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Delayed right chylothorax after left blunt chest trauma: a case report
© The Author(s). 2017
Received: 17 August 2016
Accepted: 26 February 2017
Published: 10 April 2017
Chylothorax is a disease that has various causes such as neoplasm, infection, post-surgery trauma, congenital, and venous thrombosis. In approximately 15% of cases of chylothorax, the exact cause is unknown. We report a case of delayed occurrence of right chylothorax in a patient who had multiple segmental ribs fracture on his left side.
A 70-year-old Asian man had a “rollover” accident in which the cultivator he was driving overturned. He presented to our hospital with the main complaint of severe dyspnea. On chest computed tomography, multiple ribs fracture from the first to the eighth rib of the left side of his chest and left-sided hemopneumothorax were presented, but there was no evidence of fracture in the right side of his chest.
After closed thoracostomy, an emergency operation for open reduction of fractured ribs was performed. On the fifth postoperative day, tubal feeding was performed. On the next day, a plain chest X-ray image showed pleural effusion of the right side of his chest. After insertion of a small-bore chest tube, 3390 ml of fluid for 24 hours was drained. The body fluid analysis revealed triglycerides levels of 1000 mg/dL, which led to a diagnosis of chylothorax. Although non-oral feeding and total parenteral nutrition were sustained, drain amount was increased on the fifth day. Surgical treatment (thoracoscopic thoracic duct ligation and pleurectomy) was performed in the early phase. The right chest tube was removed on the 14th postoperative day after the effusion completely resolved and he was uneventfully discharged.
In this case, as our patient was in old age and had multiple traumas, surgical treatment for chylothorax needed to be performed in the early phase.
Chylothorax occurs as the result of laceration, rupture, or obstruction in the thoracic duct or its branches. Common causes of chylothorax include neoplasm, trauma, infection, and venous thrombosis [1–3] and it has been known that nearly 30% of cases are accompanied by fatal complications such as heart failure, malnutrition, and immunodepression . The exact cause of chylothorax is unknown in approximately 15% of cases. We intend to introduce the progress and treatment of delayed chylothorax that occurred contralaterally after trauma.
Traumatic injury to the thoracic duct may occur after cervical, thoracic, or abdominal surgical procedures or as a result of penetrating or blunt trauma. Chylothorax is a rare complication of blunt chest trauma, as the thoracic duct is generally well protected by the spine posteriorly and mediastinal contents anteriorly. Although thoracic or lumbar spinal injury is a common occurrence after blunt chest trauma, very few patients will have an associated chylothorax. The most common mechanism of injury to the thoracic duct after blunt trauma appears to be sudden hyperextension of the spine [4, 5]. This results in rupture of the duct due to stretching over the vertebral bodies or a shearing of the duct by the right crus of the diaphragm, even without evidence of vertebra fracture or dislocation . In this case, our patient had no evidence of vertebra injury, but delayed right chylothorax may have occurred after spine hyperextension not accompanied by vertebra fracture.
The loss of chyle and lymph into the pleural space can lead to loss of water, electrolytes, proteins, immunoglobulins, fat, and essential vitamins. Patients are usually able to compensate in the early stages but in advanced cases there may be signs and symptoms of malnutrition and hypovolemia. Acidosis, hyponatremia, and hypocalcemia are the most common abnormalities . Continued loss of proteins, immunoglobulins, B lymphocytes, and T lymphocytes into the pleural space can lead to immunosuppression .
In 50% of the cases, non-surgical treatment for 10 to 14 days cured the disease . If the conservative treatment fails so much that the drainage has accelerated in daily output to 200 to 500 mL per day for 1 to 3 weeks, it may be possible to consider an operative technique such as thoracic duct ligation or thoracic duct embolization. Surgery enables a reduction in the period of being hospitalized and prevents complications that may have occurred by chylothorax . However, there is no consensus on the length of time before surgical therapy should be considered in a patient whose drainage has significantly decreased. Although 4 further weeks of chest drainage has been suggested empirically , some have favored a more aggressive approach, with immediate thoracotomy and thoracic duct ligation if the leak has not resolved after 2 weeks of observation .
But, chylothorax can have an impact on respiratory distress and chronic depletion of chyle , and particularly old patients could become vulnerable to infections and malnutrition, particularly in the postoperative period . In our case, the patient recovered without any clinical symptoms of chyle loss due to early operation.
In this case, as our patient was in old age and had multiple traumas, we considered that fasting for a long time would have a bad impact on his recovery. For this reason, surgical treatment was performed in the early phase and he was discharged from our hospital without problem.
This case was presented as a poster at the Korean Society of Thoracic and Cardiovascular Surgery.
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JGL: acquisition, analysis, and interpretation of the data, and drafting the manuscript. JSC: acquisition of the data and revising the manuscript critically. HI: acquisition of the data and revising the manuscript critically. YDK: acquisition and interpretation of the data, and revising the manuscript critically. All authors have read and approved the final manuscript.
The authors declare that they have no competing interests.
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