T horacic duct injuries after blunt trauma are rare. When they occur, they are usually associated with chylothorax and spine fractures. Here we describe an unusual presentation of thoracic duct injury (TDI) with isolated chylous retroperitoneum, not previously reported in the literature.
CASE REPORTThe patient was an otherwise healthy, 43-year-old male who fell off of his motorcycle at a low speed and was pinned underneath the motorcycle; he had no loss of consciousness. He walked into the emergency department where he was found to be hemodynamically stable and with a Glasgow Coma Score (GCS) of 15. A chest X-ray was taken and revealed an enlarged mediastinum that prompted a chest computed tomography (CT) scan showing an upper mediastinal hematoma compressing the trachea posteriorly at the level of T3. The patient was intubated electively and transferred to our trauma center for further management.While in-transit, the patient experienced brief episodes of hypotension and tachycardia. Upon arrival to Boston Medical Center, he was hemodynamically stable and immediately taken to the CT scanner where he underwent a CT angiogram of the neck and chest followed by abdomen and pelvis CT scan. The mediastinal hematoma was again noted compressing the trachea and esophagus ( Fig. 1) without active extravasation of contrast. No significant pleural effusion was seen and all major vascular structures were intact. However, a small pneumomediastinum near the right bronchus was noted. Of note, there were multiple left rib fractures (#2, 3, 4, 5, and 6) and right rib fractures (#3 and 4), some of which were posterior at the costovertebral junction. An esophageal injury was ruled out with a barium esophagogram. The noncontrast CT scan of the abdomen, showed fat stranding and a small amount of retroperitoneal fluid around the second portion of the duodenum without free air. Repeat CT scan of the abdomen with oral contrast, showed lack of the contrast beyond the second portion of the duodenum and interval enlargement of the fluid collection to the right of the duodenum (Fig. 2).An exploratory laparotomy was performed revealing a remarkable amount of a whitish fluid (similar to oral contrast used) accumulated diffusely throughout the retroperitoneum (Fig. 3). A Kocher maneuver and mobilization of both right and left colon, revealed no injuries or retroperitoneal hematoma. Methylene blue was instilled through the nasogastric tube but there was no evidence of extravasation of dye. The possibility that this fluid was chyle was considered and a sample was sent for triglyceride level. The patient's abdomen was irrigated and closed. He was transferred stable to the surgical Intensive Care Unit where he was successfully extubated after negative flexible bronchoscopy.Trigliceride level of the sample obtained intraoperatively was 423 mg/dL (serum triglyceride was 66 mg/dL; normal values 40 -200 mg/dL), thus confirming our suspicion of a lymphatic duct injury. The patient was kept on TPN for 4 days. A Technecium-99m lymphoscintigraphy was obta...
Postthoracotomy pain syndrome (PTPS) affects approximately 50% of patients who undergo thoracic surgery for lung cancer. The pain can be very severe and may be associated with a high level of disability. The pain can be harsh and unrelenting, preventing patients from performing basic activity of daily living. Several modalities of pain management can be effective for PTPS. Appropriate pain management starts preoperatively with preemptive analgesia with oral medications. Regional anesthetic techniques, including thoracic epidural and thoracic paravertebral block/catheter, can be utilized intraoperatively and postoperatively. For patients who develop PTPS, a pain specialist should be consulted, and a multidisciplinary pain management approach should be designed, with treatments that may include injections (paravertebral nerve blocks, intercostal nerve blocks, trigger-point injections), physical therapy, and oral pain medications.
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