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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 7  |  Issue : 4  |  Page : 279-281

Chylothorax mimicking as anastomotic leak in a case of esophageal atresia


1 Department of Pediatric Surgery, AIIMS, Jodhpur, Rajasthan, India
2 Department of Pediatrics, AIIMS, Jodhpur, Rajasthan, India

Date of Web Publication15-Oct-2018

Correspondence Address:
Dr. Manish Pathak
Department of Pediatric Surgery, AIIMS, Jodhpur - 342 005, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcn.JCN_68_18

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  Abstract 


Chylothorax, as a complication of surgery for esophageal atresia (EA), is rare. It can be misdiagnosed as reflux of milk into the chest cavity. Here, we present a case of EA complicated by chylothorax. A preterm neonate with anorectal malformation and EA (Gross type C) underwent high sigmoid colostomy and posterolateral thoracotomy. Intraoperatively, the baby was found to have a wide gap between the upper and lower end of the esophagus not amenable to primary repair. The lower esophageal end was closed using 4-0 vicryl interrupted sutures. The cervical esophagostomy, feeding gastrostomy, and chest tube insertion were done. The chest tube started draining milky fluid 2 days after starting gastrostomy feeds. It was suspected to be lower esophageal stump blow-out with reflux of gastrostomy feeds onto the chest cavity. Dye study and biochemical analysis of pleural fluid helped to make the correct diagnosis of chylothorax. Successful conservative management of chylothorax was done. In conclusion, chylothorax can mimic as anastomotic leak or reflux of gastric contents into the chest cavity and should be kept in differential diagnosis after surgery for EA. Pleural fluid analysis showing lymphocytic predominant fluid with high fluid/serum triglyceride ratio can clinch the diagnosis.

Keywords: Anastomotic leak, chylothorax, esophageal atresia, pleural fluid analysis


How to cite this article:
Pathak M, Saxena R, Gupta N, Sinha A. Chylothorax mimicking as anastomotic leak in a case of esophageal atresia. J Clin Neonatol 2018;7:279-81

How to cite this URL:
Pathak M, Saxena R, Gupta N, Sinha A. Chylothorax mimicking as anastomotic leak in a case of esophageal atresia. J Clin Neonatol [serial online] 2018 [cited 2018 Dec 16];7:279-81. Available from: http://www.jcnonweb.com/text.asp?2018/7/4/279/243341




  Introduction Top


Chylothorax, as a complication of surgery for esophageal atresia (EA), is rare. It can be misdiagnosed as reflux of milk into the chest cavity. Here, we present a case of EA complicated by chylothorax.


  Case Report Top


A preterm (32 weeks), very low birth weight (1350 g), female baby was delivered by lower segment cesarean section at our institute. Antenatal ultrasonography had shown the presence of polyhydramnios but did not detect any other congenital abnormality. The baby cried immediately after birth, and Apgar score was 5 and 7 at 1 and 5 min, respectively. Routine neonatal examination at birth revealed absent anal opening. There was normal urethral and vaginal opening in the vestibule. Nasogastric (NG) tube also could not be negotiated into the stomach. Chest and abdominal X-ray showed NG tube coiling in the upper esophageal pouch with the presence of stomach and bowel gas. Echocardiography did not reveal any associated cardiac anomaly. Based on clinical examination findings and investigations, the final diagnosis of EA (Gross type C) and imperforate anus without fistula was made. The patient underwent high sigmoid colostomy and posterolateral thoracotomy. Intraoperatively, the baby was found to have a wide gap between the upper and lower end of the esophagus not amenable to primary repair. In view of these findings, we decided to divert the esophagus by cervical esophagostomy. The lower esophageal end was closed using 4-0 vicryl interrupted sutures. The cervical esophagostomy, feeding gastrostomy, and chest tube insertion were done. The surgery was uneventful and did not require extensive mediastinal dissection to identify fistula or during mobilization of upper and lower esophageal ends. The gastrostomy feed was started on postoperative day 2, and the chest tube was removed on postoperative day 4. Few hours after removing the chest tube, the baby started having respiratory distress. Chest X-ray revealed pneumothorax. The chest tube was reinserted, and it drained air with few milliliters of turbid fluid. Two days later, the chest tube started draining milky fluid. Chest X-ray showed pleural effusion [Figure 1]. It was suspected to be lower esophageal stump blow-out with reflux of gastrostomy feeds into the chest cavity. Dye study through the gastrostomy did not reveal any reflux. Microscopic examination of pleural fluid showed 1500 cells/mm3, predominantly (>99%) lymphocytes, and biochemical analysis of the fluid showed triglyceride (TG) level of 761 mg/dl against the serum level of 100 mg/dl. Based on this, it was diagnosed as chylothorax and managed by conservative management. The patient was kept nil orally and started on total parenteral nutrition (TPN). Chest tube drainage decreased gradually and stopped after 12 days. Chest X-ray showed clearance of pleural effusion [Figure 2]. The patient was started on gastrostomy feeds and discharged thereafter at day 40 of life.
Figure 1: Chest X-ray showing right-sided pleural effusion with misplaced chest tube. Chest tube was repositioned later

