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Kanna S, Arora S, Goel H, Jindal P, Shad S. Chylothorax after coronary artery bypass grafting: Is it always early? J Card Surg 2021; 36:3402-3404. [PMID: 34091950 DOI: 10.1111/jocs.15686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 04/15/2021] [Accepted: 04/28/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Chylothorax is a rare complication of cardiothoracic surgical interventions and usually presents early in the postoperative period. MATERIALS AND METHODS We present a case of 63 years female who presented with chylothorax 5 months after undergoing coronary artery bypass surgery. DISCUSSION AND CONCLUSION Chylothorax should be considered in patients with recurrent pleural effusions even if the effusions do not have the typical milky appearance. Although chylothorax in most cases will present early in post operative period, it should be remembered that it can present in a delayed manner. Morbidity and health care costs associated with this entity can be remarkably high and therefore it is of great importance to diagnose and treat it.
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Affiliation(s)
- Sharmil Kanna
- Department of Cardiac Surgery, Sir Ganga Ram Hospital, , Old Rajinder Nagar, New Delhi, India
| | - Shashank Arora
- Department of Cardiac Surgery, Sir Ganga Ram Hospital, , Old Rajinder Nagar, New Delhi, India
| | - Himanshu Goel
- Department of Cardiac Surgery, Sir Ganga Ram Hospital, , Old Rajinder Nagar, New Delhi, India
| | - Pramoj Jindal
- Department of General Surgery, Sir Ganga Ram Hospital, Old Rajinder Nagar, New Delhi, India
| | - Sujay Shad
- Department of Cardiac Surgery, Sir Ganga Ram Hospital, , Old Rajinder Nagar, New Delhi, India
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Khan I, Khan ZM, Refy AE, Badry AME, Babiker TF. Chylothorax after coronary artery bypass surgery. Report of a case and review of the literature. J Saudi Heart Assoc 2020; 32:194-199. [PMID: 33154915 PMCID: PMC7640546 DOI: 10.37616/2212-5043.67] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 04/13/2020] [Accepted: 04/14/2020] [Indexed: 11/30/2022] Open
Abstract
Chylothorax after coronary artery bypass grafting is a rare complication and leads to increased mortality and morbidity. Because of the rarity of this complication, its management is debatable. We present the case of a 41 years old male patient who had a left sided chylothorax after coronary artery bypass grafting. The patient was managed conservatively with low fat diet and drainage of the chylothorax. A thorough search of the literature published on the subject was done and treatment strategies employed by various authors were studied. Various treatment options are conservative management with chest tube drainage, octreotide and low-fat diet or diet containing medium chain triglycerides. Invasive options are video assisted thoracoscopy and thoracotomy with or without ligation of thoracic duct. An account of the management strategies employed by various authors is presented in this report.
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Affiliation(s)
- Imran Khan
- Department of Cardiothoracic Surgery, Al Mana General Hospital, Al Khobar, Saudi Arabia
| | - Zahid M Khan
- Department of Cardiothoracic Surgery, Al Mana General Hospital, Al Khobar, Saudi Arabia
| | - Abdelbasset El Refy
- Department of Cardiothoracic Surgery, Al Mana General Hospital, Al Khobar, Saudi Arabia
| | | | - Tarig Faisal Babiker
- Department of Cardiothoracic Surgery, Al Mana General Hospital, Al Khobar, Saudi Arabia
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3
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Waliany S, Chandler J, Hovsepian D, Boyd J, Lui N. Yellow nail syndrome with chylothorax after coronary artery bypass grafting. J Cardiothorac Surg 2018; 13:93. [PMID: 30201014 PMCID: PMC6131875 DOI: 10.1186/s13019-018-0784-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 08/30/2018] [Indexed: 11/19/2022] Open
Abstract
Background Yellow nail syndrome is a rare condition considered secondary to functional anomalies of lymphatic drainage. Yellow nail syndrome is diagnosed through the triad of intrathoracic findings (30% being pleural effusions), nail discoloration, and lymphedema, with any two features sufficient for diagnosis. We report the second case of post-operative yellow nail syndrome. Case presentation After coronary artery bypass grafting, our patient presented with chylothorax on post-operative day 13 and yellow toenail discoloration on post-operative day 28, diagnosing yellow nail syndrome. Initial conservative management with pigtail catheter drainage and low-fat diet with medium-chain triglycerides reduced chylous drainage from 350 mL/day on post-operative day 14 to < 100 mL/day on post-operative day 17. However, by post-operative day 18, drainage returned to 350 mL/day that persisted despite attempts to readjust the catheter position, replacement of catheter with chest tube, and transition to total parenteral nutrition and octreotide while nil per os. Lymphangiogram on post-operative day 32 did not identify the thoracic duct or cisterna chyli, precluding embolization. Talc and doxycycline pleurodeses performed on post-operative days 33 and 38, respectively, resolved his chylothorax and nail discoloration. Conclusions Both yellow nail syndrome and chylothorax as a complication of coronary artery bypass grafting are rare entities. The proposed mechanism of post-operative chylothorax is iatrogenic injury to thoracic duct or collateral lymphatic vessels. Diagnosing yellow nail syndrome in patients with post-operative chylothorax (through co-existing yellow nail discoloration and/or lymphedema) may suggest predisposition to impaired lymphatic drainage, portending a difficult recovery and potentially indicating need for surgical management.
