Chylopericardium following thoracoscopic resection of a mediastinal cyst: A case report

IntroductionThoracic duct cysts are very rare, and diagnosis is often difficult. We report a rare case of chylopericardium following thoracic duct cyst resection. There are no established guidelines on the management of such cases. We reviewed the literature on postoperative complications after thoracic duct cyst resection, and conducted the first thorough review of the etiology and management of chylopericardium in surgical cases.Presentation of caseA 54-year-old male presented with cardiac tamponade due to chylopericardium. He had undergone resection of a thoracic duct cyst 2 years previously, which was complicated by postoperative chylothorax. Chyle accumulation resolved with conservative treatment.DiscussionChylothorax is a frequent complication following thoracic duct cyst resection, especially in cases where no intraoperative diagnosis is reached. Diagnosis may be difficult due to anomalous location of the cyst, as in our case. Chylopericardium is rarely reported, and may have occurred in our case because of prior pleurodesis. Chyle accumulation can reportedly be managed with diet restrictions in over half of reported cases, especially in cases of lung or mediastinal tumor resection.ConclusionThe most important points highlighted by this rare case of chylopericardium secondary to thoracic duct cyst resection are: 1) pedicles should be ligated in cyst resections, regardless of location; 2) careful assessment in the initial surgery may help identify the point of leakage; 3) low-fat diet is the first choice in the initial management of postoperative chylopericardium, but surgical repair may be considered in cases with no response after > 2 weeks of conservative treatment.     

Endobronchial ultrasonography in a patient with a mediastinal thoracic duct cyst

Mediastinal thoracic duct cysts are rare clinical findings. We report the case of a symptomatic 58-year-old woman in whom a thoracic duct cyst was successfully treated with surgical resection. Preoperative endobronchial ultrasonography revealed an oval-shaped hypoechoic area with a distinct, thick pedicle, gradual intermittent flux of the fluid content within the lesion, and endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) revealed lymphocyte predominant serous fluid without malignancy, which is consistent with features of a mediastinal thoracic duct cyst. We postulate that EBUS-TBNA can be used as a preoperative diagnostic tool for patients with possible mediastinal thoracic duct cysts.     

Balloon Catheter for Cyst Aspiration in a Thoracoscopic Resection of Mediastinal Cysts

In a thoracoscopic resection of mediastinal cysts, aspiration of the cyst contents at the beginning of the procedure is often helpful because it allows the cyst to be more easily grasped and manipulated. Spillage of the cyst contents into the thoracic cavity may, however, occur during aspiration when an ordinary aspiration needle is used. If the cyst contents are infective, then a subsequent contamination of the thoracic cavity may develop. We therefore use a specially designed double-balloon catheter for aspiration to minimize spillage of the cyst contents into the thoracic cavity. We describe herein the usefulness of this aspiration technique. Received: March 24, 2000 / Accepted: September 26, 2000     

In situ aortic allograft insertion to repair a primary aortoesophageal fistula due to thoracic aortic aneurysm

Aortoesophageal fistula due to thoracic aortic aneurysm is an uncommon cause of gastrointestinal bleeding and has an extremely poor prognosis. In the English literature, we found only 27 successfully managed cases of primary aortoesophageal fistula due to thoracic aortic aneurysm. We present a case of 74-year-old man who experienced the erosion of a thoracoabdominal aortic aneurysm into the esophagus. We successfully performed resection and replacement of the thoracoabdominal aorta with a cryopreserved allograft and total thoracic esophagectomy. A few months later, the esophagus was reconstructed with orthotopic colonic interposition. The patient recovered well and resumed a normal life (12 months' follow-up).     

