Limits...
Delayed right chylothorax after left blunt chest trauma: a case report

View Article: PubMed Central - PubMed

ABSTRACT

Background: 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.

Case presentation: 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.

Case presentation: 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.

Conclusions: 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.

No MeSH data available.


Related in: MedlinePlus

Thoracoscopic mass ligation of thoracic duct, right
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

License 1 - License 2
getmorefigures.php?uid=PMC5385601&req=5

Fig5: Thoracoscopic mass ligation of thoracic duct, right

Mentions: He was transferred to the ER of our hospital. The hemothorax and the condition of his chest wall indicated surgery and we performed emergency surgery of open reduction for fractured ribs and primary repair for lacerated lung. Due to the flail chest, he needed the support of a mechanical ventilator for stable respiration. As part of postoperative ventilator care, tubal feeding was started on the fourth postoperative day (POD). On the next day (fifth POD), a chest X-ray showed a large amount of right pleural effusion (Fig. 2). A small-bore chest catheter (16 gauge) was placed in right pleura. Approximately 880 ml of pleural fluid was initially drained and in total 3390 ml was drained for 24 hours. The color of the fluid changed from pinky to creamy (Fig. 3). Laboratory analysis of the fluid showed high triglycerides (>1000 mg/dl) and low total cholesterol levels (6 mg/dl). The amount of drainage increased to 3000 to 4000 ml/day on the fifth day after the initiation of non-oral feeding (NPO) and total parenteral nutrition (TPN). Because of the extremely large amount of drained fluid, thoracoscopic thoracic duct ligation and pleurectomy on the right was performed the next day (sixth POD). We decided to do early-phase surgery because our patient was an elderly patient with trauma and a long period of fasting would be likely to cause problems with nutrition. His chest was explored, but no obvious leak was identified. The pleura between his aorta and esophagus was dissected at the base of his diaphragm and the dissection continued toward his right-sided thorax between his posterior aorta and the vertebral bodies. There was a mass-like lesion combined with pericardial fat and chyle (Figs. 4 and 5). After this finding, surgical ligation of his thoracic duct was decided and a pleurectomy was performed to reduce the risk of recurrent malignant effusion. Immediately postoperatively, the drainage changed to serosanguineous fluid, without any evidence of chyle. Two days after the operation, the drains were serous and the amount of drainage was reduced to less than 100 ml/day. He started a fat-free diet after surgery and then his diet was changed to fat content and medium-chain triglycerides diet.Fig. 2


Delayed right chylothorax after left blunt chest trauma: a case report
Thoracoscopic mass ligation of thoracic duct, right
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC5385601&req=5

Fig5: Thoracoscopic mass ligation of thoracic duct, right
Mentions: He was transferred to the ER of our hospital. The hemothorax and the condition of his chest wall indicated surgery and we performed emergency surgery of open reduction for fractured ribs and primary repair for lacerated lung. Due to the flail chest, he needed the support of a mechanical ventilator for stable respiration. As part of postoperative ventilator care, tubal feeding was started on the fourth postoperative day (POD). On the next day (fifth POD), a chest X-ray showed a large amount of right pleural effusion (Fig. 2). A small-bore chest catheter (16 gauge) was placed in right pleura. Approximately 880 ml of pleural fluid was initially drained and in total 3390 ml was drained for 24 hours. The color of the fluid changed from pinky to creamy (Fig. 3). Laboratory analysis of the fluid showed high triglycerides (>1000 mg/dl) and low total cholesterol levels (6 mg/dl). The amount of drainage increased to 3000 to 4000 ml/day on the fifth day after the initiation of non-oral feeding (NPO) and total parenteral nutrition (TPN). Because of the extremely large amount of drained fluid, thoracoscopic thoracic duct ligation and pleurectomy on the right was performed the next day (sixth POD). We decided to do early-phase surgery because our patient was an elderly patient with trauma and a long period of fasting would be likely to cause problems with nutrition. His chest was explored, but no obvious leak was identified. The pleura between his aorta and esophagus was dissected at the base of his diaphragm and the dissection continued toward his right-sided thorax between his posterior aorta and the vertebral bodies. There was a mass-like lesion combined with pericardial fat and chyle (Figs. 4 and 5). After this finding, surgical ligation of his thoracic duct was decided and a pleurectomy was performed to reduce the risk of recurrent malignant effusion. Immediately postoperatively, the drainage changed to serosanguineous fluid, without any evidence of chyle. Two days after the operation, the drains were serous and the amount of drainage was reduced to less than 100 ml/day. He started a fat-free diet after surgery and then his diet was changed to fat content and medium-chain triglycerides diet.Fig. 2

View Article: PubMed Central - PubMed

ABSTRACT

Background: 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.

Case presentation: 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.

Case presentation: 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.

Conclusions: 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.

No MeSH data available.


Related in: MedlinePlus