BILATERAL CHYLOTHORAX FOLLOWING THORACOLUMBAR SUGERY

Abstract

SESSION TITLE: Medical Student/Resident Disorders of the Pleura Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pleural effusions commonly occur in the setting of infection, malignancy, and volume-overload, and are diagnosed based on clinical history and fluid analysis. Chylothorax is an uncommon cause of pleural effusion defined by a pleural fluid triglyceride concentration >110mg/dL or the detection of chylomicrons by electrophoresis. Chylothoraces may be traumatic (surgical or non-surgical) or non-traumatic (malignant or non-malignant). Iatrogenic chylothorax occurs bilaterally in approximately 13% of cases. Management involves a combination of conservative, percutaneous, or surgical approaches. CASE PRESENTATION: The patient is a 37 year old male with a history of IV drug use who presented with acute on chronic back pain and was found to have T11-12 discitis, osteomyelitis, and epidural phlegmon. He underwent posterior T9-L2 decompression and fusion complicated by post-op dyspnea. Imaging showed new, large, bilateral pleural effusions. Right sided thoracentesis removed 2L of fluid, which rapidly re-accumulated. Fluid analysis revealed a triglyceride concentration of 709mg/dL consistent with chylothorax. Lymphangiogram demonstrated transection of the main thoracic duct at T11-12, which was successfully embolized. Bilateral chest tubes were placed with large volume drainage (>1L/day) and were removed upon resolution of effusions. DISCUSSION: The thoracic duct originates from the cisterna chyli at approximately L1 in the anterior midline. It ascends into the posterior mediastinum crossing from right to left at approximately T5 and is vulnerable to damage during surgery. One case series showed that 89% of traumatic chylothoraces were due to surgical complication. Other studies show that 1-3% of chylothoraces caused by surgery or trauma occurred following spinal or back surgery. Most chylothoraces are unilateral. In this patient, duct injury so close to the cisterna chyli may have precipitated bilateral effusions. Accumulation of chyle can impair respiration and promote malnutrition, with recurrent or large volume effusions necessitating definitive intervention. Prior studies found that most patients with traumatic chylothorax fail conservative management prompting surgery. In more recent literature, lymphangiography followed by duct embolization has been shown to successfully repair significant chyle leaks without requiring surgery. CONCLUSIONS: Bilateral chylothorax following spinal surgery represents an unusual presentation of an already uncommon complication. In patients with marked bilateral effusions and severe lymphatic leak, lymphangiography and duct embolization can serve as an effective, minimally invasive treatment, obviating the need for surgical intervention. Reference #1: Itkin, Maxim, et al. “Nonoperative thoracic duct embolization for traumatic thoracic duct leak: experience in 109 patients.” The Journal of thoracic and cardiovascular surgery 139.3 (2010): 584-590. Reference #2: Valentine, Vincent G., and Thomas A. Raffin. “The management of chylothorax.” Chest 102.2 (1992): 586-591. Reference #3: Doerr, Clinton H., et al. “Etiology of chylothorax in 203 patients.” Mayo Clinic Proceedings. Vol. 80. No. 7. Elsevier, 2005. DISCLOSURES: No relevant relationships by Nina Chan, source=Web Response No relevant relationships by Aaron Kaye, source=Web Response No relevant relationships by Brandon Menachem, source=Web Response No relevant relationships by Sandra Weibel, source=Web Response