A 40 y.o. male who had a claviculectomy for thoracic outlet presents with drainage from the wound.

What is wrong?

lymph.jpg

Our patient had lymphatic fluid draining from the R chest wound. While thoracic duct injury is most often noted in the L chest; there is significant lymphatic drainage on the R as well which can be injured by thoracic surgery or neck dissection. The  typical L sided thoracic duct occurs in only 65% of the population due to variations which include multiple thoracic duct branches.

 R sided lymphatic drainage

R sided lymphatic drainage

Another cause of chylous effusion is central line placement.  Cases have been reported of chylous effusions after IJ placement. In addition to trauma; chylothorax can occur  after childbirth, in association with lymphoma (accounts for 70% of non traumatic cases) , sarcoid,  thoracic goiters, amyloidosis, filariasis, SVC thrombosis and yellow nail syndrome which is a congenital abnormality of the lymph system.

 A chylous effusion can also look like a pink milkshake as it did in a second pt seen this week in the ED

A chylous effusion can also look like a pink milkshake as it did in a second pt seen this week in the ED

Injury to the thoracic duct can result in cervical chylous fistula, chylothorax or chylopericardium.   Since 2.4 L of chyle is transported through the lymp system every day; a large effusion can rapidly accumulate causing dyspnea. .

The diagnosis is made by sending triglycerides on the fluid and the cell count should be lymphocyte predominant. Both of our patients were diagnosed in the ED by sending triglycerides on the fluid

Conservative management of  a lymphatic injury includes low-fat diet, TPN and drainage of the chylothorax.  Failing conservative management results in either lymphangiogram with embolization of the leak or thoracic duct ligation surgically.

Our first pt had a lymphangiogram demonstrating leakage of lymph and underwent repair of his subclavian stenosis.  The drainage stopped.  The second patient was presumed to have chylothorax from malignancy and was referred to oncology.

 

 

 

Kumar S, Kumar P.  Thoracoscopic management of thoracic duct injury: Is there a place for conservatism. J Postgrad Med. 2004 Jan-Mar ;50(1): 57-9.

 

Saxene P, Shankar S, Kumar V, Naithani,N.  Bilateral chylothorax as a complication of internal jugular vein cannulation. Lung India. 2015 v 32(4) July-Aug . 370-74.

McGrath E, Blades X, Anderson P. Chylothorax: Aetiology, diagnosis and therapeutic opaions. Respiratory Medicine. V 104 (1) Jan 2010:1-8.

Nair SK, Petko M, Hayward MP.  Aetiology and management of chylothorax in adults.  Eur J Cardiothorac Surg. 32(2). 362-369.c