Successful management of aorto esophageal fistula due to rupture thoracic aortic aneurysm in an elderly patient

Aorto-esophageal fistula due to ruptured thoracic aortic aneurysm is very rare but is associated with extremely high mortality. An 81-year-old woman was admitted due to repeated hematemesis. Endoscopic examination revealed ulceration with blood clot on the mid-esophagus and compression of an extra-esophageal mass. The thoracic CT scan revealed an aortoesophageal fistula due to a ruptured descending thoracic aortic aneurysm. Surgery was performed on April 3, 1996. We report an aorto-esophageal fistula managed successfully in one stage by resection and replacement of the aortic aneurysm with a prosthetic graft and total esophageal resection. The esophagus was reconstructed using orthotopic gastric interposition with omentopexy around the prosthetic aortic graft. The postoperative course was uneventful and theere have been no signs of mediastinal sepsis, graft infection or pyothorax 12 months postoperatively. We suggest that the resection of both the aneurysm and the esophagus as well as the immediate reconstruction of the esophagus by orthotopic gastric interposition to obliterate the retrosternal space are important technique in the management of intrathoracic infections.     

Restoration of atrioventricular conduction after surgical removal of a hydatid cyst of the interventricular septum

During thoracic exploration for resection of an esophageal duplication cyst, a second such cyst was encountered and removed. Although the association of esophageal duplication cysts with other intestinal duplications has been described, to our knowledge this is the first reported case of multiple esophageal duplication cysts.     

Successful lung lobectomy for a lung cancer following thoracic endovascular aortic repair for a thoracic aortic aneurysm: report of a case

Lung cancer and a thoracic aortic aneurysm were detected simultaneously in a 79-year-old male patient with diabetes. The aneurysm was first treated by thoracic endovascular aortic repair. A right lower lobectomy was subsequently performed after the blood flow of the bronchial and intercostal arteries was confirmed by computed tomographic angiography. The bronchial stump was covered with an intercostal muscle flap. The patient’s postoperative course was uneventful. Thoracic endovascular aortic repair is a useful and less invasive treatment for such cases, but a blood flow evaluation of the aortic branches should be done following this procedure before a lung resection is considered.     

Correction of Thoracic Aortic Aneurysm-Bronchial Fistula

The descending thoracic aorta is the most common site for thoracic aneurysms to occur and may present asymptomatically or manifest itself with an array of symptoms depending on the involvement of adjacent structures. Hemoptysis may occur due to erosion of the aneurysm into a bronchus or the pulmonary parenchyma. This report describes the technique in a patient with a descending thoracic aneurysm who underwent emergent resection of the aneurysm with en bloc removal of the involved left lower lobe of the lung.     

Thoracic aorta endograft as an adjunct to resection of a locally invasive tumor: a new indication to endograft

Covered stent grafts are currently used for arterial aneurysm exclusion, aortic dissection, or peripheral occlusive disease. A new indication to endograft was applied to perform resection of the thoracic aorta for infiltration of an adjacent lung cancer into the vessel wall, avoiding a major vascular intervention for aortic graft interposition associated with tumor resection.     

Combined resection of the thoracic esophagus and thoracic descending aorta.

We conducted combined resection of the thoracic esophagus and thoracic descending aorta in 2 patients, one with advanced esophageal cancer with aortic invasion and the other aortoesophageal fistula caused by a false aortic aneurysm. Combined resection of esophageal tumor and adjacent involved organs was conducted in 14 patients with A3:T4 esophageal cancer but none survived 3 years and resecting tumor-invaded organs did not improve patient survival. One major problem of combined resection of the esophagus and aorta is contamination of the posterior mediastinum. In 1 patient, 2-stage surgery for the esophagus and in situ aortic replacement was conducted to reduce operative risk and avoiding infection of the prosthetic vascular graft. With thoracic descending aortic aneurysm adjacent to the esophagus on the increase, cardiovascular surgeons should prepared to undertake combined resection of both the aorta and esophagus.     

