Vol 43 # 2 June 2011 - Kma.org.kw

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144 Late-Onset Chylothorax after a Pneumonectomy for Lung Cancer: A Case Report June 2011 Fig. 1: Chest radiograph taken on admission revealed expected anatomic changes with rising fluid level at second rib on right side. revealed loss of air fluid level line appearance with mild mediastinal shift to the right side. Blood gas results were acceptable for pneumonectomy Daily blood count and biochemical values were within normal range on following days. Respiratory distress was not obvious. Cultures of pleural fluid revealed no bacterial growth. Daily pleural fluid drainage was 150 - 200 ml with serous appearance. Decreasing daily drainaige, improvement in general status, acceptable blood gas analysis results and higher albumin levels prompted us to adopt a conservative approach. But hospitalization course was complicated with an epileptic attack. Neurologic examination revealed cerebral atropy associated with narrowed carotid lumen. Cerebral metastasis was uncertain on radiological evaluation. On the 12 th day of hospitalization when sitting in bed, he suddenly developed dyspnea followed by cardio-pulmonary arrest. Although we performed resuscitation he could not be revived. The cause of sudden death was obscure because his family seemed unwilling to approve autopsy. Neverthless a few cases of sudden death after pneumonectomies were reported in literature and thromboembolic events were usually blamed in the etiology. DISCUSSION Lung cancer is one of leading cause of death in developed countries. Although there is improvement in chemotherapy and radiation therapy, surgery is still the best solution for better survival. Resection is indicated in stage 1 ,2 and some 3 non-small cell lung cancer. Pneumonectomy is one of the resection options with tumors involving main bronchus and pulmonary artery or extension across the major fissure [3,4] . Most of complications of pneumonectomy are pulmonary or cardiovascular in origin. Less frequently oncologic gastroesophageal and neurologic morbidity is encountered in practice [3,4] . Traumatization of thoracic duct and tributaries usually leads to accumulation of Fig. 2: Chest radiograph after decompression revealed loss of air fluid level line appearance with mild mediastinal shift to right side a large amount of lymphatic fluid in thoracic cavity. Various invasive and surgical procedures of thorax and neck , cancer invasion, direct or indirect trauma to the duct may result in damage to the thoracic duct [5] . On the other hand, chylothorax after a pulmonary resection is relatively rare but may lead to respiratory, hemodynamic, metabolic, immunologic or nutritional disturbances [4,5] . The prevalence ranges from 1 - 2%, and without treatment mortality rate is around 50%. Chylothorax after a pulmonary resection is usually diagnosed within three days after surgery because oral intake usually starts on the first postoperative day [6] . During the convalesence period the diagnosis is more diffucult. Symptoms and findings are usually non-specific and can easily be overlooked. Dyspnea, cough, and chest discomfort are frequently observed symptoms. Pleuritic chest pain and fever are uncommon because chyle is not irritant to the pleural surface. Chylic fluid accumulation in pneumonectomy cavity may cause mechanical compression of contralateral lung and mediastinal structures and compromise pulmonary and cardiovascular function [5,7] . Deterioration of nutritional status makes the patient more susceptible to infection. Dehydration is also considerable in some cases [5,7] . Radiologic findings are not specific for chylothorax. Unexpected accumulation of fluid into the pleural cavity in the postoperative period should raise suspicion for hemorrhage, infection, or development of a chylothorax [3,4] . Decision of thoracentesis is the cornerstone and diagnosis can be verified via fluid analysis. Early recognition does not only prevent further deterioration of patient but the less invasive therapeutic modalities may be more appropriate to treat this condition [5] . Pleural fluid cholesterol / triglyceride ratio of less than 1 and triglyceride level greater than 110 are chyle characteristics [3] . Suspicion should arise when there is excessive tube drainage over 72 hours after surgery.
