Endocrine Abstracts

Introduction: Chylous leaks after neck dissections occur in 1-2% of patients. However, bilateral chylothorax after neck dissections for thyroid carcinoma is extremely rare. We report the case of a bilateral chylothorax after a total thyroidectomy and left sided modified neck dissection for thyroid carcinoma and management of chylous leak.

Case Report: A 39-year-old patient presented with a two-week history of a palpable tumor measuring 3 × 3 cm in the left thyroid lobe. Cytology was suspicious for papillary thyroid carcinoma. Ultrasound (US) guided fine-needle aspiration biopsy of the lymph node lateral to the left carotid artery was performed, which revealed a metastasis of papillary thyroid cancer. The patient underwent a total thyroidectomy, left sided central and lateral neck dissection. In the morning of the second postoperative day (POD), left side of the neck was swollen and an ultrasound examination suspected a hematoma. During surgical revision no free fluid was present and only edema of tissues was found. However, the patient complained of dyspnea and chest discomfort in the afternoon of the same day. Because pulmonary embolism was suspected, a computed tomography of the chest was performed, which revealed massive bilateral pleural effusions. Bilateral thoracic drainages were inserted and about 1,5 L of milky white fluid were evacuated. The patient had a total parenteral nutrition for the following eight days. The patient was re-operated on POD 5 due to persisting chylous thoracic discharge. The thoracic duct was prepared in a length of 5 cm and a yellow spot with a diameter of 3 x 2 mm was found on the front side, from which there was no outflow of lymph during the operation. The thoracic duct was ligated. The thoracic drains were removed on POD 10 and a regular diet was started again. The patient was discharged on POD 11. Histology showed a papillary thyroid carcinoma stage pT4N1b. Two months after surgery postoperative external beam radiotherapy to the neck and superior mediastinum with 50.5 Grays was performed and five months after surgery the patient had ablation of thyroid remnant with 103 mCi of radioiodine. The patient has no evidence of disease 14 years after initial treatment of thyroid carcinoma.

Conclusions: A bilateral chylothorax is a potentially life-threatening condition. A bilateral chylothorax was diagnosed with a computed tomography of the chest and treated with bilateral thoracic drainage, a total parenteral nutrition and ligature of damaged thoracic duct.