Interact CardioVasc Thorac Surg 2009;8:176-177. doi:10.1510/icvts.2008.190561
© 2009 European Association of Cardio-Thoracic Surgery
Chylopericardial tamponade complicating oesophago-gastrectomy
Duncan Stewarta,*,
Timothy Chicob and
Roger Ackroyda
a Department of Upper GI Surgery, Royal Hallamshire Hospital, Beech Hill Road, S10 2JF, Sheffield, UK
b Department of Cardiology, Royal Hallamshire Hospital, Sheffield, UK
Received 11 August 2008;
received in revised form 22 September 2008;
accepted 24 September 2008
*Corresponding author. Tel.: +44 114 2761398; fax: +44 114 2713512.
E-mail address: duncan.stewart{at}sth.nhs.uk (D. Stewart).
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Abstract
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Although unusual, chyle leak following oesophagectomy is a recognised complication affecting 2–4% of patients. We describe the hitherto unreported sequelae of a chyle leak causing cardiovascular compromise secondary to pericardial tamponade 13 days after Ivor-Lewis oesophago-gastrectomy.
Key Words: Oesophageal cancer; Oesophagectomy; Chylothorax; Cardiac tamponade
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1. Case report
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A 45-year-old female underwent Ivor-Lewis oesophago-gastrectomy for high-grade dysplasia within a segment of Barrett's metaplasia. The procedure was without intra-operative complication, involving wide dissection at the diaphragmatic hiatus, opening right and left pleurae and excision of para-oeosophageal mediastinal nodal tissue with the operative specimen. The thoracic duct was identified, preserved and not ligated. The patient had an uneventful initial postoperative recovery period.
Following commencement of enteral feeding via a surgically positioned jejunostomy catheter, the volume of pleural drainage increased and was noted to change from a serous appearance to an opaque, ‘creamy’ fluid. The diagnosis of chylothorax was made and enteral feeding stopped. Despite this, bilateral loculated intra-pleural collections developed, necessitating the insertion of additional ultrasound-guided drains. A contrast swallow confirmed integrity of the oesophago-gastric anastomosis, the gastric tube and the pyloromyotomy. Pleural drainage continued at a rate of more than 2000 ml/24 h for the following seven days.
The patient returned to the operating theatre on the 13th postoperative day, the right thoracotomy was re-opened and two areas of chyle leakage along the length of the duct were identified and over sewn. The pericardium was not opened during the dissection. Twelve hours following the surgery the patient became increasingly tachycardic with hypotension unresponsive to fluid boluses. A bedside echocardiogram showed a large pericardial fluid collection causing significant diastolic collapse and a pericardial drain was inserted via the sub-xiphoid approach. Immediately, 300 ml of chylous fluid was drained, with a rapid improvement in haemodynamics. The pericardial drain was removed after three days with no subsequent recurrence of the pericardial effusion. The patient was discharged home on the 30th postoperative day (from original operation).
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2. Discussion
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The clinical syndrome of pericardial tamponade is relatively well reported after oesophagectomy. Acute distension of the gastric tube [1], herniation of omentum [2], mediastinal bleeding [3] and even volvulus of interposed colon [4] have been implicated in its presentation. However, cardiac tamponade due to intra-pericardial fluid following oesophagectomy is an exceptionally rare complication, having been reported only on two previous occasions. In the first example, Mizuguchi et al. attribute the tamponade to acute pericarditis following oesophageal resection and three-field lymphadenectomy [5]. In the second report, Kats et al. blame a torn epicardial vein leading to the accumulation of intra-pericardial blood. This is theorised to have occurred through retraction of the heart during a transhiatal-oesophagectomy [6]. There are no previous reports of chylopericardium following oesophagectomy.
Lymph drainage from the heart occurs via two main trunks. The right efferent lymphatic trunk drains principally from the right ventricle and empties into the arch of the thoracic duct via the left anterior mediastinal lymph node chain. The left efferent lymphatic trunk drains predominantly from the left ventricle and also empties most frequently into the arch of the thoracic duct. However, very occasionally the left trunk drains into the thoracic duct within the mediastinum via the right paratracheal lymph nodes and the left superior bronchial lymph nodes [7]. In addition, lymph drainage from the lateral and posterior aspects and the diaphragmatic surface of the pericardium has been shown to channel into various different groups of mediastinal lymph nodes including the juxta-oesophageal group [8]. It is therefore feasible that lymphatic drainage of the heart and pericardium was interrupted during the additional mediastinal dissection undertaken during the second surgical procedure, leading to the accumulation of chyle within the pericardium. Although it is thought that intra-thoracic lymphatic pathways are relatively constant [7], it is perfectly possible that a rarely encountered anatomical variant may have been the cause, which would explain the lack of precedent for this report.
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References
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- Cherian V, Divatia JV, Kulkarni A, Dasgupta D. Cardiomediastinal tamponade and shock following three-stage transthoracic oesophagectomy. J Postgrad Med 2001;47:185–187.[Medline]
- Granke K, Hoshal VL Jr, Vanden Belt RJ. Extrapericardial tamponade with herniated omentum after transhiatal esophagectomy. J Surg Oncol 1990;44:273–275.[CrossRef][Medline]
- Thangathurai D, Roffey P, Mogos M, Riad M, Bohorguez A. Mediastinal haemorrhage mimicking tamponade during en-bloc oesophagectomy. Eur J Anaesthesiol 2005;22:555–556.[CrossRef][Medline]
- Canivet JL, Piret S, Hick G, Damas P. Cardiac tamponade and pulmonary compression due to volvulus of oesophageal coloplasty. Acta Anaesthesiol Belg 2004;55:125–127.[Medline]
- Mizuguchi Y, Takeda S, Miyashita M, Ikezaki H, Nakajima Y, Akada S, Makino H, Futami R, Arai M, Sasajima K, Tajiri T, Tanaka K. A case of cardiac tamponade following esophageal resection. J Anesth 2005;19:249–251.[CrossRef][Medline]
- Kats S, Nieuwenhuijzen GA, van Straten BH, Schonberger JP. Cardiac tamponade: an unusual, lifethreatening complication after transhiatal resection of the esophagus. Interact CardioVasc Thorac Surg 2007;6:238–239.[Abstract/Free Full Text]
- Riquet M, Le Pimpec, Barthes F, Souilamas R, Hidden G. Thoracic duct tributaries from intrathoracic organs. Ann Thorac Surg 2002;73:892–898.[Abstract/Free Full Text]
- Eliskova M, Eliska O, Miller AJ. The lymphatic drainage of the parietal pericardium in man. Lymphology 1995;28:208–217.[Medline]
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Abstract
1. Case report