- Email: [email protected]
Postoperative chylothorax
Postoperative chylothorax Six cases in 2,500 operations, with a survey of the world literature We have systematically reviewed the literature concerning iatrogenic chylothorax and shall report our personal observations on the subject. Despite an increasing number of thoracic operations, injuries to the thoracic duct are infrequent. Cardiovascular and esophageal procedures are the most frequent causes of chylothorax. Malformations of the thoracic duct and other organs of the mediastinum have often been involved in lymphatic injury. Consequently, we believe that a complicating chylothorax may result from varied causes rather than solely from a surgical error.
P. G. Cevese,* R. Vecchioni,** D. F. D'Amico,*** C. Cordiano,** R. Biasiato,* G. Favia,* and G. A. Farello,* Verona and Padova, Italy
-L'uring the past decade, the incidence of postoperative chylothorax has increased concomitantly with the increased volume of thoracic trauma and thoracic surgery. Except for a few cases observed after cervical or abdominal surgery, chylothorax is most commonly a complication of mediastinal operations. Those surgical situations after which chylothorax may occur are as follows: (1) cardiovascular surgery, (2) esophageal surgery, (3) pleuropulmonary surgery, (4) mediastinal surgery, (5) diaphragmatic surgery, (6) cervical surgery, (7) sympathetic nerve surgery, and (8) costovertebral surgery. The anatomic relationships of the
From the University of Padova at Verona and the University of Padova, Padova, Italy. Received for publication Nov. 9, 1974. •From the Department of General Surgery, School of Medicine, University of Padova, Padova, Italy (Chief Professor P. G. Cevese). **From the Department of General Surgery, School of Medicine. University of Padova at Verona, Verona, Italy (Chief Professor R. Vecchioni). •*'Research Fellow in Thoracic Surgery, Harvard Medical School, Massachusetts General Hospital; Department of General Surgery, School of Medicine, University of Padova, Padova, Italy.
966
upper thoracic duct and the mediastinal organs are illustrated in Fig. 1. We have encountered 6 cases of chylous effusion (Table I ) . Of these, 2 cases have been observed after cardiovascular surgery, 1 after esophageal surgery, 1 after mediastinal surgery, 1 after hiatal hernia repair, and 1 after thyroidectomy and neck dissection. These cases of postoperative chylothorax were observed in a total of 2,500 thoracic operations. This frequency of 0.2 per cent is in accord with the observations of the majority of authors. Postoperative chylothorax Chylothorax after cardiovascular surgery. We have encountered 2 cases of chylothorax in 1,550 operations for cardiovascular disease (see Table I and Fig. 2 ) , an incidence of less than 0.2 per cent. Maloney and Spencer32 have reported 13 cases of postoperative chylothorax in 2,600 operations for cardiovascular disease, an incidence of about 0.5 per cent. Bower4 has reported an incidence of 0.3 per cent. The thoracic duct is liable to be injured during cardiovascular surgery because of its proximity to the great vessels in the
Postoperative chylothorax
967
Fig. 1. Anatomic relationships of the upper thoracic duct and mediastinal organs. 1, Thoracic duct. 2, Left internal jugular vein. 3, Thyroid. 4, Left carotid artery. 5, Innominate vein. 6, Left vagus nerve. 7, Left subclavian artery. 5, Innominate artery. 9, Sympathetic cardiac nerve. 10, Left recurrent laryngeal nerve. / / , Aorta. 12, Thoracic duct. 13, Esophagus. 14, Azygos vein. 15, Aortic arch. 16, Sympathetic chain. 17, Esophagus. 18, Trachea. 19, Right recurrent laryngeal nerve. 20, Right vagus nerve.
mediastinum, where the duct courses from right to left (Fig. 1). In this location, mobilization of the aorta or the left subclavian artery may easily result in injury to the duct. Chylothorax has been reported after surgical treatment of the following cardiovascular malformations: tetralogy of Fallot,2' "• 39 patent ductus arteriosus, 1 ' 2 ' 20' "■ 27 ' 44 tricuspid atresia,32 coarctation of the aorta, 2 ' 23 and several complex malformations. These included 1 case of repair of a ventricular septal defect with abnormal drainage of the pulmonary veins23; 1 case of repair of a patent ductus arteriosus with atrial and septal defects43; ligation of an anomalous subclavian artery13; valvulotomy for isolated stenosis of a pul-
Fig. 2. Left chylothorax following resection of recurrent patent ductus arteriosus. (Case 2, Table I).
The Journal of
968
Cevese et al.
Thoracic and Cardiovascular Surgery
Table I. Personal observations of postoperative chylothorax (0.2 per cent in 2,500 operations) Case No.
Patient 1 (sex, age)
Disease
Operation
Side
Treatment
Fig. No.
