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J Thorac Cardiovasc Surg 1994;108:1155-1156
© 1994 Mosby, Inc.
LETTERS TO THE EDITOR |
Department of Cardiothoracic Surgery
Groby Road Hospital
Leicester LE3 9QE, United Kingdom
To the Editor:
Chylothorax after myocardial revascularization is rare Chaiyaroj, Mullerworth, and Tatoulis
1 recently reported a case of chylothorax after myocardial revascularization done with the internal thoracic artery (ITA), in which the site of leakage was clearly identified and controlled. We present a similar case of postoperative chylothorax in which further evidence of unusual lymph collection is seen and which required surgical intervention. The need for the surgeon to be aware of the possibility of lymph leakage around the origin of the ITA is reiterated.
The accumulation of chyle within the pleural cavity (chylothorax) is a widely recognized complication of thoracic surgery and thoracic trauma. Although first reported by Bartolet in 1622, 2 it was not described as a postoperative complication until Blalock, Cunningham, and Robinson 3 described it in 1936. Chylothorax has been shown to occur in 0.25% to 0.5% of cardiothoracic operations performed through a thoracotomy incision, such as the creation of Blalock-Taussig shunts. It is an even more unusual complication after median sternotomy.
A 48-year-old man with ischemic heart disease underwent coronary artery bypass grafting with the ITA and the long saphenous vein. The ITA was dissected from the chest wall, up to its origin from the first part of the subclavian artery, with diathermy and Liga-Clip devices (United States Surgical Corporation, Auto Suture Company Division, Norwalk, Conn.) used to achieve hemostasis. The saphenous vein was harvested from the lower part of the left leg with 3-0 silk ties (Ethicon, Inc., Somerville, N.J.) used to ligate the branches, with care taken to preserve the saphenous nerve. The initial postoperative recovery was uncomplicated and the patient was discharged to his home after 8 days.
Three weeks after discharge he was readmitted with worsening dyspnea. A chest x-ray film showed a large left pleural effusion. Serum electrolyte concentrations, liver function tests, and lipid levels were within normal limits. White cell count was 9.1 x 109/L (normal 4 to11 x 109/L). Initially, 3.5 L of chylous fluid was drained (Table I). The patient was managed as an outpatient with intercostal tube drainage and a low-fat diet for 4 weeks until drainage had stopped. The intercostal drain was then removed.
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(Table I). Repeated aspiration failed, and formal incision and drainage had to be carried out to relieve this problem. The patient was finally discharged 1 year after the operation with no evidence of further lymph collection.
Chylothorax after median sternotomy and intrapericardial cardiac operations remains rare. Several cases have been reported but only seven of these followed coronary artery bypass grafting, five of which were with the ITA. 1
In the superior mediastinum several lymphatic tributaries may be present, including bronchomediastinal, left jugular, and left subclavian trunks. They may all open separately into one or another of the great veins or they may unite in a variety of ways. The internal thoracic lymphatic trunk arises from nodes along the back of the sternum and is either connected to the bronchomediastinal trunk or drains directly into the upper end of the thoracic duct.
The main lymphatic drainage from the lower limb lies in close proximity to the long saphenous vein. It is therefore always at risk when the long saphenous vein is harvested for coronary bypass grafting, but lymphoceles are rarely encounted.
Direct cautery damage is the likely cause of the chylothorax in this case because of the close proximity of structures at the root of the neck (Fig. 1). Electrocautery to the lymphatic tissue is unlikely to produce a seal, inasmuch as this requires the formation of a proteinaceous coagulum and lymph contains fewer proteins than plasma (Table I).
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4 Injury to the thoracic duct during harvesting of the ITA would pass unnoticed as drainage tubes are removed before dietary fat is ingested.
Varying forms of treatment of chylothorax are reported, ranging from triglyceride substitution diets to surgical intervention. 1, 5 In the case we describe, intercostal tube drainage and a low-fat diet were successful. Should drainage be massive despite these measures, then total parenteral nutrition would be the next step. Surgical intervention would require ligation of the thoracic duct.
Our report is different from those described previously in that in this case further evidence of lymph collection is seen along the site of surgical intervention. In addition to the left chylothorax, a small lymphocele necessitating surgical drainage developed in the lower leg wound.
References
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