Ten-Year Clinical Experience on Chylothorax after Cardiovascular Surgery
Keywords:Chylothorax, pseudochylothorax, octreotide, cardiac surgery, duct ligation, pleurodesis.
Background: Chylothorax or pseudo-chylothorax is a serious complication after adult and pediatric cardiac surgery. This study presents our 10-year clinical experience of chylothorax after cardiac surgery.
Methods: Between January 2008 and February 2019, 4896 cardiovascular surgeries were performed in 2 tertiary clinics, with 416 patients in the pediatric age group (8.4%). Chylothorax and pseudo-chylothorax were detected in 47 patients (22 adult and 20 pediatric patients, 4.8%).
Pseudo-chylothorax was seen in 5 adult patients. In 27 patients, a pleural effusion developed on the left side (64.2%). Quantities of chylomicron in pleural effusion were significant in all patients. In addition, protein and lactate dehydrogenase levels were >2.9 g/dL. The cholesterol level in the pleural effusion was >2.49 mmol/L in all patients. The mean latency period was 8 days (range 3.1 to 63.1). For the management of chylothorax, somatostatin or octreotide as a somatostatin analog was administered in 23 patients (15 adult and 8 pediatric) in the intensive care unit. Somatostatin or octreotide was administered intravenously or subcutaneously at a dose of 0.3 to 4 µg/(kg · h–1). We used dexamethasone as a steroid combined with somatostatin in patients who were resistant to medical treatment before pleurodesis or ductus closure. Classic chemical pleurodesis combined with fibrin glue was performed in 11 patients (8 adult and 3 pediatric). Surgical duct ligation, as the last option, was performed in 7 patients.
Results: No mortality or morbidity was observed.
Chylothorax improved with the medical approach in 23 patients within 24.2 ± 11.3 days (48.9%). We successfully performed the pleurodesis procedure using fibrin glue in addition to the classic method. The mean duration of conservative treatment was 27.1 days (range 11 to 39). After discharge from the hospital, 2 children had recurrence of chylothorax, and the ductus thoracicus was surgically ligated. No complication was seen during or after ductus ligation.
Conclusions: According to our clinical experience, chylothorax is not an extremely rare complication after cardiac surgery in pediatric cardiovascular surgery. A number of patients with chylothorax may be treated medically and with diet adjustment. Medical treatment including steroid administration may be the first treatment strategy immediately after diagnosis. Classic chemical pleurodesis combined with fibrin glue may be applied in the early stages. Surgical ligation of the ductus thoracicus should be considered the last treatment option.
Beghetti M, La Scala G, Belli D, Bugmann P, Kalangos A, Le
Coultre C. Etiology and management of pediatric chylothorax. J Pediatr 2000;136:653-658.
Büttiker V, Fanconi S, Burger R. Chylothorax in children: Guidelines for diagnosis and management. Chest 1999;116:682-687.
Cannizzaro V, Frey B, Bernet-Buettiker V. The role of somatostatin in the treatment of persistent chylothorax in children. Eur J Cardiothorac Surg 2006;30:49-53.
Chalret du Rieu M, Baulieux J, Rode A, Mabrut JY. Management of postoperative chylothorax. J Visc Surg 2011;148:346-352.
Chan EH, Russell JL, Williams WG, Van Arsdell GS, Coles JG, McCrindle BW. Postoperative chylothorax after cardiothoracic surgery in children. Ann Thorac Surg 2005;80:1864-1870.
Chan SY, Lau W, Wong WH, Cheng LC, Chau AK, Cheung YF.
Chylothorax in children after congenital heart surgery. Ann Thorac Surg 2006;82:1650-1656.
Coulter DM. Successful treatment with octreotide spontaneous of chylothorax in a premature infant. J Perinatol 2004;24:194-195.
Doğan R, Demircin M, Dogan OF, Kuzgun E. Effectiveness of somatostatin in the conservative management of chylothorax. Turk J Pediatr 2004;46:262-264.
Heffner JE, Sahn SA, Brown LK. Multilevel likelihood ratios for identifying exudative pleural effusions. Chest 2002;121:1916-1920.
Hillerdal G. Chylothorax and pseudochylothorax. Eur Respir J 1997;10:1157-1162.
Ismail SR, Kabbani MS, Najm HK, Shaath GA, Jijeh AM, Hijazi OM. Impact of chylothorax on the early post operative outcome after pediatric cardiovascular surgery. J Saudi Heart Assoc 2014;26:87-92.
Jenkins KJ, Gauvreau K, Newburger JW, Spray TL, Moller JH, Iezzoni LI. Consensus-based method for risk adjustment for surgery for congenital heart disease. J Thorac Cardiovasc Surg 2002;123:110-118.
Kara H, Uzun K, Bozok S. Tension chylothorax after coronary artery bypass grafting surgery. Turk J Thorac Cardiovasc Surg 2014;22:419-422.
Keceligil HT, Bahcivan M, Demirag MK. Treatment of persistent chylothorax with somatostatin. A case report. Chirurgia 2005;18:409-410.
Liu CS, Tsai HL, Chin TW, Wei CF. Surgical treatment of chylothorax caused by cardiothoracic surgery in children. J Chin Med Assoc 2005;68:234-236.
Merrigan BA, Winter DC, O’Sullivan GC. Chylothorax. Br J Surg 1997;84:15-20.
Nair SK, Petko M, Hayward MP. Aetiology and management of chylothorax in adults. Eur J Cardiothorac Surg 2007;32:362-369.
Nath DS, Savla J, Khemani RG, Nussbaum DP, Greene CL, Wells WJ. Thoracic duct ligation for persistent chylothorax after pediatric cardiothoracic surgery. Ann Thorac Surg 2009;88:246-251.
Oishi H, Hoshikawa Y, Sado T, Watanabe T, Sakurada A, Kondo T, Okada Y. A case of successful therapy by intrapleural injection of fibrin glue for chylothorax after lung transplantation for lymphangioleiomyomatosis. Ann Thorac Cardiovasc Surg 2017;20:40-44.
Sapmaz E, Karataş O, Işık H. Right chylothorax after thoracic sympathicotomy: A very rare case. Turk J Thorac Cardiovasc Surg 2018;26:484-486.
Sersar SI. Predictors of prolonged drainage of chylothorax after cardiac surgery: Single centre study. Pediatr Surg Int 2011;27:811-815.
Stenzl WStenzl W, Rigler B, Tscheliessnigg KH, Beitzke A, Metzler H. Treatment of postsurgical chylothorax with fibrin glue. Thorac Cardiovasc Surg 1983;31:35-36.
Tatar T, Kilic D, Ozkan M, Hatipoglu A, Aslamaci S. Management of chylothorax with octreotide after congenital heart surgery. Thorac Cardiovasc Surg 2011;59:298-301.
Yeh J, Brown ER, Kellogg KA, et al. Utility of a clinical practice guideline in treatment of chylothorax in the postoperative congenital heart patient. Ann Thorac Surg 2013;96:930-936.
Yıldız O, Öztürk E, Fırat Altın H, Ayyıldız P, Kasar T, İrdem A, et al. Chylothorax following pediatric cardiac surgery. Turk J Thorac Cardiovasc Surg 2015;23:434-440.
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