1
B. M. (F,7)
Coarctation of the aorta
Resection
Left
Repeated thoracentesis
2
CM. (F, 24)
Recurrent P.D.A.
Resection
Left
Repeated thoracentesis
3
C.C. (F, 51)
Esophageal and bronchial cysts
Excision
Right
Closed thoracic drainage
4
P. F. (M, 14)
Cervicomediastinal lymphangioma
Excision
Left
Closed thoracic drainage
5
F. A. (M,58)
Sliding hiatal hernia
Allison's operation
Bilateral Thoracentesis; chylobilateral closed mediastinum thoracic drainage
4
6
D. M. (F.35)
Metastases of breast cancer
Excision
Left
5
Thoracentesis
2
3
Legend: PDA, Patent ductus arteriosus.
monary artery 3 -; and 1 case (previously mentioned) of chylothorax occurring after operation for isolated ventricular septal defect.17 Careful review of the literature has failed to reveal chylothorax after surgery for acquired valvular diseases, isolated atrial septal defect, coronary diseases, or acquired diseases of the aorta, left subclavian artery, and left carotid artery. Chylothorax after esophageal surgery. Esophageal resection may be complicated by chylothorax, although this complication is surprisingly infrequent in view of the proximity of the thoracic duct to the esophagus (Fig. 1). We have not encountered chylothorax in our series of esophageal resections. However, this complication was noted after excision of a bronchoesophageal cyst, a malformation characterized by the presence of esophageal wall and bronchial mucosa. A right chylothorax appeared 13 days after the operation and was managed conservatively. This case suggests a probable lymphatic malformation in the pathogenesis of chylothorax. Wu48 reported 2 cases of chylothorax af-
ter 79 cases of esophageal resection. Schmidt'* has reported 2 cases in 107 resections. Fekete" observed 16 instances of chylothorax in 1,017 esophageal operations. The highest incidence of chylothorax has been noted after limited resection for cancer of the middle esophagus."• 7 - ls ' •'"• '7 Chylothorax after pleuropulmonary surgery. In the literature there are a few cases of chylothorax after operations for diseases of the pleura. A moderate number of cases were reported after pulmonary surgery. Endoscopic pleurolysis has frequently caused chylothorax.'" 2-' 1S- -■" 3S Thoracoplasty, lobectomy, and pneumonectomy are also common causes.3-5- "■ 2 0 ' -s- 3 0 ' 3 4 , 3 7 ' ,0 Kuntz29 has reported some instances of chylothorax after segmental resection and resection as well as 1 case after pulmonary decortication. Chylothorax after mediastinal surgery. Chylothorax occurs relatively often after operations for cysts and tumors of the mediastinum. There are frequent observations of chylothorax after the removal of mediastinal or cervicomediastinal lymphangioma. The statistical incidence of such a
Volume 69 Number 6 June, 1975
Fig. 3. Lymphangiogram of thoracic duct in a patient with cervicomediastinal lymphangioma demonstrates anomalous drainage on the right (Case 4, Table I).
complication in this group is about 1.8 per cent."1 It is necessary to distinguish postoperative chylothorax from that which appears spontaneously in primitive lymphangioma of the thoracic duct. Gruwez J1 has reported a case of chylothorax after removal of a mediastinal goiter. We have observed 5 patients with mediastinal or cervicomediastinal lymphangioma. In 1 of these cases, the operation was complicated by a chylous effusion. In this patient, a 14-year-old boy, lymphangiography showed that the duct was positioned abnormally (Fig. 3). During the operation a mass adherent to the trachea, esophagus, and the innominate trunk was discovered. Despite careful dissection, we were unable to identify the thoracic duct, which was believed involved in the lymphangioma. The chylothorax appeared 5 days after the operation and resolved after 21 days of repeated thoracentesis. Chylothorax after diaphragmatic surgery. Pequet's cisterna, from which the thoracic duct originates, is located in the central part of the second lumbar vertebra. The abdominal portion of the duct is positioned
Postoperative chylothorax
969
Fig. 4. Chylothorax and chylomediastinum following Allison repair of sliding hiatus hernia (Case 5, Table I).
at the level of the first lumbar and the twelfth thoracic vertebrae behind the aorta. In this same area are located the right and left medial pillars of the diaphragm. These pillars are usually not involved in the operation for diaphragmatic hernias. We have observed 1 case of chylothorax following repair of a bleeding hiatus hernia. This patient, a 58-year-old man, underwent Allison's operation in another surgical unit. The isolation of the cardia and stomach and the reconstruction of the posterior pillars were technically difficult. Three days after the operation a chylous effusion appeared in the right pleural space (Fig. 4). The patient was then treated with bilateral drainage and supportive therapy. The disease cleared 30 days after the operation. Chylothorax after cervical surgery. Extensive neck dissections may give rise to postoperative chylothorax.7- ir- 10> -'• '- The possibility of injury to the thoracic duct is always present during operations for neoplasms of the cervical area, particularly in radical procedures necessitating removal of the jugular vein and the sternocleidomastoid muscle.s We observed 1 interesting case of postoperative chylothorax after cervical surgery. The patient had a carcinoma of the thyroid
The Journal of
9 70
Cevese et al.
