphocyte count decreasing to abnormal levels. All oral intake was withheld and intravenous total parenteral nutrition was initiated. Within 1 week the output from the chest tube and retroperitoneal drain decreased substantially. The retroperitoneum was sclerosed with 1 gm. tetracycline in 100 cc normal saline. Within a few days the chest tube and retroperitoneal drainage was minimal with decreased triglycerides. Total parenteral nutrition was continued for an additional week. A regular diet was then resumed without change in drainage. The chest tube and later the retroperitoneal drain were removed. The patient was asymptomatic with a normal chest x-ray 6 months later. DISCUSSION
To our knowledge chylothorax is a previously unreported complication of radical nephrectomy. Other chylous complications of urological procedures are also rare. A total of 15 cases of chylous ascites after retroperitoneal lymph node dissection for testis tumor has been reported in the literature with few simultaneous occurrences of chylothorax. In a previous review 4 cases of chylous ascites were reported following radical nephrectomy but all had concomitant regional lymphadenectomy.1 Lymphoceles and chylo-retroperitoneums are probably under-diagnosed, since they are usually self-limiting and rarely become clinically evident. 2 The lumbar lymphatic trunks form at the aortic bifurcation and ascend on either side of the aorta to the Ll-L2 level, where they join to form the cisterna chyli · behind the right diaphragmatic crus. The left lumbar trunk usually receives the drainage from the intestinal lacteals and
Fm. 3. CT shows large left chylo-retroperitoneum tracking under diaphragm.
carries most of the chylous lymph. Flow through the thoracic duct may increase to more than 200 cc per hour after a fatty meal. Chylothoraces have multiple etiologies, including neoplasm, trauma, and iatrogenic and congenital processes, but they are rarely secondary to a primary chylous ascites or chylo-retroperitoneum. The apparent etiology in our case was a primary chylo-retroperitoneum that entered the chest. The cause for the chylo-retroperitoneum was unclear, since lymphadenectomy was not performed; however, medial dissection or retractor placement may have lacerated the left lumbar trunk or mesenteric root. It is unclear how the chyle then entered the chest, especially since chylothorax occurred suddenly 3 weeks postoperatively. One explanation is an iatrogenic diaphragmatic rent that initially sealed but later reopened secondary to increased pressure from the enlarging chylo-retroperitoneum. Another possibility is that the chylo-retroperitoneum slowly dissected into the posterior mediastinum with subsequent rupture into the left chest, which is how some cases of "spontaneous" chylothorax have occurred as described in the literature.3 The diagnosis of chylothorax requires examination of the thoracentesis fluid. The hallmark of chylous fluid is an elevated triglyceride level. If the triglyceride level is greater than 110 mg./dl. there is a 99% chance that the fluid is chylous. The presence of chylomicrons is also diagnostic. It is important to test amylase levels to rule out pancreatic injury. Chylothorax, manifested by dyspnea and shortness of breath, usually occurs by day 4 or 5 after a regular diet is resumed. There are several methods of localizing the source of a chylous leak. In the absence of a chest tube, ethiodized lymphangiography or nuclear lymphangiography with technetium-antimony colloid may show the site of leakage. 4 If an operation to ligate the lymphatics is contemplated cream or olive oil with or without dye (Sudan III or Evans blue) is administered preoperatively to assist in identifying the lymphatic leak during laparotomy, thoracotomy or thorascopy. 