A case of intractable bilateral chylothorax and chylopericardium successfully treated with bilateral pleuroperitoneal shunt and thoracoscopic pericardiotomy

Abstract

A 65-year-old female was admitted to our hospital because of bilateral pleural and pericardial effusion. She underwent pacemaker implantation elsewhere for complete A-V block at age 60, re-implantation at age 61 due to pacemaker pocket infection, and was treated with antibiotics for idiopathic mediastinitis at age 65. She was diagnosed with bilateral chylothoraces and chylopericardium by thoracocentesis and pericardiocentesis. Bilateral pleural drains and a pericardial drain were inserted. Neither lymphangiography nor radioisotope lymphography revealed the site of chyle leakage. Her pleural and pericardial effusion did not decrease in spite of a low-fat diet. So, she underwent thoracoscopic ligation of the thoracic duct and pericardiotomy through the right thorax. After the surgery, pericardial effusion disappeared but pleural effusion persisted. She developed respiratory failure because of pleural effusion, and had to undergo thoracocentesis repeatedly. As her malnutrition progressed gradually due to the loss of chyle, bilateral pleuroperitoneal shunt (using Denver Shunt^®) was performed 84 days after the first surgery. Bilateral pleural effusion was well controled, her nutrition status recovered, and no further therapeutic intervention for chylothorax was required. She underwent removal of the initially inplanted pacemaker lead due to a subsequent septic episode 17 months after the shunt operation, and no further pumping of the shunt tube was needed thereafter. This is a rare case in which the pacemaker lead was a possible cause of chylothorax. We think that pleuroperitoneal shunt can be an effective therapy for persistent chylothorax.