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© 2004 European Association of Cardio-Thoracic Surgery
Recurrent dysphagia after oesophagectomy caused by chylomediastinum
a Department of Radiology, The Royal Devon and Exeter Hospital (Wonford), Barrack Road, Exeter, EX2 5DW, UK
* Corresponding author. Tel.: +44-1392-403742; fax: +44-1392-402330 Received August 5, 2003; received in revised form September 25, 2003; accepted September 28, 2003
Chylothorax is an uncommon but recognized complication of oesophagectomy. We present a case where there was an isolated mediastinal collection of chyle presenting with recurrent dysphagia.
Key Words: Oesophagectomy; Chyle; Chylomediastinum; Dysphagia
A 76-year-old female presented with dysphagia of insidious onset over the preceding 8 weeks. Clinical examination was essentially normal. A Barium Swallow demonstrated a lesion in the mid-oesophagus with irregular mucosa and shouldering that slowed the passage of a semi-solid food bolus. The presumed diagnosis was of oesophageal malignancy. A staging CT scan confirmed the presence of oesophageal thickening in its mid-portion but did not demonstrate evidence of local or distant disease. She underwent sub-total thoracic oesophagectomy via an Ivor–Lewis approach with a high oesophago-gastric anastomosis. The thoracic duct was identified and ligated during the procedure. Histology confirmed that the lesion was a moderately differentiated, keratinizing squamous cell carcinoma which had penetrated to the adventitia and four out of six nodes were positive for tumour. This was a T3 N1 M0 carcinoma. Postoperatively the output from the intercostal drain increased to a maximum of 800 ml in 24 h on the third postoperative day. The output volume steadily decreased thereafter and the drain was removed on the sixth postoperative day. The patient was discharged home 48 h later. She was readmitted 2 days later with difficulty swallowing and an endoscopy was performed. No abnormality was seen at the oesophago-gastric anastomosis or within the intra-thoracic stomach. She settled with conservative treatment. Sixteen days following her operation she was again readmitted with worsening dysphagia. A Barium Swallow demonstrated no passage of contrast beyond the level of the carina and possible extrinsic compression of the intra-thoracic stomach (Fig. 1). A chest radiograph revealed some mediastinal widening. A thoracic CT with intra-venous enhancement (50 ml Niopam 300 at 3 ml/s, GE Pace) showed a well-defined mediastinal collection with an average Hounsfield Unit of –11 (Fig. 2). This was drained percutaneously on day 20 under CT guidance using a 5F pigtail catheter (Bjaeverskov, William Cook, Europe). Chylous fluid was obtained. Following this procedure her symptoms improved but significant volumes of chyle continued to drain, despite attempts to sclerose the cavity and keeping it on suction drainage. The patient returned to theatre on the 28th day following the initial operation for laying-open of the mediastinal collection and re-ligation of the thoracic duct (it had been ligated prophylactically at the original operation). Following this she made a good recovery.
The patient died 6 months after initial presentation due to metastatic disease.
The thoracic duct is at risk during oesophagectomy due to its close relationship to the oesophagus. The thoracic duct is formed by the confluence of lymphatic channels anterior to the upper lumbar vertebrae. It passes with the aorta behind the median arcuate ligament of the diaphragm, lying to the right of the midline, and ascends posterior to the oesophagus. At the level of the seventh to fifth thoracic vertebrae the duct crosses the midline and lies along the left side of the oesophagus. It continues to the root of the neck where it arches anteriorly to enter the left subclavian vein [1]. Damage to the thoracic duct usually leads to the development of a chylous pleural effusion and persistent drainage via intercostal drains. Chylothorax after oesophagectomy occurs in up to 2% of cases [2]. This may be difficult to diagnose in the immediate postoperative period, as the fluid may be straw coloured whilst the patient is fasting. The fact that the fluid is chyle can be confirmed by lymphography or lymphoscintigraphy and the ingestion of fatty foods may turn the fluid milky [2]. Analysis of the fluid will reveal the presence of chylomicrons and a high lymphocyte count [3]. The management may be conservative or operative [4]. If the pleura is not breached the chyle collects in the mediastinum. This may be termed a loculated chylothorax or chylomediastinum. This is rare. In this unique case it caused extrinsic compression of the oesophagus and dysphagia. Previous reports of chylomediastinum have also been made after cardiac surgery [5] and mediastinoscopy [6] and, in one report, caused respiratory embarrassment following oesophagectomy, initially misdiagnosed as asthma [3]. The differential diagnosis includes abscess, anastomotic leak, seroma and mucocoele of the oesophagus [7]. CT can confirm the presence of a collection in the mediastinum, and may suggest the presence of chyle if the fluid is of fat density as in this case. As discussed above this is not invariable and lymphoscintigraphy or lymphography may be used to confirm and demonstrate the site of the leak. However, CT-guided intervention offers a diagnostic and therapeutic option, where fluid can be obtained for analysis and drainage instituted. Alternative therapies include dietary restriction, open repair or percutaneous catheterization and embolization of the thoracic duct [8]. Oesophageal cancer is increasing in incidence [9] and oesophageal surgery is commonly being performed. Chylomediastinum is rare, but must be remembered in the differential diagnosis of a mediastinal collection, as this is a remediable cause of symptoms such as recurrent postoperative dysphagia and respiratory embarrassment.
ICVTS on-line discussion Author: Dr. Jaroslaw Kuzdzal, Pulmonary Hospital Zakopane, Department of Thoracic Surgery, ul. Gladkie 1, Zakopane, 34-500 Poland Date: 03-Nov-2003 Message: This is an interesting paper, pointing out difficulties one may encounter treating patients with chyle extravasation. In this patient the chyle collection in mediastinum developed despite prior thoracic duct ligation. The cause of this may be an anatomic variation of the thoracic duct, which may form two or even multiple channels. Such variation is frequent in patients with lymphangioleiomyomatosis, but may also occur in others, making complete ligation of the duct difficult. This fact stresses the need for very wide encircling with the ligature all tissue between aorta, azygos vein, oesophagus and vertebral column reaching area far right of the midline of vertebral body. Response Author: Mr. Richard Berrisford, NHS, Department of Cardiothoracic Surgery, Royal Devon and Exeter Hospital, Exeter, UK Date: 21-Nov-2003 Message: I agree that suture ligation of the thoracic duct at the diaphragm needs to include as wide an area as possible. Furthermore, some surgeons have advocated injection of cream into the feeding jejunostomy after the abdominal phase of the procedure to identify unsuspected chyle leaks in the chest. doi:10.1016/S1569-9293(03)00227-5
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Abstract
1. History
