Successful Management Of Chylothorax After Thoracoscopic Removal Of Cystic Mediastinal Lymphangioma
Ju Sik Yun1, Sang Gi Oh2, Sang Yun Song1, Seok Kim1, Kook Joo Na1.
1Chonnam National University Hwasun Hospital, Hwasun-gun, Jeollanam-do, Korea, Republic of, 2Chonnam National University Hospital, Gwangju, Korea, Republic of.
Lymphangiomas are rare benign tumors that present mainly in childhood in the cervical region. Less than 1% of the cases of cystic lymphangiomas occur in the mediastinum. Surgical resection is the preferred treatment modality, although complete excision is impossible in most cases with the involvement of vital structures and some postoperative complications have been reported.
A 37-year old asymptomatic man was referred to our center with a cystic mass lesion located in the superior mediastinum. The lesion was incidentally detected in computed tomography (CT) for routine health check-up. A chest CT showed a 7 X 11cm sized, non-enhancing cystic mass with a well-defined border in posterior mediastinum, compressing the tracheal and upper esophageal lumen. We planned a video-assisted thoracoscopic surgery (VATS) based on a presumed diagnosis of a benign bronchogenic or esophageal cyst.
A cystic tumor was located at superior mediastinum which was abutting to the trachea and upper esophagus. During dissection of the cystic wall from base, the cyst was ruptured and yellowish serous fluid was released. Although a large portion of the cystic wall is removed, the cyst was excised incompletely because of the risk of vessel injury and a presumed diagnosis of a benign cystic tumor. On postoperative day (POD) 2, the pleural drainage changed from yellow serous to milky white, and the diagnosis of chylous leakage was made with elevated level of the pleural fluid triglyceride. On POD 4, the patient complained of a left-sided neck swelling and the chest x-ray showed a enlarged upper mediastinal shadow. And contrary to expectation, Pathologic examination confirmed the diagnosis of lymphangioma. So, the patient underwent clipping of thoracic duct with VATS immediately. The pleural drainage became serous in nature and preoperative symptom of neck swelling was relieved. On POD 8 (four days after reoperation), the patient was discharged without any other complication.
Although cystic lymphangiomas are very rare, they should be considered in the differential diagnosis of patients with cystic mediastinal tumor. Complete surgical resection is recommended for definitive diagnostic and therapeutic purposes.
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