Etiology and Management of Chylothorax Following Pediatric Heart Surgery

Abstract

Background: Chylothorax after congenital heart surgery (CHD) is a potentially challenging complication. The purpose of this study was to review our experience with the management of chylothorax following congenital heart surgery. Methods: Between September 1997 and August 2006, of 1341 pediatric patients undergoing correction of congenital heart disease in our institution, 18 (1.3%) developed chylothorax postoperatively. Surgical procedures included tetralogy of Fallot repair in 10 patients, ventricular septal defect closure (one), atrial septal defect with pulmonary stenosis repair (one), Fontan procedure (three), coarctation of the aorta repair (one), aortopulmonary shunt (one), and ligation of patent ductus arteriosus in one patient. All patients followed a therapeutic protocol including complete drainage of chyle collection and controlled nutrition. Somatostatin was used adjunctively in six (33.3%) patients. Surgical intervention was reserved for persistent lymph leak despite maximal therapy. Following resolution of chylothorax, a medium-chain triglyceride diet was implemented for six weeks. Results: There were no deaths. Fifteen patients (83.3%) responded to conservative therapy. Lymph leak ranged from 2.5 to 14.7 mL/kg per day for 8 to 42 days. Three patients with persistent drainage required thoracotomy with pleurodesis to achieve resolution, in two of which previously attempted chemical pleurodesis with doxycycline proved ineffective. Duration of lymph leak in this subgroup ranged from 15 to 47 days with 5.1 to 7.4 mL/kg per day output. Conclusions: Postoperative chylothorax is an infrequent complication of surgery for congenital heart disease and can occur even after median sternotomy in the absence of pathologically elevated venous pressure or Fontan circulation. Although hospitalization can be prolonged, conservative therapy is effective in most cases, while surgical pleurodesis proved successful in the refractory cases. doi: 10.1111/j.1540-8191.2008.00781.x (J Card Surg 2009;24:369-373) Postoperative chylothorax in childhood is a potentially serious complication of any thoracic surgical procedure and its management represents a serious challenge. In particular, chylothorax occurring after pediatric congenital heart surgery is an uncommon complication, occurring in 0.6% to 2% in reported series. 1,2 The intent of our study was to explore the etiology and present our experience with the management of this type of chylothorax. MATERIALS AND METHODS The hospital records of all children with a postop-

Chylothorax following pediatric cardiac surgery

“…[10] In our study, three patients died (8.5%), which was similar to previous studies that had mortality rates of between 6 and 21%. [1,9,12,13] The cause of death in our patients was likely multifactorial due to the unfavorable hemodynamics, sepsis, and multiple organ dysfunction. The most observed complication in our study was septicemia in nine patients.…”

“…[12] Nevertheless, it is generally accepted that in spite of the use of conservative therapy, if lymphatic leakage persists beyond a few weeks or if massive fluid and nutritional losses present a danger to the patient, then operative intervention is indicated. [12] Some authors have recommended that the surgery take place within five to seven days to limit the morbidity and mortality associated with the operation, [12] but others believe it is better to wait for approximately two weeks or longer in order to provide an adequate time for medical treatment. [8,12] Two surgical strategies predominate: direct wound ligature and en masse supradiaphragmatic ligature.…”

“…[12] Some authors have recommended that the surgery take place within five to seven days to limit the morbidity and mortality associated with the operation, [12] but others believe it is better to wait for approximately two weeks or longer in order to provide an adequate time for medical treatment. [8,12] Two surgical strategies predominate: direct wound ligature and en masse supradiaphragmatic ligature. Particularly for our patients with a single ventricle, we treated the postoperative chylothorax aggressively, believing that we should not wait for pleurodesis and ligation.…”

“…[10] The optimal management of chylothorax is unclear because no prospective studies exist to aide in the choice of therapy since different protocols and strategies are followed in each center. [11,12] The primary modes of treatment include pleural space evacuation, the use of MCT oil-based formulas, enteric rest, and parenteral alimentation, [12,13] and these have shown a success rate of 77% within a maximum of 45 days, with an average time of approximately 12 days. [14] Previous studies have suggested that persistent chylous output for more than three weeks and lesions associated with elevated systemic venous pressure were risk factors for the failure of conservative management options.…”

Chylothorax in Infants and Children

“…2 It occurs as a postoperative complication after various surgeries involving structures in the neck and thorax. [39][40][41][42][43][44] Other surgeries that can be complicated by chylothorax in children include those for treatment of scoliosis, [45][46][47][48] vascular rings, 49,50 and diaphragmatic hernia. 51 In children, the reported incidence of chylothorax after cardiothoracic surgery is between 0.85% and 6.6%.…”