Combined resection of the thoracic esophagus and thoracic descending aorta

We conducted combined resection of the thoracic esophagus and thoracic descending aorta in 2 patients, one with advanced esophageal cancer with aortic invasion and the other aortoesophageal fistula caused by a false aortic aneurysm. Combined resection of esophageal tumor and adjacent involved organs was conducted in 14 patients with A3:T4 esophageal cancer but none survived 3 years and resecting tumor-invaded organs did not improve patient survival. One major problem of combined resection of the esophagus and aorta is contamination of the posterior mediastinum. In 1 patient, 2-stage surgery for the esophagus and in situ aortic replacement was conducted to reduce operative risk and avoiding infection of the prosthetic vascular graft. With thoracic descending aortic aneurysm adjacent to the esophagus on the increase, cardiovascular surgeons should prepared to undertake combined resection of both the aorta and esophagus.     

胸主动脉瘤及主动脉夹层外科治疗进展

胸主动脉瘤及主动脉夹层病情凶险，死亡率和病残率均很高。近几年在保留和不保留主动脉瓣的主动脉根重建术治疗升主动脉瘤，弓部主动脉瘤切除与脑保护，胸主动脉瘤或胸腹主动脉瘤切除与脊髓保护，以及主动脉腔内支架移植术等方面取得了较大的进展。手术死亡率已从31．4％下降至3．3％－4．8％。胸主动脉瘤，特别是主动脉夹层系一全身性主动脉病变，近年来手术疗效有所改善，但远期复发率和再手术率仍较高。主动脉内支架移植与外科手术结合应用，对复杂的伴有降主动脉病变的A型主动脉夹层治疗，可能是一种安全而有效的方法。     

Large thoracic duct cyst – a case report and review of the literature

Large thoracic duct cysts are rare and standard lateral thoracotomy is usually used for resection. In the reported case the combination of an antero-lateral thoracotomy with a partial longitudinal median sternotomy (hemiclamshell approach) allowed an excellent visualization and dissection of a large thoracic duct cyst expanding in the anterior cervico-thoracic junction, and was associated with an uncomplicated recovery.     

Traumatic coronary-pulmonary artery fistula, 23 years after a stab wound

We describe a 50-year-old man with onset of severe hemoptysis and anemia. Twenty-three years earlier, he had undergone a surgical procedure for a left thoracic wound as a result of a knife injury. Current diagnosis of aneurysm of the left ventricle and coronary-pulmonary artery fistula was made after coronary arteriography. The patient underwent resection of the aneurysm and repair of the fistula.     

Postoperative chylothorax in patients with a thoracic aortic aneurysm.

OBJECTIVES: Postoperative chylothorax in patients with a thoracic aneurysm is generally infrequent. We report a mode of surgery to reduce the incidence of paraplegia. We review our experience with chylothorax after resection of an aneurysm to find its cause and to evaluate the success of management. PATIENTS AND METHODS: For descending thoracic aneurysms, intercostal arteries in the aneurysm were exposed before incising the aneurysm and, they were only sacrificed no change in motor-evoked potentials (MEPs) occurred after temporary occlusion. Between January 2001 and December 2003, out of a total of 147 aneurysms including thoracic and thoracoabdominal, 4 consecutive patients (2.7%) with chylothorax were reviewed. RESULTS: The chylothorax was diagnosed 1.5 days after operation (range 1 to 2 days). All patients were initially treated by the cessation of oral intake. This treatment was successful for 2 patients and the remaining 2 required surgical intervention to control the fistula. Chylothorax was cured in all patients. CONCLUSION: We postulate that chylothorax is caused by injury of the thoracic duct or its branch during the exposing the intercostal arteries. In the management of chylothorax, early intervention is recommended when the volume of chylous fluid is not decreased by conservative treatment.     

Debatable questions in the surgical treatment of thoracic aortic aneurysms

Some controversies in the surgical approach to thoracic aortic aneurysms are discussed. The author recommends: to perform echocardiography in patients with aortic aneurysms for detection of intracardiac pathology which may complicate the postoperative course; to combine thoracic aortography with selective coronary angiography in patients with thoracic aortic aneurysm for diagnosis of coronary artery disease; to operate asymptomatic fusiform aneurysm that measure twice or more the size of the normal aorta; to resect and replace dissections of the ascending aorta during cardio-pulmonary bypass; and to use active shunts during resection of the descending and thoraco-abdominal aneurysm.     