Thoracic and Cardiovascular Surgery
measures which will lead to a successful outcome. REFERENCES
Fig. 5. Stasis and extravascular effusion following iatrogenic injury of the thoracic duct (Case 6, Table I). with cervical metastasis. A chylous effusion appeared 5 days after removal of the tumor and radical dissection of the neck but disappeared after thoracic drainage (Fig. 5). Chylothorax after sympathetic nerve surgery. The first observations of postoperative chylothorax were made after thoracoscopic approaches to the thoracic sympathetic chain. Chylothorax may appear after sympathectomy by open thoracotomy3"'' 1G as well as after extrapleural sympathectomy.33 The majority of these observations are not recent, the last case having been reported 10 years ago. Chylothorax after costovertebral surgery. Despite the nearness of the thoracic duct to the vertebrae, chylothorax after operations on the ribs and the vertebrae is a rarity. We have found only one such report, which described chylothorax occurring after excision of the tenth rib for Ewing's tumor.40 Conclusion Chylothorax is an infrequent complication of cardiothoracic surgery. When it does occur, however, it may represent a serious or lethal complication. The surgeon should be aware of this possibility, have a knowledge of the detailed anatomy of the thoracic duct, and be prepared to take appropriate
1 Azzolina, G.: Chilotorace secondario a divisione del dotto arterioso di Botallo, Minerva Chir. 23: 268, 1968. 2 Baffes, T. G., and Potts, W. J.: Postoperative Chylothorax, Ann. Surg. 139: 501, 1954. 3 Baumann, J., and Verdoux, P.: Chylothorax apres pneumonectomie gauche, Mem. Acad. Chir. 83: 215, 1957. 4 Bower, G. C : Chylothorax. Observations in 20 Cases, Chest 46: 464, 1964. 5 Braillon, Schneyder, Genty, Le Brigand, Delie, and Pigot: Les chylothorax par traumatisme chirurgical des vaisseaux linphatiques, Poumon 9: 117, 1953. 6 Bressler, S., Wiener, D., and Thompson, S. A.: Traumatic Chylothorax Following Esophageal Resection, J. THORAC. SURG. 26: 321,
1953.
7 Brewer, L. A., Ill: Surgical Management of Lesions of the Thoracic Duct, Am. J. Surg. 90: 210, 1955. 8 Cevese, P. G., and Fabris, F.: Interventi chirurgici per metastasi linfatiche dei tumori, Lego Ed. Vicenza, 1953. 9 Cevese, P. G., and Gallucci, V.: La patologia dell'arteria succlavia, Recent. Prog. Med. 49: 164, 1970. 10 Cordiano, C : II linfangioma mediastinico e cervico-mediastinico, Chir. Torac. 21: 560, 1968. 11 Cummins, C : Thoracic Duct Fistula Following Thoracoplasty, Br. J. Tuberc. 47: 101, 1953. 12 Douday, D., Dupuy, D., and Bouvrain, Y.: Chylothorax benin apres section d'adherences pleurales, Arch. Med. Chir. Resp. 13: 284, 1938. 13 Effler, D. B.: Chylothorax: A Conservative Method of Management, Cleve. Clin. Q. 19: 6, 1952. 14 Fekete, F., Prandi, D., and Lortat-Jacob, J. L.: Les chylothorax postoperatoires en chirurgie oesophagienne, Ann. Chir. 26: 19, 1972. 15 Fitz-Hugh, G. S., and Cowgill, R.: Chylous Fistula: Complication of Neck Dissection, Arch. Otolaryngol. 9: 543, 1970. 16 Frazell, E. L., Harrold, C. C , and Rasmussen, L.: Bilateral Chylothorax, Ann. Surg. 134: 135, 1951. 17 Garamella, J. J.: Chylothorax Treated by Ligation of the Thoracic Duct and Studies in Thoracic Ductography, Arch. Surg. 76: 46, 1958. 18 Gingell. G. C : Treatment of Chylothorax by Producing Pleurodesis Using Iodized Talc, Thorax 20: 261, 1965. 19 Godart, S., Collette, G., and Dalem, J.:
Volume 69
Postoperative chylothorax 9 7 1
Number 6 June, 1975
20
21
22
23
Pathologie chirurgicale des vaisseaux linphatiques, Acta Chir. Belg. Suppl. 1: 5, 1964. Gotsman, M. S.: Chylothorax After Closure of a Patent Ductus Arteriosus, Thorax 21: 129, 1966. Gruwez, J., Lacquet, A., Gardoen, G., Dive, C , and Beart, A.: Consideration sur le chylothorax, Acta Chir. Belg. 66: 64, 1967. Hardy, G. D., Walker, G. R., and De Guzman, V. C : Thoracic Duct Fistula in Infant: Blue Dye Localization and Operative Closure, J. A. M. A. 182: 187, 1962. Higgins, C. B., and Mulder, D . G.: Chylothorax After Surgery for Congenital Heart Disease,
24
25
26
27
sus,
28
29
30
31 32
J.
