Ligation of the thoracic duct for the treatment of chylothorax in heart diseases

Abstract

If conservative treatment is not effective, surgical treatment should be considered 8 . Studies indicate that ligation of the thoracic duct and pleurodesis are efficient alternatives for resolution of chylothorax 9 .Recently, thoracic duct ligation through video-assisted thoracic surgery has been used in patients who did not respond to conservative treatment. Kirby et al 11 describe this conduct as less painful and with fewer postoperative complications.Pereira et al 12 describe the use of lymphatic ligation for the treatment of postoperative chylopericardium. However, in our country, ligation of the thoracic duct for the treatment of postoperative chylothorax is still a rare procedure, and at what point the conservative treatment should be replaced by postsurgical treatment is still controversial. Thus, our study evaluates the initial results of ligation of the thoracic tract in 4 patients with chylothorax unresponsive to conservative treatment. Case ReportsCase 1 -A four-year-old-male patient with congenital cardiopathy and cyanosis at birth with a previous history of pulmonary atresia without interventricular communication, single left ventricle, hypoplastic right ventricle with sinusoids, left pulmonary artery stenosis, and coronary artery cavitary fistulas. At 5 days of life, he underwent atrial septotomy with the Rashkind procedure, and after 2 days, he underwent a modified left Blalock Taussig shunt procedure. At 4 years old, he underwent a bidirectional Glenn operation with maintenance of the previous Blalock shunt, evolving, in the postoperative period with low cardiac output maintained with vasoactive drugs. He was discharged on the 5th postoperative day, when minor pleural effusion was suspected. A chest X-ray was indicated.After chylothorax was diagnosed, pleural drainage was started. Parenteral nutrition and fasting were introduced after 1 week. The patient evolved with significant persistence of pleural drainage. Nineteen days after the initial In children, chylothorax occurs mainly after cardiac and thoracic surgeries. One of the recommended postsurgery treatments is ligation of the thoracic tract, when all other conservative treatments have failed. We report 4 cases of chylothorax in patients who were successfully treated with this approach, which resulted in a decrease in pleural drainage without recurrent chylothorax.Chylothorax refers to the presence of lymphatic fluid in one or both pleural spaces, secondary to leakage in the thoracic duct or one of its main tributaries 1 . Quinke 2 first described traumatic chylothorax in 1875, after rupture of the thoracic duct.When chylothorax is not treated, the risk of death is high, with rates above 45% 3 , requiring, in the majority of the cases, aggressive treatment.According to DeMeester 4 , chylothorax may be according to its cause, either congenital, traumatic, neoplastic, or multiple causes. Among the traumatic causes surgical procedures with a thoracic approach may cause thoracic duct lesions, leading to the development of chylothorax. Postoperat...

Videotoracoscopia como uma opção no tratamento cirúrgico do quilotórax após cirurgia cardíaca pediátrica

“…(4,(6)(7)(8)(9) Various surgical techniques have been employed, such as pleurodesis with pleural abrasion (or with pleurectomy), pleuroperitoneal shunt, shunt between the pleural cavity and the subclavian vein, anastomosis between the thoracic duct and the azygos vein, and thoracic duct ligation, the last being the most commonly performed. (4,8,(12)(13)(14)(15) The thoracic duct ligation technique has two variants. Mass ligature of the thoracic duct is performed without the individual dissection of the thoracic duct, and all of the tissue of the aorta, thoracic spine, esophagus, and azygos vein is mass ligated.…”

“…However, in most studies, surgical interventions are recommended when there is no resolution after 1-3 weeks of clinical treatment, or if the daily drainage exceeds 100 mL/kg. (4,8,(12)(13)(14)(15) Thoracic duct ligation, performed for the first time by Lampson in 1948, (16) is an efficient treatment option for patients with low morbidity. The use of videoassisted techniques has recently been described.…”

Fístula linfática após tratamento cirúrgico de síndrome do desfiladeiro torácico à direita

“…(8) Postoperative chylothorax is an uncommon situation which can manifest at up to four weeks after the initial procedure, presenting an significant risk of mortality, which can reach 50%. (11,12) The consequences include possible impairment (mechanical, immunological and metabolic). (8,12) The quantity of lymphatic fluid accumulated in one hemithorax can cause the compression of in recommending surgery could lead to unnecessary nutritional and immunological depletion.…”

Steroids as a possible effective therapy in the management of large isolated chylopericardium following open heart surgery

“…Some other studies reported using pleurodesis, pleurectomy, low ligation of the thoracic duct by video-assisted thoracoscopic surgery, thoracic duct embolisation, and pericardial-peritoneal shunting. 11,[21][22][23] Few reports have been published on the off-label use of the long-acting somatostatin analog, octreotide, that is presumed to cause a reduction in chyle production and thoracic duct flow rate. [24][25][26][27] The use of non-steroidal anti-inflammatory drugs has been the cornerstone in the treatment of patients with pericarditis, but no studies were published on its use in chylopericardium.…”