Postoperative chylothorax with a duplicated left-sided thoracic duct: a case report and review of the literature
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CASE REPORT
Postoperative chylothorax with a duplicated left‑sided thoracic duct: a case report and review of the literature Ryoma Haneda1,2 · Eisuke Booka1 · Kenjiro Ishii1 · Hirotoshi Kikuchi2 · Yoshihiro Hiramatsu2 · Kinji Kamiya2 · Takeshi Aramaki3 · Hiroya Takeuchi2 · Yasuhiro Tsubosa1 Received: 4 March 2020 / Accepted: 22 April 2020 © The Japanese Association for Thoracic Surgery 2020
Abstract Postoperative chylothorax is a potentially lethal complication after esophagectomy. A 53-year-old woman underwent subtotal esophagectomy. The thoracic duct was resected due to swollen lymph nodes. Postoperative chylothorax was diagnosed but conservative treatment was ineffective. Lipiodol lymphangiography revealed leakage from a duplicated left-sided thoracic duct. Left-sided video-assisted thoracoscopic ligation of the left-sided thoracic duct was performed. Because anatomical variations in the thoracic duct contribute to refractory chylothorax, lymphangiography is useful in detecting the position of thoracic duct injury as well as any duct anomalies. Based on lymphangiography, left-sided video-assisted thoracoscopic surgery could be considered in case of left-sided thoracic duct injury. Keywords Esophageal cancer · Esophagectomy · Postoperative chylothorax · Video-assisted thoracoscopic surgery · Duplicated left-sided thoracic duct
Introduction
Case presentation
Postoperative chylothorax is a serious complication. The occurrence of chylothorax is associated with an increase in the incidence of major complications and malnutrition, leading to a risk of hospital mortality. Early diagnosis and effective management determine the outcome. This is a case of postoperative chylothorax caused by injury to the leftsided thoracic duct (TD), ligated by left-sided video-assisted thoracoscopic surgery in right decubitus position.
A 53-year-old woman presented with obstruction to food passage. Computed tomography (CT) revealed tumor invasion to the descending aorta (Fig. 1a) and swollen lymph nodes at the left paracardial area (Fig. 1b, c). Clinical findings, determined based on the Japanese Classification of Esophageal Cancer, 11th edition [1], showed squamous cell carcinoma (cT4b, cN1, cM0, cStageIVa). The patient received three courses of chemotherapy of docetaxel, cisplatin and 5-fluorouracil. Subtotal esophagectomy by thoracotomy with three-field lymphadenectomy in left decubitus position and reconstruction at the neck via the retrosternal route was performed. The left mediastinal pleura was partially resected around the tumor. TD was resected at the lower intrathoracic esophagus because the lymph nodes along the TD were swollen. A 24-Fr thoracic drain was inserted into the right thorax and negative pressure up to 10 cmH2O was applied. The histological diagnosis was no residual cancer cell (pT0, N0, M0, pStage0). Peripheral parenteral nutrition was initiated, but a large amount of pleural effusion flowed on postoperative day (POD) 1. After refilling phase, pleural effusion slightly decreased and an elemental diet started
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