THORAC.
CARDIOVASC.
SURG.
61:
411, 1971. Holmberg, L.: Notes on the Anatomy and Physiology of the Thoracic Duct and on the Treatment of Injuries to It, Acta Chir. Scand. 97: 215, 1948/1949. Jaubert De Beaujeu, M., Raton, D., and Andrie, G.: Chylothorax apres clivage d*adherences par voie endoscopique, ligature du canal thoracique, Pouman 7: 9 1 , 1951. Jimenez, E. S., and Majano, M. L.: Chylothorax as Complication in Pulmonary Resection, Chest 32: 344, 1957. Jones, J. C : Twenty-five Years' Experience With the Surgery of Patent Ductus ArterioJ.
THORAC.
CARDIOVASC. SURG.
SO:
149,
1965. Kriiger, B. J., and Jagdschian, V.: "Der traumatische Chylothorax und seine Behandlung, Thoraxchirurgie 12: 208, 1962. Kuntz, E.: Eine Ubersicht iiber das Schrifttum von 1945 bis 1965 mit 297 Fallen und Bericht iiber 3 eigene Beobachtungen, Beitr. Klin. Tuberk. 133: 98, 1966. Laumonier, P., Lachapele, A. P., Counrand, L., Hugues, A., Lagarde, C , and Mage, J.: Une application de la linphografie au diagnostic et au traitment du chylothorax, Presse Med. 70: 2630, 1962. Maier, H. C : Chylous Reflux in Lung and Pleura, Thorax 23: 281, 1968. Maloney, J. V., Jr., and Spencer, F . C : The Nonoperative Treatment of Traumatic Chylothorax, Surgery 40: 121, 1956.
33 McGregor, A. L.: Injuries to the Large Lymphatic Duct, Br. J. Surg. 40: 569, 1953. 34 Metras, D . : Cited by Verdoux, P. 4 5 35 Peet, M. M., and Campbell, K. N . : Massive Chylothorax Following Splanchnicectomy, Univ. Hosp. Bull. Ann. Arbor. 9: 2, 1943. 36 Prouvost, M., and Brincourt, G.: Chylothorax grave consecutif a une section debride, Rev. Tuber. 7: 133, 1943. 37 Saenz-Jiminez, E., and Lopez-Majano, V.: Chylothorax as Complication in Pulmonary Resection, Chest 32: 344, 1957. 38 Schmidt, A.: Chylothorax: Review of 5 Years* Cases in the Literature and Report of a Case, Acta Chir. Scand. 118: 5, 1959. 39 Shumacker, H. B., Jr., and Moore, T. C : Surgical Management of Traumatic Chylothorax, Surg. Gynecol. Obstet. 9 3 : 46, 1951. 40 Shidt, D . D., and Woliver, E.: Traumatic Chylothorax, Arch. Surg. 4 3 : 627, 1941. 41 Steiger, Z., Weinberg, M., and Fell, E. H.: Postoperative Chylothorax, Am. J. Surg. 100: 8, 1960. 42 Tauroff, A. S. W., and Seley, G. P . : Chronic Chylothorax Associated With Hygroma of the Mediastinum, J. THORAC. SURG. 26: 318, 1953.
43 Thomas, C. S., Jr., and McGoon, D. C : Isolated Massive Chylopericardium Following Cardiopulmonary Bypass, J. THORAC. CARDIOVASC. SURG. 61: 945, 1971.
44 Vandecasteele, J., and Soots, G.: Chylothorax apres cure chirurgicale du canal arteriel persistant. Guerison par traitment medical, Lille Chir. 16: 93, 1961. 45 Verdoux, P.: Les chylothorax traumatiques, France Med. 20: 26, 1957. 46 Whitcomb, B. B., and Scoville, W. B.: Postoperative Chylothorax: Sudden Death Following the Infusion of Aspirated Chyle, Arch. Surg. 45: 747, 1942. 47 Williams, K. R., and Burford, T. H.: T h e Management of Chylothorax, Ann. Surg. 160: 131, 1964. 48 Wu, Ying-K'Ai: Surgical Treatment of Carcinoma of the Esophagus and Cardia of the Stomach, Chinese Med. J. 7 3 : 181, 1955.
