Conservative management of chylothorax after coronary artery bypass grafting

Late-Onset Chylothorax After Coronary Artery Bypass Grafting

Chylothorax, the presence of lymph in the pleural cavity, is a significant post-cardiac surgery complication. Historically linked to left internal mammary artery (LIMA) harvesting, its occurrence in cases without LIMA usage is uncommon. This paper details a case of chylothorax in an 84-year-old female patient who underwent coronary artery bypass grafting (CABG) without LIMA harvesting. Three months post-surgery, she manifested symptoms of exertional shortness of breath and diminished breath sounds on the left side. Diagnostic measures, including echocardiography and chest X-rays, revealed a pronounced left-sided pleural effusion. Diagnostic thoracocentesis yielded a milky fluid, and laboratory analysis confirmed its chylous nature. Therapeutic interventions comprised chest tube insertion, drainage of the milky fluid, dietary modifications, and the performance of talc pleurodesis after a fatty food-provocation test resulted in increased fluid collection. The patient's journey highlights the challenges of diagnosing and managing post-cardiosurgical chylothorax. The paper emphasizes the importance of early detection and appropriate interventions to prevent complications associated with a heightened mortality risk.

Chylothorax after coronary artery bypass grafting: Is it always early?

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.

Treatment of Chylothorax following Coronary Artery Bypass Grafting

Chylothorax post-coronary artery bypass grafting is a rare complication. The treatment protocol is not well described due to its rarity. The current treatment options for a chylothorax include: conservative medical treatment or interventional approach (i.e. thoracic duct embolization or surgical ligation of the thoracic duct). With high chest tube output, medical treatment has a high failure rate, and early embolization or surgical ligation of the thoracic duct should be considered to reduce hospital stay cost and morbidity. We present two cases of chylothorax after coronary artery bypass grafting with different treatment approaches.

Chylothorax after coronary artery bypass surgery. Report of a case and review of the literature

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.

Yellow nail syndrome with chylothorax after coronary artery bypass grafting

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.