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Figure 2: Chest X-ray showing the resolution of pleural effusion

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  Discussion Top


Anastomotic leak or lower esophageal end blow-out is not uncommon in an operated case of EA. Drainage of milky fluid by chest drain in an operated case of EA usually leads to suspicion of anastomotic leak with reflux of gastric feeding contents into the chest cavity. Although rare but similar findings can be seen in chylothorax, the incidence of chylothorax is approximately 1 in 24,000 neonates and is estimated to be 0.25%–0.5% following cardiovascular surgery.[1]

It is important to keep chylothorax as differential diagnosis in such cases. Chylothorax is accumulation of lymphatic fluid in the pleural cavity. It usually occurs after surgical or traumatic injury to the thoracic duct. Other causes of chylothorax include lymphatic malformation or malignant neoplasm.[2],[3] Contrast esophagogram, microscopic, and biochemical analysis of thoracentesis can help in confirming the diagnosis. Chyle has a characteristic white, odorless, and milky appearance. It forms an immiscible layer at the surface of the fluid on standing.[4] Staats et al. have led down the most commonly used criteria to diagnose the presence of chyle. Pleural fluid TG >110 mg/dl suggests chylothorax, and TG <50 mg/dl makes chylothorax unlikely.[2] Büttiker et al. have suggested that pleural fluid absolute cell count >1000 cells/microliter and lymphocyte fraction >80% suggests chylothorax.[5] Lipoprotein electrophoresis can be used in selected cases where TG criteria and visual inspection disagree, in equivocal cases (TG values between 50 and 110 mg/dl) or where clinical suspicion of chylothorax is high.[4]

Dye study through gastrostomy, in our case, ruled out the gastroesophageal reflux. The biochemical and microscopic analysis of pleural fluid met the criteria of chylothorax led by Staats et al. and Büttiker et al. Thus, the diagnosis of chylothorax was confirmed, and the management started accordingly. Panthongviriyakul et al. have suggested a therapeutic algorithm for the management of postoperative chylothorax.[6] Conservative management is tried initially, and it includes keeping the child nil orally or giving enteral medium-chain TG s with or without TPN. Somatostatin/octreotide infusion may be tried in selected cases. Refractory cases require surgical intervention. Surgical options include direct ligation of the thoracic duct, pleurodesis, and placement of pleuroperitoneal shunt. Our case responded to few days of conservative management by keeping the baby nil orally and on TPN. This case emphasizes the importance of keeping chylothorax as differential diagnosis in such cases and following the standard diagnostic and therapeutic algorithm. Although our case developed chylothorax even without any extensive mediastinal dissection, it is important that careful mediastinal dissection is done to minimize the risk of postoperative chylothorax.


  Conclusion Top


Chylothorax can mimic as anastomotic leak or reflux of gastric contents into the chest cavity and should be kept in differential diagnosis after surgery for EA. Pleural fluid analysis showing lymphocytic predominant fluid with high fluid TG level can clinch the diagnosis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bialkowski A, Poets CF, Franz AR; Erhebungseinheit für seltene pädiatrische Erkrankungen in Deutschland Study Group. Congenital chylothorax: A prospective nationwide epidemiological study in Germany. Arch Dis Child Fetal Neonatal Ed 2015;100:F169-72.  Back to cited text no. 1
    
2.
Staats BA, Ellefson RD, Budahn LL, Dines DE, Prakash UB, Offord K, et al. The lipoprotein profile of chylous and nonchylous pleural effusions. Mayo Clin Proc 1980;55:700-4.  Back to cited text no. 2
    
3.
Maldonado F, Cartin-Ceba R, Hawkins FJ, Ryu JH. Medical and surgical management of chylothorax and associated outcomes. Am J Med Sci 2010;339:314-8.  Back to cited text no. 3
    
4.
Gibbons SM, Ahmed F. Chylothorax diagnosis: Can the clinical chemistry laboratory do more? Ann Clin Biochem 2015;52:173-6.  Back to cited text no. 4
    
5.
Büttiker V, Fanconi S, Burger R. Chylothorax in children: Guidelines for diagnosis and management. Chest 1999;116:682-7.  Back to cited text no. 5
    
6.
Panthongviriyakul C, Bines JE. Post-operative chylothorax in children: An evidence-based management algorithm. J Paediatr Child Health 2008;44:716-21.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2]



 

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