June 2011 KUWAIT MEDICAL JOURNAL 145 Pleural fluid analysis usually reveals the diagnosis but if in doubt lipoprotein analysis demonstrating chylomicrons can confirm diagnosis [3,5] . Postpneumonectomy chylothorax is a rare but serious complication. It needs prompt diagnosis and intervention. Non-operative and operative approaches depend on the situation and surgeon's preference [1,5,8] . Non-operative approach includes drainage of pleural cavity, enteral rest and total parenteral nutrition until chylic fluid drainage ceases [1,5] . Recently, octreotide, a long acting somatostatin analog, administation has been shown to yields some benefit to reduce thoracic ductal flow [9] . If the non-operative approach fails surgical intervention is indicated. Leakage for more than five days at the rate of 1.5 l/day, leakage persisting over 15 days and detoriation of nutritional and immunological status of the patient are indications for operation [3,10] . Once the oozing site is identified, the leakage can be treated with suture, clips, fibrin glue, or talcage [11] . This case report is noteworthy in several respects. First, this is one of the late onset cases that developed chylothorax 45 days after the operation. Presenting symptoms were non-specific to arouse early suspicion. Chest radiograph revealed expected anatomic changes after operation. Unfortunately, in slowly progressing cases radiologic findings are usually silient. Except leucocytosis blood count was normal. The relation between leucocytosis and chylothorax is not clear. Interestingly, preserved total plasma protein values and mildly decreased albumin concentration supported the delayed onset of this condition. We did not apply any test to assess his nutritional status but oral intake before and after hospitalization was satisfactory. Mediastinal lymphoid tissue dissection was performed for staging. It is difficult to see thoracic duct with naked eye during operation and trauma to the duct may be easily overlooked. Stopped oral intake a day before operation decreased lymph flow and this might have lead to difficulties in recognizing the oozing of chyle. Lastly, late onset chyclothoraces may result due to eradication of the duct by residual tumoral growth after operation. CONCLUSION Chylothorax is a rare but life-threatening complication. Early recognition and prompt treatment is essential. Although radiologic and laboratory findings are normal, any symptom developed after sleeve lobectomy must be considered important and has to be investigated. REFERENCES 1. Vallieres E, Shamji FM, Todd TR, Postpneumonectomy chylothorax. Ann Thorac Surg 1993; 55:1006-1008. 2. Terzi A, Furlan G, Magnanelli G, Terrini A, Ivic N. Chylothorax after pleuro-pulmonary surgery: a rare but unavoidable complication. Thorac Cardiovasc Surg 1994; 42:81-84. 3. Shields TW. Chylothorax, In: Shields TW, Locicero III J, Ponn RB, editors. General Thoracic Surgery, 6th Ed., Philadelphia: Lippincott Williams & Wilkins; 2005. p 881-888. 4. Non-Small Cell Lung Cancer (PDQ®): Treatment PDQ Cancer. Information Summaries: Adult Treatment, National Cancer Institute, Bethesda, MD, 2005. p 7-9. 5. Nair SK, Petko M, Hayward MP. Aetiology and management of chylothorax in adults. Eur J Cardiothorac Surg 2007; 32:362-369. 6. Sieczka EM, Harvey JC. Early thoracic duct ligation for postoperative chylothorax. J Surg Oncol 1996; 61:56- 60. 7. Merrigan BA, Winter DC, O’Sullivan GC. Chylothorax. Br J Surg 1997; 84:15-20. 8. Kopec SE, Irwin RS, Umali-Torres CB, Balikian JP, Conlan AA. The postpneumonectomy state. Chest 1998; 114:1158-1184. 9. Kalomenidis I. Octreotide and chylothorax. Curr Opin Pulm Med 2006; 12: 264-267. 10. Selle JG, Snyder WH 3rd, Schreiber JT. Chylothorax: indications for surgery. Ann Surg 1973; 177:245-249. 11. Browse NL, Allen DR, Wilson NM. Management of chylothorax. Br J Surg 1997; 84:1711–1716.
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