5 The initial therapy for chylous ascites or chylothorax is dietary manipulation with a low fat or elemental diet using medium chain triglycerides, which are absorbed directly into the portal venous system. This treatment decreases flow in the thoracic duct by 70 to 80%, allowing the damaged lymphatic channels to seal. Decompression of the involved chest with repeat thoracentesis or with a chest tube is necessary. Our case is unusual in that the source of chyle was from the retroperitoneum with a fistulous communication into the chest leading to chylothorax. For this reason retroperitoneal drainage was also necessary, since chest drainage alone would maintain patency of the transdiaphragmatic fistula. If the chylous output is not substantially decreased after 2 to 3 weeks of therapy or if the patient fails after starting a regular diet again, as in our case, then the patient should take nothing orally and should be placed on total parenteral nutrition. This regimen will further decrease lymphatic flow, since any oral intake will create some lymphatic flow. While ligation of the supradiaphragmatic thoracic duct is an option in primary intrathoracic chylothorax, in our case the chyle was leaking proximal to the thoracic duct and ligation could have aggravated the problem. Attempts to reinfuse aspirated chylous fluid into the venous system are not recommended, since this approach has been associated with fat emboli. 6 The necessary duration of dietary modification or total par. enteral nutrition to ensure fistula closure is unclear. If the patient receives adequate nutrition and maintains an adequate lymphocyte count there is no definite time frame in which dietary therapy or total parenteral nutrition must yield to surgical therapy. Surgical intervention is usually indicated if average chyle loss is greater than 1,500 cc per day for more than 5 days in adults or greater than 100 cc per year of age per day for more than 5 days in children, chyle flow has not
CHYLO'THORAX FOLLOWING RADICAL NEPHRECTO:MY
diminished after 14 of or total parenteral nutrition therapy, or metabolic or nutritional complications occur. 7 Procedures most likely to control the lymphatic leak in primary chylothorax include direct closure of the leaking lymphatic channel, ligation of the thoracic duct at the diaphragm with closure of the leaking mediastinal pleura, and mass ligature of the tissue found between the azygos vein and the aorta. 8 Since our case involved a secondary chylothorax, for which a paucity ofliterature exists, it is unclear whether any of these procedures would have been more effective than the nonoperative approach taken. Sclerotherapy of the retroperitoneum, which has not been described previously, appeared to be helpful in this case. Pleurodesis using talc and tetracycline has been described previously and appears to be helpful in the treatment of a primary chylothorax. 9 Although there was little reason to suspect obstruction of the lymphatics by cancer cells in our patient, this phenomenon does occur in a small number of cases. These cases are best treated with chemotherapy and/or radiation therapy if the tumor is sensitive to these modalities. 10 In summary, we report a case of chylothorax following radical nephrectomy that was treated successfully with a combination of total parenteral nutrition, chest drainage, retroperitoneal drainage and sclerotherapy.
1897
REFERENCES
Ferrigni, R. G. and Novicki, D. E.: Chylous ascites complicating genitourinary oncological surgery. J. Urn!., 134: 774, 1985. 2. Herz, J., Shapiro, S. R., Konrad, P. and Palmer, J.: Chylous ascites following retroperitoneal lymphadenectomy: report of 2 cases with guidelines for diagnosis and treatment. Cancer, 42: 349, 1.
1978. 3. Ross, J. K.: A review of the surgery of the thoracic duct. Thorax, 16: 12, 1961.
4. Sachs, P. B., Zelch, M. G., Rice, T. W., Geisinger, M. A., Risius, B. and Lammert, G. K.: Diagnosis and localization of laceration
5. 6. 7.
8.
of the thoracic duct: usefulness of lymphangiography and CT. AJR, 157: 703, 1991. Toshizumi, S., Amano, J. and Takabe, K: Thorascopic diagnosis and treatment of chylothorax after pneumonectomy. Ann. Thorac. Surg., 52: 306, 1991. Vasko, J. S. and Tapper, R. I.: The surgical significance of chylous ascites. Arch. Surg., 95: 355, 1967. Selle, J. G., Snyder, W. H., III and Schreiber, J. T.: Chylothorax: indications for surgery. Ann. Surg., 177: 245, 1973. DeMeester, T. R. and Lafontaine, E.: The pleura. In: Gibbon's Surgery of the Chest. Edited by D. C. Sabiston and F. C. Spencer. Philadelphia: W. B. Saunders Co., vol. 1, chapt. 16, pp. 455-458,
1990. 9. Adler, R. H. and Levinsky, L.: Persistent chylothorax. Treatment by talc pleurodesis. J. Thorac. Carcliovasc. Surg., 76: 859, 1978.
10. Sassoon, C. S. and Light, R. W.: Chylothorax and pseudochylothorax. Clin. Chest Med., 6: 163, 1985.