Resection of a symptomatic pericardial cyst using the computer-enhanced da Vinci Surgical System

Traditionally, symptomatic pericardial cysts have been treated with thoracotomy and resection. More recently, video-assisted thoracoscopic procedures for pericardial cysts have been reported. We present the case of a 43-year-old man who was suffering from a symptomatic pericardial cyst. He underwent successful resection using a computer-enhanced robotic surgical system. This case is an example of the continued extension of robotic-assisted thoracic surgery.     

Surgical resection of sequential thoracic aortic aneurysms in Wiskott-Aldrich syndrome

Wiskott-Aldrich syndrome is a rare X-linked disorder. Vasculitis and aneurysm formation are extremely rare but potentially fatal complications of the disease. Aortitis and aneurysm formation seem to be progressive in patients with Wiskott-Aldrich syndrome. The risk of death from aneurysmal rupture in patients with Wiskott-Aldrich syndrome is high and hence surgery is required for resection of aneurysms. We report a case where a successful resection of a descending thoracic aneurysm was carried out in a patient who previously had undergone a composite root replacement for aortic root dilatation.     

One-stage operation for descending thoracic aortic aneurysm and left lung cancer: a case report.

We performed concomitant graft replacement for descending thoracic aortic aneurysm and pulmonary resection for squamous cell carcinoma of the left upper lobe in a 79-year-old man. The tumor reached the parietal pleura. No distance metastasis was found, and the tumor was diagnosed preoperatively as a stage IIB (N0, M0, T3) tumor. The descending thoracic aortic aneurysm was saccular, with greatest diameter being 55 mm, and extending from TH5 to TH8. A left upper lobectomy was performed, and after irrigation with a large volume of saline diluted with povidone iodine, graft replacement for the aortic aneurysm was performed under femoro-femoral partial bypass. To prevent postoperative graft infection, the greater omentum was dissected and placed over the resected pulmonary hilum and the graft. The patient's postoperative course was uneventful. There was no sign of infection, and the patient was discharged 1 month after surgery. Artificial graft wrapping with the greater omentum was useful for the prevention of the postoperative graft infection in this case of surgical treatment of lung cancer and descending thoracic aortic aneurysm.     

Hypothermic circulatory arrest does not increase the risk of ascending thoracic aortic aneurysm resection.

OBJECTIVE: The purpose of this study was to investigate the safety and efficacy of a period of deep hypothermic circulatory arrest (DHCA) during elective replacement of the ascending thoracic aorta. SUMMARY BACKGROUND DATA: DHCA has been implemented in ascending thoracic aortic aneurysm resection whenever the anatomy or pathology of the aorta or arch vessels prevents safe or adequate cross-clamping. Profound hypothermia and retrograde cerebral perfusion have been shown to be neurologically protective during ascending aortic replacement under circulatory arrest. METHODS: The authors conducted a retrospective analysis of 91 consecutive patients who underwent repair of chronic ascending thoracic aortic aneurysms from 1986 to present. The authors hypothesized that patients undergoing DHCA with or without retrograde cerebral perfusion during aneurysm repair were at no greater operative risk than patients who received aneurysm resection while on standard cardiopulmonary bypass. RESULTS: There were no significant differences in hospital mortality, stroke rate, or operative morbidity between patients repaired on DHCA when compared to those repaired on cardiopulmonary bypass. CONCLUSIONS: DHCA with or without retrograde cerebral perfusion does not result in increased morbidity or mortality during the resection of ascending thoracic aortic aneurysms. In fact, this technique may prevent damage to the arch vessels in select cases and avoid the possible complications associated with cross-clamping a friable or atherosclerotic aorta.