Chylous pericardial tamponade following postoperative chylothorax after right upper lobectomy: a case report of a rare entity

BACKGROUND: Postoperative chylothorax is a known but uncommon complication of lung cancer surgery. Progression to chylous pericardial effusion and tamponade is exceedingly rare but can be rapidly fatal if not recognized and treated promptly. CASE PRESENTATION: A 72-year-old man underwent right upper lobectomy with bronchus-sleeve resection and systematic mediastinal lymphadenectomy for squamous cell carcinoma. In the early postoperative course, a high-output chylothorax was diagnosed. On postoperative day (POD) 4, he developed paroxysmal atrial fibrillation with hemodynamic instability, requiring brief ICU admission for cardioversion. On POD 6, he suddenly deteriorated with obstructive shock with hypotension, tachycardia, pronounced mottled skin extending to the abdomen, and decreased level of consciousness. Bedside transthoracic echocardiography revealed a large pericardial effusion with tamponade physiology. Emergency pericardiocentesis drained 800 mL of milky fluid with high triglycerides, consistent with chylopericardium, and resulted in immediate hemodynamic stabilization. Interventional radiology attempted bilateral intranodal lymphangiography and thoracic duct embolization via lymphatic, venous and percutaneous routes; despite partial opacification of lymphatic channels, catheterization and embolization was unsuccessful. On POD 7, surgical re-thoracotomy with thoracic duct ligation above the diaphragm and lymphatic fistula closure was performed. The pericardial drain was removed on POD 8, echocardiography confirmed no recurrence, and the patient recovered uneventfully. DISCUSSION: Chylous pericardial tamponade is extremely rare but life-threatening. Previous reports describe a spectrum from successful conservative therapy to surgical interventions, with at least one fatal outcome despite drainage (Fukumoto et al. Surg Case Rep. 11:87; 2025). Our case highlights three points: (1) transthoracic echocardiography is indispensable for rapid diagnosis of tamponade in unstable postoperative patients; (2) interventional radiology, although attempted, was unsuccessful and should not delay definitive treatment; (3) surgical thoracic duct ligation and pericardial drainage remain the most reliable interventions. CONCLUSION: Chylous pericardial tamponade should be considered in patients with postoperative chylothorax who deteriorate hemodynamically. Rapid echocardiography, emergency pericardial drainage, and timely surgical management are key to survival.