2000 OPEN FORUM Abstracts
CHYLOTHORAX: A RARE LATE PRESENTATION OF ANTERIOR THORACIC INTERBODY FUSION
Jain Hitender, MD, Albornoz MA, MD, Greenblatt JM, MD, Draganescu JM, MD, Korman M, MD, McMaster J, DO, Taheer M, MD. Mercy Catholic Medical Center, Darby, PA
Chylothorax is the accumulation of opalescent, milky fluid, rich in triglycerides (TG) and chylomicrons in the pleural space. Chylothorax, unless diagnosed quickly, carries a 50% mortality rate. It is a rare immediate postoperative complication of an anterior approach to fusion of the thoracic spine, with only few case reports cited in the literature. It is reported to occur in 0.2% of intra-thoracic operations and is most common with cardiac surgery, neck operations, sympathectomy and esophagectomy. We present a patient with chylothorax that developed 4 weeks after anterior fusion of the thoracic spine.
Case: A 30 year old female with cerebral palsy and HTN was admitted with paraplegia after a fall at home. She was diagnosed as having a T10 hemangioma-induced pathological fracture. She underwent transthoracic corpectomy at T10 via an anterior approach with excision of the hemangioma and interbody fusion and fixation. Following a week stay, the patient was discharged paraplegic, but in stable condition. Approximately four weeks after the operation, the patient was admitted with repeated vomiting. She was found to have paralytic illeus and a moderate right-sided pleural effusion. Thoracocentesis yielded 750cc of yellow, cloudy opalescent fluid with WBC count of 1700, 92% lymphocytes, protein 4.6 gm, amylase 15 and LDH 124. All pleural fluid cultures including AFB and fungal were negative. A PPD test was negative and a chest CT revealed a right sided pleural effusion and no mass or adenopathy. Rapid accumulation of the pleural effusion resulted in moderate respiratory distress. Chest tube drainage produced 2.5 liters of opalescent fluid. Because of previous spinal surgery, chylothorax was suspected. Pleural fluid TG levels was found to be 170 mg/dl (serum TG level 110 mg/dl). The pleural fluid also showed presence of fat globules. The patient responded to supportive nutritional management and chest tube drainage initially and has been symptom-free for 11 months.
Discussion: The hallmark for the diagnosis of chylothorax is an elevated pleural fluid triglyceride level greater than 110 mg /dl. Typically it presents 4-5 days after resumption of regular diet postoperatively, and only rarely 4-6 weeks after surgery. If conservative management with parentral medium chain triglycerides and chest tube drainage with continuous suction fails, ligation of thoracic duct, pleuroperitoneal shunt, pleurodesis, and sealing of fistula with thoracoscopic fibrin glue are other treatment modalities that have been shown to be beneficial. In appropriate clinical setting, physicians are well advised to maintain a high index of suspicion for chylothorax, as early diagnosis and treatment are associated with a significant reduction in mortality.