P. G. Cevese,* R. Vecchioni,** D. F. D'Amico,*** C. Cordiano,** R. Biasiato,* G. Favia,* and G. A. Farello,* Verona and Padova, Italy
-L'uring the past decade, the incidence of postoperative chylothorax has increased concomitantly with the increased volume of thoracic trauma and thoracic surgery. Except for a few cases observed after cervical or abdominal surgery, chylothorax is most commonly a complication of mediastinal operations. Those surgical situations after which chylothorax may occur are as follows: (1) cardiovascular surgery, (2) esophageal surgery, (3) pleuropulmonary surgery, (4) mediastinal surgery, (5) diaphragmatic surgery, (6) cervical surgery, (7) sympathetic nerve surgery, and (8) costovertebral surgery. The anatomic relationships of the
From the University of Padova at Verona and the University of Padova, Padova, Italy. Received for publication Nov. 9, 1974. •From the Department of General Surgery, School of Medicine, University of Padova, Padova, Italy (Chief Professor P. G. Cevese). **From the Department of General Surgery, School of Medicine. University of Padova at Verona, Verona, Italy (Chief Professor R. Vecchioni). •*'Research Fellow in Thoracic Surgery, Harvard Medical School, Massachusetts General Hospital; Department of General Surgery, School of Medicine, University of Padova, Padova, Italy.
966
upper thoracic duct and the mediastinal organs are illustrated in Fig. 1. We have encountered 6 cases of chylous effusion (Table I ) . Of these, 2 cases have been observed after cardiovascular surgery, 1 after esophageal surgery, 1 after mediastinal surgery, 1 after hiatal hernia repair, and 1 after thyroidectomy and neck dissection. These cases of postoperative chylothorax were observed in a total of 2,500 thoracic operations. This frequency of 0.2 per cent is in accord with the observations of the majority of authors. Postoperative chylothorax Chylothorax after cardiovascular surgery. We have encountered 2 cases of chylothorax in 1,550 operations for cardiovascular disease (see Table I and Fig. 2 ) , an incidence of less than 0.2 per cent. Maloney and Spencer32 have reported 13 cases of postoperative chylothorax in 2,600 operations for cardiovascular disease, an incidence of about 0.5 per cent. Bower4 has reported an incidence of 0.3 per cent. The thoracic duct is liable to be injured during cardiovascular surgery because of its proximity to the great vessels in the
Postoperative chylothorax
967
Fig. 1. Anatomic relationships of the upper thoracic duct and mediastinal organs. 1, Thoracic duct. 2, Left internal jugular vein. 3, Thyroid. 4, Left carotid artery. 5, Innominate vein. 6, Left vagus nerve. 7, Left subclavian artery. 5, Innominate artery. 9, Sympathetic cardiac nerve. 10, Left recurrent laryngeal nerve. / / , Aorta. 12, Thoracic duct. 13, Esophagus. 14, Azygos vein. 15, Aortic arch. 16, Sympathetic chain. 17, Esophagus. 18, Trachea. 19, Right recurrent laryngeal nerve. 20, Right vagus nerve.
mediastinum, where the duct courses from right to left (Fig. 1). In this location, mobilization of the aorta or the left subclavian artery may easily result in injury to the duct. Chylothorax has been reported after surgical treatment of the following cardiovascular malformations: tetralogy of Fallot,2' "• 39 patent ductus arteriosus, 1 ' 2 ' 20' "■ 27 ' 44 tricuspid atresia,32 coarctation of the aorta, 2 ' 23 and several complex malformations. These included 1 case of repair of a ventricular septal defect with abnormal drainage of the pulmonary veins23; 1 case of repair of a patent ductus arteriosus with atrial and septal defects43; ligation of an anomalous subclavian artery13; valvulotomy for isolated stenosis of a pul-
Fig. 2. Left chylothorax following resection of recurrent patent ductus arteriosus. (Case 2, Table I).
The Journal of
968
Cevese et al.
Thoracic and Cardiovascular Surgery
Table I. Personal observations of postoperative chylothorax (0.2 per cent in 2,500 operations) Case No.
Patient 1 (sex, age)
Disease
Operation
Side
Treatment
Fig. No.
1
B. M. (F,7)
Coarctation of the aorta
Resection
Left
Repeated thoracentesis
2
CM. (F, 24)
Recurrent P.D.A.
