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Mediastinal chyloma after lung cancer surgery: case report
© The Author(s). 2016
Received: 3 March 2016
Accepted: 27 July 2016
Published: 2 August 2016
Chylothorax is a relatively rare but well-known complication of thoracic surgery.
A 70-year-old man underwent right upper and middle bilobectomy and systematic lymph node dissection through a posterolateral thoracotomy for lung cancer. On the second postoperative day, he developed chylothorax that was treated with dietary management and pleurodesis. The discharge diminished and his chest tube was removed on the ninth postoperative day. On the 14th postoperative day, the patient complained of dyspnea and dysphagia, and imaging studies revealed mediastinal chyloma. Thoracoscopic surgical drainage was performed and the site of chyle leakage was sutured.
This report presents an unexpected complication of chemical pleurodesis and reviews the indications for surgical intervention in cases of postoperative chylothorax.
Chylothorax is a relatively rare but well-known complication of thoracic surgery. It is treated with some conservative approaches such as oral intake cessation including nil per os with total parenteral nutrition, low-fat diet management, and chemical pleurodesis . Surgical intervention is considered only when conservative treatments have failed. We report a case of mediastinal chyloma possibly induced by pleurodesis to treat chylothorax following lung cancer surgery.
Chylothorax after lung cancer surgery is relatively rare, occurring in only 2.2–2.4 % of cases [1–3]. Management strategies for chylothorax have been well discussed, but so far there is no consensus as to protocol. Traditionally, chylothorax is treated conservatively with dietary modification. The basic principle of conservative treatment for chylothorax is to inflate the remnant lung to decrease the dead space and to promote spontaneous adhesion around the injured thoracic duct . Cerfolio et al.  recommended observation of the patient for seven days with dietary management. At that point, if the drainage is still greater than 1000 mL/day, reoperation to ligate the thoracic duct is necessary. In cases where dietary management are insufficient, pleurodesis must be considered. Since the amount of chylous fluid may reduce the efficacy of pleurodesis, Shimizu et al.  recommended early surgical intervention if chest tube drainage of more than 500 mL of chylous fluid was observed during the first 24 h after complete oral intake cessation and the initiation of total parenteral nutrition. It should also be noted that pleurodesis has the potential to make subsequent surgery more difficult. In fact, in this case we found several fibrous adhesions around the remnant lower lobe during the second surgery, which could eventually lead to chyloma formation. Suzuki et al.  likewise reported a case of a mediastinal chyloma after a conservative treatment with OK-432 following right upper lobectomy and systematic lymph node dissection. They reported that the thick capsule of the chyloma may have been the results of severe inflammation response caused by the intrapleural injection of OK-432. Their report and our case both suggest that pleurodesis may fail to promote proper adhesion around the injured thoracic duct when it is difficult to inflate the remnant lung because a large amount of chylous discharge is located in the dead space. If there are some chyle flow rate and pressure, once the growth of fibrous adhesions following pleurodesis blocks chylous discharge from entering the chest tube, occult chyloma could arise despite a seemingly successful pleurodesis with apparent cessation of drainage.
This report presents the serious complications and limitations of chemical pleurodesis and reviews the indications for surgical intervention in postoperative chylothorax. Although mediastinal chyloma is quite rare, it is important to note that it can develop following chemical pleurodesis treatment for chylothorax with a large amount of discharge and that it can present symptoms due to compression of the trachea and/or the esophagus.
MF drafted the manuscript and assisted the operations. HT and KO performed the surgeries. TT participated in writing the article. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Ethics approval and consent to participate
Written informed consent was obtained from the patient for the publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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