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Affiliation(s)
- Sarah Waliany
- Stanford University School of Medicine, Stanford, CA, USA
| | - Julia Chandler
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - David Hovsepian
- Department of Interventional Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Jack Boyd
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305, USA
| | - Natalie Lui
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305, USA. .,Department of Cardiothoracic Surgery, Division of Thoracic Surgery, Stanford University School of Medicine, Stanford, CA, USA.
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Sabzi F, Yaghoubi A. The combination of breast necrosis and chylothorax following the OPCAB. J Cardiovasc Thorac Res 2016; 8:88-90. [PMID: 27493707 PMCID: PMC4972404 DOI: 10.15171/jcvtr.2016.18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2015] [Accepted: 05/06/2016] [Indexed: 11/23/2022] Open
Abstract
Due to long term patency, the internal mammary artery is considered as a conduit of choice for revascularization of the left anterior descending coronary artery. The internal mammary artery and its accessory branches in addition to perfusing the chest wall structures also contributes to supplying, part of the female breast arteries. In addition, due to the accompaniment of thoracic duct branches with the left internal mammary artery, harvesting may be associated with injury to these branches and contribute to chylothorax. We report a rare case of chylothorax and the breast necrosis following the coronary artery bypass grafting. The chylothorax was started in the second postoperative day and ceased gradually in the 12th day of operation. The breast necrosis appeared in the 3th weeks of operation with pain, and tenderness and black skin color change. The patient underwent total mastectomy in the 4th weeks of operation.
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Affiliation(s)
- Feridoun Sabzi
- Department of Cardiovascular Surgery, Imam Ali Heart Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Alireza Yaghoubi
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
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Ergenoglu MU, Sanisoglu I, Sagbas E, Yaman R, Guden M, Akpinar B. Chylothorax after aortic valve replacement. Asian Cardiovasc Thorac Ann 2006; 14:e63-4. [PMID: 16714688 DOI: 10.1177/021849230601400332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A 71-year-old-man was diagnosed with chylothorax after aortic valve replacement. He was treated with a low-fat diet and pleural drainage with thoracentesis. The pleural effusion completely resolved by the 14th postoperative day.
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Affiliation(s)
- Mehmet U Ergenoglu
- Department of Cardiovascular Surgery, Florence Nightingale Hospital, Abide-i Hurriyet Cad., No: 290, Caglayan, Sisli, Istanbul 80290, Turkey.
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Abid Q, Millner RW. Chylothorax following coronary bypass grafting: treatment by talc pleurodesis. Asian Cardiovasc Thorac Ann 2003; 11:355-6. [PMID: 14681102 DOI: 10.1177/021849230301100420] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Chylothorax after myocardial revascularization is a rare but serious complication. There is as yet no definitive treatment. We report a case in which chylothorax was diagnosed on the 3rd postoperative day. Conservative management with dietary restriction to medium-chain triglyceride led to reduction of chyle leakage from 300 to 400 mL/day to 50 to 60 mL/day 3 days later. However, the leak persisted until talc pleurodesis was performed.
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Affiliation(s)
- Qamar Abid
- Department of Cardiothoracic Surgery, Victoria Hospital, Blackpool, United Kingdom.
