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Ann Thorac Surg 2005;80:1870-1871
© 2005 The Society of Thoracic Surgeons
Department of Cardiothoracic Surgery, Drexel University College of Medicine, Section of Cardiothoracic Surgery, Saint Christopher's Hospital for Children, Erie Ave at Front St, Philadelphia, PA19134
(Email: gpelleti{at}drexelmed.edu).
Chylothorax after repair of congenital heart defects is an infrequent complication, but one that can cause significant morbidity. One of the challenges of managing this complication, especially in neonates and small infants, is to maintain fluid, electrolyte, and nutritional homeostasis while trying to eliminate the lymphatic leak using therapies that are often lengthy. Chan and colleagues [1] in their relatively large, retrospective series report an incidence of 3.8% for chylothorax, which is comparable with other contemporary series. Treatment was determined by physician preference rather than a protocol that was later proposed. However, the median length of hospitalization for patients who had a postoperative chylothorax develop was 22 days compared with 8 days for patients without this complication. This prolonged hospitalization underscores the often protracted course from postoperative chylothorax and its morbidity potential.
A definitive treatment strategy for postoperative chylothorax is currently elusive. The therapeutic modalities include drainage of the pleural space, diets low in long chain triglycerides and enriched with medium chain triglycerides, or complete abstinence from enteral nutrition opting for parenteral calorie delivery. Surgical ligation of the thoracic duct, and recently octreotide administration, have been used when dietary restrictions fail. The authors report a 71% success rate for resolution of chylothorax using a low fat, medium chain triglycerides enriched diet. When total parenteral nutrition was used, only 6 of 11 patients had elimination of the chylothorax. Five patients received octreotide as second line therapy, but 4 showed no overall decrease in chylous drainage. Thoracic duct ligation was performed on 4 patients between 20 and 161 days after cardiac surgery. Three of these patients demonstrated a decline in daily drainage, but survival in this group was 50%. In addition, patients were at risk for prolonged chylous drainage (50% drained longer than 30 days) after a cavopulmonary anastomosis, including the Fontan operation. Furthermore, increased duration of drainage was associated with delay in diagnosis of chylothorax, and a trend emerged between greater maximum daily drainage and longer duration of chylous drainage. These results support the principle of early diagnosis and expeditious resolution of chylothorax, especially in patients after having cavopulmonary anastomoses.
The algorithm for diagnosis and management of chylothorax offered by the authors is well organized and promotes specific criteria to govern therapy for this challenging problem. However the treatment goal for chylothorax should be rapid resolution to minimize the morbidity associated with lipid and protein losses, immunosuppression, long-term chest tube and intravenous access, and hospitalization. An additional therapeutic modality demonstrated to be effective in adults with chylothorax is percutaneous embolization of the thoracic duct. This technique may provide a means to quickly achieve early closure of the lymphatic fistula in children, particularly those patients believed to have a chylous leak secondary to elevated lymphatic pressures after cavopulmonary anastomosis.
The authors mention fluid and electrolyte losses and acquired immunodeficiency from lymphocyte depletion as consequences of chylothorax, but they discuss little about their replacement therapy. In cavopulmonary anastomosis or Fontan patients, in particular, we have practiced partial volume replacement with fresh frozen plasma to prevent depletion of proteins including immunoglobulins and some important naturally occurring anticoagulants such as proteins S and C.
Steroid therapy is a protocol in the care algorithm to treat chylothorax after failure of dietary restrictions and total parenteral nutrition; however the authors did not discuss this treatment in the article. Given the important morbidity associated with chylothorax, yet the rarity of the complication, perhaps a multi-institutional study comparing steroids versus octreotide, both with dietary restrictions, could show a benefit to one therapy in comparison with another in the management of postoperative chylothorax.
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  S.-y. Chan, W. Lau, W. H.S. Wong, L.-c. Cheng, A. K.T. Chau, and Y.-f. Cheung Chylothorax in Children After Congenital Heart Surgery Ann. Thorac. Surg., November 1, 2006; 82(5): 1650 - 1656. [Abstract] [Full Text] [PDF]
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