Resection
Left
Repeated thoracentesis
3
C.C. (F, 51)
Esophageal and bronchial cysts
Excision
Right
Closed thoracic drainage
4
P. F. (M, 14)
Cervicomediastinal lymphangioma
Excision
Left
Closed thoracic drainage
5
F. A. (M,58)
Sliding hiatal hernia
Allison's operation
Bilateral Thoracentesis; chylobilateral closed mediastinum thoracic drainage
4
6
D. M. (F.35)
Metastases of breast cancer
Excision
Left
5
Thoracentesis
2
3
Legend: PDA, Patent ductus arteriosus.
monary artery 3 -; and 1 case (previously mentioned) of chylothorax occurring after operation for isolated ventricular septal defect.17 Careful review of the literature has failed to reveal chylothorax after surgery for acquired valvular diseases, isolated atrial septal defect, coronary diseases, or acquired diseases of the aorta, left subclavian artery, and left carotid artery. Chylothorax after esophageal surgery. Esophageal resection may be complicated by chylothorax, although this complication is surprisingly infrequent in view of the proximity of the thoracic duct to the esophagus (Fig. 1). We have not encountered chylothorax in our series of esophageal resections. However, this complication was noted after excision of a bronchoesophageal cyst, a malformation characterized by the presence of esophageal wall and bronchial mucosa. A right chylothorax appeared 13 days after the operation and was managed conservatively. This case suggests a probable lymphatic malformation in the pathogenesis of chylothorax. Wu48 reported 2 cases of chylothorax af-
ter 79 cases of esophageal resection. Schmidt'* has reported 2 cases in 107 resections. Fekete" observed 16 instances of chylothorax in 1,017 esophageal operations. The highest incidence of chylothorax has been noted after limited resection for cancer of the middle esophagus."• 7 - ls ' •'"• '7 Chylothorax after pleuropulmonary surgery. In the literature there are a few cases of chylothorax after operations for diseases of the pleura. A moderate number of cases were reported after pulmonary surgery. Endoscopic pleurolysis has frequently caused chylothorax.'" 2-' 1S- -■" 3S Thoracoplasty, lobectomy, and pneumonectomy are also common causes.3-5- "■ 2 0 ' -s- 3 0 ' 3 4 , 3 7 ' ,0 Kuntz29 has reported some instances of chylothorax after segmental resection and resection as well as 1 case after pulmonary decortication. Chylothorax after mediastinal surgery. Chylothorax occurs relatively often after operations for cysts and tumors of the mediastinum. There are frequent observations of chylothorax after the removal of mediastinal or cervicomediastinal lymphangioma. The statistical incidence of such a
Volume 69 Number 6 June, 1975
Fig. 3. Lymphangiogram of thoracic duct in a patient with cervicomediastinal lymphangioma demonstrates anomalous drainage on the right (Case 4, Table I).
complication in this group is about 1.8 per cent."1 It is necessary to distinguish postoperative chylothorax from that which appears spontaneously in primitive lymphangioma of the thoracic duct. Gruwez J1 has reported a case of chylothorax after removal of a mediastinal goiter. We have observed 5 patients with mediastinal or cervicomediastinal lymphangioma. In 1 of these cases, the operation was complicated by a chylous effusion. In this patient, a 14-year-old boy, lymphangiography showed that the duct was positioned abnormally (Fig. 3). During the operation a mass adherent to the trachea, esophagus, and the innominate trunk was discovered. Despite careful dissection, we were unable to identify the thoracic duct, which was believed involved in the lymphangioma. The chylothorax appeared 5 days after the operation and resolved after 21 days of repeated thoracentesis. Chylothorax after diaphragmatic surgery. Pequet's cisterna, from which the thoracic duct originates, is located in the central part of the second lumbar vertebra. The abdominal portion of the duct is positioned
Postoperative chylothorax
969
Fig. 4. Chylothorax and chylomediastinum following Allison repair of sliding hiatus hernia (Case 5, Table I).
at the level of the first lumbar and the twelfth thoracic vertebrae behind the aorta. In this same area are located the right and left medial pillars of the diaphragm. These pillars are usually not involved in the operation for diaphragmatic hernias. We have observed 1 case of chylothorax following repair of a bleeding hiatus hernia. This patient, a 58-year-old man, underwent Allison's operation in another surgical unit. The isolation of the cardia and stomach and the reconstruction of the posterior pillars were technically difficult. Three days after the operation a chylous effusion appeared in the right pleural space (Fig. 4). The patient was then treated with bilateral drainage and supportive therapy. The disease cleared 30 days after the operation. Chylothorax after cervical surgery. Extensive neck dissections may give rise to postoperative chylothorax.7- ir- 10> -'• '- The possibility of injury to the thoracic duct is always present during operations for neoplasms of the cervical area, particularly in radical procedures necessitating removal of the jugular vein and the sternocleidomastoid muscle.s We observed 1 interesting case of postoperative chylothorax after cervical surgery. The patient had a carcinoma of the thyroid
The Journal of
9 70
Cevese et al.