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Abstract
Reports of chylothorax (CT) following median sternotomy are rare, amounting so far to 16 cases in the English literature, of which 6 were cases of postcoronary artery bypass grafting (CABG). This report deals with an additional case of a 70-year-old woman who developed left pleural chylous effusion following CABG. It is suggested that the incidence of this type of pleural effusion is considerably greater than the few cases hitherto reported. Moreover, as CT may produce serious pulmonary and/or pleural functional impairment, it is proposed that a diagnostic tap be performed more often in cases of post CABG pleural effusion and that preventive drainage be instituted when CT is diagnosed.
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Affiliation(s)
- R Zaidenstein
- Department of Internal Medicine A, Assaf Harofeh Medical Center, Zerifin, Israel
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Abstract
We report the case of a 73-year-old woman who developed a left chylothorax subsequent to surgical myocardial revascularization using the left internal mammary artery. This complication was successfully managed with thoracostomy tube drainage, chemical pleurodesis, and dietary manipulation. We review the literature regarding chylothorax after coronary artery bypass surgery and discuss the etiology and management of this rare complication.
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Affiliation(s)
| | - Loralee A. Rader
- Department of Surgery Singing River Hospital Pascagoula, MS, USA
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Surgery in the management of chylothorax after coronary artery bypass with left internal mammary artery. J Thorac Cardiovasc Surg 1993. [DOI: 10.1016/s0022-5223(19)33727-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Abstract
To investigate the morbidity after coronary artery bypass grafting, one hundred and seventy-eight patients were retrospectively studied with a minimum follow-up period of one year. Although there was no difference in the incidence and distribution of pain in hospital, seventy percent of patients who had an internal mammary artery used as one of the bypass conduits experienced chest wound pain after discharge from hospital compared to 51.7% of patients who had vein grafts alone (P less than 0.05). Twenty-three percent of patients who had left internal mammary arteries harvested experienced chronic left-sided chest wall pain compared to 4.5% of patients who had vein grafts only (P less than 0.005). The possible factors responsible are discussed and a review made of the complications which may result from using the internal mammary artery in coronary artery surgery.
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Affiliation(s)
- J Eng
- Cardiothoracic Surgical Unit, Papworth Hospital, Papworth Everard, Cambridge, U.K
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Zakhour BJ, Drucker MH, Franco AA. Chylothorax as a complication of aortocoronary bypass. Two case reports and a review of the literature. SCANDINAVIAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 1988; 22:93-5. [PMID: 3291103 DOI: 10.3109/14017438809106060] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Iatrogenic chylothorax is a well-recognized complication following thoracic surgery, but is a rare occurrence after aortocoronary bypass. Only two cases have been previously reported. Two additional cases from our hospital are presented. All four male patients responded to conservative management within two weeks of initiation of treatment. Only 12 cases of chylothorax following median sternotomy have been reported (nine women and three men). Five of the nine women required surgical exploration after a course of unsuccessful management ranging from 14 to 26 days. The cause of the chylothorax was considered to be injury to lymphatic collaterals in the anterior mediastinum, which resulted in a retrograde chyle flow; the main duct remained intact. This article reviews the normal anatomy of the thoracic duct and variations of chylothorax, and describes the mechanism of injury in aortocoronary bypass, the prevention of this complication, and the results of treatment.
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Affiliation(s)
- B J Zakhour
- Department of Surgery, St. Elizabeth Hospital Medical Center, Youngstown, Ohio
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Di Lello F, Werner PH, Kleinman LH, Mullen DC, Flemma RJ. Life-threatening chylothorax after left internal mammary artery dissection: therapeutic considerations. Ann Thorac Surg 1987; 44:660-1. [PMID: 2446575 DOI: 10.1016/s0003-4975(10)62159-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Persistent chylothorax developed in a 53-year-old man after left internal mammary artery (LIMA) takedown and required surgical intervention. After an unsuccessful supraclavicular approach, left-sided standard thoracotomy showed thick adhesions around the LIMA takeoff with a diffuse oozing rather than an identifiable discrete leak. A possible leaking point was stitched, the area was sealed with fibrin adhesive, and complete remission ensued. Operation for chylothorax after LIMA takedown is challenging. A left-sided standard thoracotomy with minimal dissection and use of fibrin adhesive rather than blind stitching are recommended.
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Affiliation(s)
- F Di Lello
- St. Luke's Hospital, Medical College of Wisconsin, Milwaukee
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