Asian Cardiovasc Thorac Ann 2003;11:355-356
© 2003 Asia Publishing EXchange Ltd
Chylothorax Following Coronary Bypass Grafting: Treatment by Talc Pleurodesis
Qamar Abid, FRCS(CTh),
Russel W Millner, FRCS(CTh)
Department of Cardiothoracic Surgery, Victoria Hospital, Blackpool, United Kingdom
For reprint information contact: Qamar Abid, FRCS(CTh) Tel: 44 1782 555 005 Fax: 44 1782 555 058 email: qumarabid{at}hotmail.com University Hospital North Stafford, Princess Road, Hartshill, Stoke-on-Trent ST4 7LN, United Kingdom.
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ABSTRACT
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Chylothorax after myocardial revascularization is a rare but serious complication. There is as yet no definitive treatment. We report a case in which chylothorax was diagnosed on the 3rd postoperative day. Conservative management with dietary restriction to medium-chain triglyceride led to reduction of chyle leakage from 300 to 400 mL/day to 50 to 60 mL/day 3 days later. However, the leak persisted until talc pleurodesis was performed.
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INTRODUCTION
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Chylothorax after cardiac surgery is a rare complication. Although a few cases have been reported,1–3 the choice of treatment for these patients remains a matter of personal preference. Mostly, conservative management is initially attempted by restricting fat in the diet to medium-chain triglyceride. Varying degrees of success and failure by conservative measures have been described. We report a case of chylothorax, which was diagnosed on day 3 following myocardial revascularization, that responded to talc pleurodesis after conservative management failed.
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CASE REPORT
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A 58-year-old Asian male insulin-dependent diabetic was evaluated for recurrent episodes of angina. He was found to have triple-vessel coronary artery disease with good left ventricular function. His ascending aorta was dilated but measured less than 4 cm in diameter on echocardiography.
After median sternotomy, the thymic tissue was divided with electrocautery but not ligated. The left internal mammary artery (LIMA) was dissected as high as the first intercostal branch, which was ligated with a Ligaclip (Ethicon Inc., Somerville, NJ, USA). The left pleura was opened widely. He underwent quadruple coronary artery bypass grafting using the LIMA and long saphenous vein grafts. The chest was closed in a routine fashion with 3 vacuum suction drains inserted in the mediastinal, pericardial, and pleural cavities.
The patient was transferred to the ward the following day in a satisfactory condition. He was started on regular diet. The mediastinal and pericardial drains were removed after 48 hours, but the pleural drain was left in for 4 days following protocol. On the 3rd postoperative day, the drainage was noticed to change from being bloodstained to milky. Biochemical examination of the fluid confirmed it to be consistent with chyle. He was started on food containing medium-chain triglyceride. Chyle production decreased from an average of 300 to 400 mL/day to 50 to 60 mL/day after 3 days, but the effusion persisted. The vacuum suction drain was removed and used for gravity drainage.
The patient was discharged home with the pleural drain in situ and appropriate dietary advice. Follow-up 1 week later showed no sign of improvement, with chyle drainage remaining around 50 to 60 mL/day. A decision was made to perform talc pleurodesis with the patient’s informed consent. A 50-mL cocktail of 1 g of talc powder diluted in 30 mL of normal saline mixed with 20 mL of 1% lignocaine was instilled through the pleural drain. The drain was kept clamped for 4 hours. The patient’s position was changed every 45 minutes in order to achieve homogeneous application of the talc mixture. The position was initially changed from supine to left lateral, then prone and right lateral. Finally, the head of the bed was kept up by 45 degrees for 30 minutes and then down by 45 degrees for another 30 minutes. The patient was discharged home on the same day with the drainage bag. At 1-week follow-up, there was no drainage, even after challenge with a fatty diet. The drain was removed. There was no recurrence at 6-week follow-up. The patient was on regular diet and enjoying a good quality of life.
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DISCUSSION
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Chylothorax following thoracic surgery is a well-known complication. The reported incidence varies from 0.3% to 0.42%, but none of these cases were following cardiac surgery.1,2 The occurrence of chylothorax following cardiac surgery in children has been reported, but in the authors’ experience of over 2,000 cases this complication had never occurred after adult cardiac surgery.3 There are very few reported cases after myocardial revascularization.4,5
The actual mechanism of chylothorax in adults following cardiac surgery is not very clear. The thoracic duct enters the left subclavian vein near its junction with the left external jugular vein at the base of the neck. Damage to the thoracic duct during harvesting of the LIMA is suggested but is unlikely because of the anatomical position of the subclavian vein. Although the major lymphatic drainage system lies extrapleurally, numerous tributaries may be present in the superior mediastinum. Damage to these tributaries during division of the thymus by electrocautery is a more likely cause of chyle leakage. The other possible source is from injury to the left internal mammary lymphatics during dissection of the LIMA.
Risk factors such as congenital malformation, reoperation, previous thoracotomy, and the use of electrocautery instead of ligation to divide the lymphatics have been reported.6,7 The use of electrocautery to divide the thymus, instead of suture ligation, is our preferred method. This is the likely cause of the lymphatic leakage in our case. A widely open pleura could have allowed the leaked mediastinal chyle to accumulate in the pleural cavity.
The ideal management of chylothorax has not been established, and treatment can be extremely difficult. Conservative management has been advocated,8 which includes continuous closed chest drainage, a diet consisting of medium-chain triglycerides (as they are absorbed directly into the portal system rather than into the intestinal lymphatics), and careful monitoring of the nutritional status of the patient. Parenteral nutrition may be indicated. Using these measures in our patient, leakage persisted, although the amount decreased.
Surgical intervention is recommended if chyle leakage persists for more than 3 weeks, daily loss exceeds 1.5 L, or there is imminent nutritional complication in debilitated patients.6 Identification of the source of leakage and surgical division of the fistula are ideal in these patients. However, identification of the actual site may be difficult. Other common surgical interventions are thoracotomy and thoracic duct ligation, pleuroperitoneal fistula, and pleuroperitoneal fistula combined with thoracic duct ligation. However, management of a persistent small chyle leak, despite conservative treatment, is not clearly established.
Talc powder produces chemical inflammation leading to intense inflammatory response. This is followed by adhesion and fibrosis, which seals the area of the leak. Our case demonstrates that talc pleurodesis may be considered as an alternative option. It avoids the morbidity associated with persistent leakage as well as unnecessary exploration with its associated complications. Thymic tissue ligation, instead of electrocautery alone, should be the preferred option to avoid this complication.
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REFERENCES
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