Thoracic and Cardiovascular Surgery
measures which will lead to a successful outcome. REFERENCES
Fig. 5. Stasis and extravascular effusion following iatrogenic injury of the thoracic duct (Case 6, Table I). with cervical metastasis. A chylous effusion appeared 5 days after removal of the tumor and radical dissection of the neck but disappeared after thoracic drainage (Fig. 5). Chylothorax after sympathetic nerve surgery. The first observations of postoperative chylothorax were made after thoracoscopic approaches to the thoracic sympathetic chain. Chylothorax may appear after sympathectomy by open thoracotomy3"'' 1G as well as after extrapleural sympathectomy.33 The majority of these observations are not recent, the last case having been reported 10 years ago. Chylothorax after costovertebral surgery. Despite the nearness of the thoracic duct to the vertebrae, chylothorax after operations on the ribs and the vertebrae is a rarity. We have found only one such report, which described chylothorax occurring after excision of the tenth rib for Ewing's tumor.40 Conclusion Chylothorax is an infrequent complication of cardiothoracic surgery. When it does occur, however, it may represent a serious or lethal complication. The surgeon should be aware of this possibility, have a knowledge of the detailed anatomy of the thoracic duct, and be prepared to take appropriate
1 Azzolina, G.: Chilotorace secondario a divisione del dotto arterioso di Botallo, Minerva Chir. 23: 268, 1968. 2 Baffes, T. G., and Potts, W. J.: Postoperative Chylothorax, Ann. Surg. 139: 501, 1954. 3 Baumann, J., and Verdoux, P.: Chylothorax apres pneumonectomie gauche, Mem. Acad. Chir. 83: 215, 1957. 4 Bower, G. C : Chylothorax. Observations in 20 Cases, Chest 46: 464, 1964. 5 Braillon, Schneyder, Genty, Le Brigand, Delie, and Pigot: Les chylothorax par traumatisme chirurgical des vaisseaux linphatiques, Poumon 9: 117, 1953. 6 Bressler, S., Wiener, D., and Thompson, S. A.: Traumatic Chylothorax Following Esophageal Resection, J. THORAC. SURG. 26: 321,
1953.
7 Brewer, L. A., Ill: Surgical Management of Lesions of the Thoracic Duct, Am. J. Surg. 90: 210, 1955. 8 Cevese, P. G., and Fabris, F.: Interventi chirurgici per metastasi linfatiche dei tumori, Lego Ed. Vicenza, 1953. 9 Cevese, P. G., and Gallucci, V.: La patologia dell'arteria succlavia, Recent. Prog. Med. 49: 164, 1970. 10 Cordiano, C : II linfangioma mediastinico e cervico-mediastinico, Chir. Torac. 21: 560, 1968. 11 Cummins, C : Thoracic Duct Fistula Following Thoracoplasty, Br. J. Tuberc. 47: 101, 1953. 12 Douday, D., Dupuy, D., and Bouvrain, Y.: Chylothorax benin apres section d'adherences pleurales, Arch. Med. Chir. Resp. 13: 284, 1938. 13 Effler, D. B.: Chylothorax: A Conservative Method of Management, Cleve. Clin. Q. 19: 6, 1952. 14 Fekete, F., Prandi, D., and Lortat-Jacob, J. L.: Les chylothorax postoperatoires en chirurgie oesophagienne, Ann. Chir. 26: 19, 1972. 15 Fitz-Hugh, G. S., and Cowgill, R.: Chylous Fistula: Complication of Neck Dissection, Arch. Otolaryngol. 9: 543, 1970. 16 Frazell, E. L., Harrold, C. C , and Rasmussen, L.: Bilateral Chylothorax, Ann. Surg. 134: 135, 1951. 17 Garamella, J. J.: Chylothorax Treated by Ligation of the Thoracic Duct and Studies in Thoracic Ductography, Arch. Surg. 76: 46, 1958. 18 Gingell. G. C : Treatment of Chylothorax by Producing Pleurodesis Using Iodized Talc, Thorax 20: 261, 1965. 19 Godart, S., Collette, G., and Dalem, J.:
Volume 69
Postoperative chylothorax 9 7 1
Number 6 June, 1975
20
21
22
23
Pathologie chirurgicale des vaisseaux linphatiques, Acta Chir. Belg. Suppl. 1: 5, 1964. Gotsman, M. S.: Chylothorax After Closure of a Patent Ductus Arteriosus, Thorax 21: 129, 1966. Gruwez, J., Lacquet, A., Gardoen, G., Dive, C , and Beart, A.: Consideration sur le chylothorax, Acta Chir. Belg. 66: 64, 1967. Hardy, G. D., Walker, G. R., and De Guzman, V. C : Thoracic Duct Fistula in Infant: Blue Dye Localization and Operative Closure, J. A. M. A. 182: 187, 1962. Higgins, C. B., and Mulder, D . G.: Chylothorax After Surgery for Congenital Heart Disease,
24
25
26
27
sus,
28
29
30
31 32
J.
