P39 CHYLOPTYSIS AFTER ESOPHAGECTOMY FOR ESOPHAGEAL CANCER; A RARE COMPLICATION
Authors: Saana Andersson , Juha Kauppi , Jari Räsänen 
Published: November 2019

Abstract

Aim
We present a case of chyloptysis after esophageal resection for esophageal squamous cell cancer. Symptoms were caused by chylous casts occluding the airways. This necessitated surgical ligation of the main thoracic duct and sealing the airway fistula with a latissimus dorsi muscle flap.

Background & Methods
Chyloptysis is rare and usually occurs spontaneously and secondary to disorders of the mediastinal lymphatic system. Chyloptysis manifests with the production of milky-white sputum or the formation and expectoration of bronchial casts. Initially no more than 20 cases have been reported in the literature (1,2). There are two mechanisms for the pathogenesis of chyloptysis: 1) congenital or acquired incompetence of the lymphatic valves and 2) occurrence of bronchopleural fistula in the context of chylous effusion (3,4). However, iatrogenic injury also can be a cause, in which injury to the thoracic duct leading to chylous pleural effusion with coexisting esofagotracheal fistula facilitates chyloptysis.

Results
A 66-year-old mal underwent a mini-invasive esophagectomy and gastric tube reconstruction for epidermoid cancer of the esophagus. Neoadjuvant chemo-radiation was given before operation. Post-operatively a minor chylous leak was managed by total parenteral nutrition for one week. He was discharged 15 days after operation. Four weeks after surgery he was readmitted because of fever, hypoxemia, wheezing, and expectoration of bronchial casts. He had fever, C-reactive protein level was 353 mg/l and white blood cell count 15.4 E9/l. He was intubated for respiratory failure and taken to ICU for treatment of aspiration pneumonia. Both chest x-ray and i.v. contrasted computed tomography (CT)of the chest confirmed bilateral aspiration pneumonia ( Figure 1). In bronchoscopy, occluding whitish mass was evacuated from both sides of the airways and this was thought to be because of aspiration (Figure 2). Infection responded to antibiotics and he was weaned from mechanic ventilation with tracheostomy until his symptoms recurred. Fiberoptic bronchoscopy revealed again milky-white sputum on both sides of the bronchial three. This time, a hole in the posterior tracheal wall was noticed and tracheal stent was applied to cover possible fistula to the esophagus or gastric conduit. However, in gastroskopy, such fistula could not be confirmed. Patient was under total parenteral nutrition (TPN) and after seven days since readmission, jejunal feeding was started. This caused a third deterioration period. Analysis of the bronchial aspiration revealed an elevated triglyceride level which was consistent with chyle and chylous fistula to the airways was therefore the most likely diagnosis. A right posterolateral thoracotomy was performed, and during surgery, thicker fibrous tissue was removed around the fistulae. Chylous reflux was observed form the fistula. Latissimus dorsi muscle flap was applied to cover the TEF and a main thoracic duct was controlled by ligating all soft tissue between descending aorta and azygous vein at the level of the diaphragm. After surgery, patient had TPN for 10 days. Enteral feeding was started to jejunal tube and we served a fat-free diet gradually increasing the fat content. Patient had tracheostomy and 2 weeks after operation he was noted to have recurrent TEF, and esophageal stent was applied. Postoperative recovery showed no further chyloptysis and he was discharged eventually 96 days after original operation.

Conclusion
Surgical ligation of thoracic duct resulted in complete resolution of chyloptysis. Surgery is the treatment of choice, although radiation therapy, chemotherapy, laser, and sclerosing agents have been described with varying success. To our knowledge, this is the first reported case of iatrogenic induced chyloptysis after esophageal resection.