THORAC.
CARDIOVASC.
SURG.
61:
411, 1971. Holmberg, L.: Notes on the Anatomy and Physiology of the Thoracic Duct and on the Treatment of Injuries to It, Acta Chir. Scand. 97: 215, 1948/1949. Jaubert De Beaujeu, M., Raton, D., and Andrie, G.: Chylothorax apres clivage d*adherences par voie endoscopique, ligature du canal thoracique, Pouman 7: 9 1 , 1951. Jimenez, E. S., and Majano, M. L.: Chylothorax as Complication in Pulmonary Resection, Chest 32: 344, 1957. Jones, J. C : Twenty-five Years' Experience With the Surgery of Patent Ductus ArterioJ.
THORAC.
CARDIOVASC. SURG.
SO:
149,
1965. Kriiger, B. J., and Jagdschian, V.: "Der traumatische Chylothorax und seine Behandlung, Thoraxchirurgie 12: 208, 1962. Kuntz, E.: Eine Ubersicht iiber das Schrifttum von 1945 bis 1965 mit 297 Fallen und Bericht iiber 3 eigene Beobachtungen, Beitr. Klin. Tuberk. 133: 98, 1966. Laumonier, P., Lachapele, A. P., Counrand, L., Hugues, A., Lagarde, C , and Mage, J.: Une application de la linphografie au diagnostic et au traitment du chylothorax, Presse Med. 70: 2630, 1962. Maier, H. C : Chylous Reflux in Lung and Pleura, Thorax 23: 281, 1968. Maloney, J. V., Jr., and Spencer, F . C : The Nonoperative Treatment of Traumatic Chylothorax, Surgery 40: 121, 1956.
33 McGregor, A. L.: Injuries to the Large Lymphatic Duct, Br. J. Surg. 40: 569, 1953. 34 Metras, D . : Cited by Verdoux, P. 4 5 35 Peet, M. M., and Campbell, K. N . : Massive Chylothorax Following Splanchnicectomy, Univ. Hosp. Bull. Ann. Arbor. 9: 2, 1943. 36 Prouvost, M., and Brincourt, G.: Chylothorax grave consecutif a une section debride, Rev. Tuber. 7: 133, 1943. 37 Saenz-Jiminez, E., and Lopez-Majano, V.: Chylothorax as Complication in Pulmonary Resection, Chest 32: 344, 1957. 38 Schmidt, A.: Chylothorax: Review of 5 Years* Cases in the Literature and Report of a Case, Acta Chir. Scand. 118: 5, 1959. 39 Shumacker, H. B., Jr., and Moore, T. C : Surgical Management of Traumatic Chylothorax, Surg. Gynecol. Obstet. 9 3 : 46, 1951. 40 Shidt, D . D., and Woliver, E.: Traumatic Chylothorax, Arch. Surg. 4 3 : 627, 1941. 41 Steiger, Z., Weinberg, M., and Fell, E. H.: Postoperative Chylothorax, Am. J. Surg. 100: 8, 1960. 42 Tauroff, A. S. W., and Seley, G. P . : Chronic Chylothorax Associated With Hygroma of the Mediastinum, J. THORAC. SURG. 26: 318, 1953.
43 Thomas, C. S., Jr., and McGoon, D. C : Isolated Massive Chylopericardium Following Cardiopulmonary Bypass, J. THORAC. CARDIOVASC. SURG. 61: 945, 1971.
44 Vandecasteele, J., and Soots, G.: Chylothorax apres cure chirurgicale du canal arteriel persistant. Guerison par traitment medical, Lille Chir. 16: 93, 1961. 45 Verdoux, P.: Les chylothorax traumatiques, France Med. 20: 26, 1957. 46 Whitcomb, B. B., and Scoville, W. B.: Postoperative Chylothorax: Sudden Death Following the Infusion of Aspirated Chyle, Arch. Surg. 45: 747, 1942. 47 Williams, K. R., and Burford, T. H.: T h e Management of Chylothorax, Ann. Surg. 160: 131, 1964. 48 Wu, Ying-K'Ai: Surgical Treatment of Carcinoma of the Esophagus and Cardia of the Stomach, Chinese Med. J. 7 3 : 181, 1955.