Chylothorax following Bochdalek herniorrhaphy in an infant

Post-operative chylothorax in children: an evidence-based management algorithm

AIM

To develop an evidence-based algorithm for the therapeutic approach to the management of post-operative chylothorax.

METHODS

Review and analysis of published literature sourced from Medline from 1964-2007.

RESULTS

Understanding the pathophysiology of chylothorax and the anatomical structure of the thoracic duct assisted clinical decision making in the management of a patient with chylothorax. Treatment options for post-operative chlothorax include conservative management with medium chain triglyceride-enriched diet or total parenteral nutrition in combination with adequate drainage of pleural fluid, somatostatin or octreotide therapy or surgical intervention. Based on analysis of the available evidence an algorithm for therapeutic approach to the management of post-operative chylothorax has been developed.

CONCLUSION

Post-operative chylothorax is associated with significant morbidity and prolonged hospitalization. An evidence based algorithm to guide the therapeutic approach to management of post-operative chylolthorax is proposed.

Chylothorax after repair of congenital diaphragmatic hernia--risk factors and morbidity

BACKGROUND/PURPOSE

Chylothoraces have been reported rarely after congenital diaphragmatic hernia (CDH) repair, but that is contrary to the authors' experience. The aim of this study was to audit the outcome of antenatally diagnosed CDH cases to determine the incidence, possible risk factors, and morbidity associated with chylothorax in CDH patents.

METHODS

Twenty-four of 35 consecutive infants with CDH (69%) underwent surgical repair and survived the immediate postoperative period.

RESULTS

Effusions developed in all 22 for whom chest radiographs were available. Six of the eight infants whose effusions required drainage had a chylothorax. Those six infants required a mean of 8 days of thoracentesis, during which a mean total volume of 358 mL/kg of fluid was removed. The infants remained on a medium-chain triglyceride (MCT) formula for a mean of 81 days. The six infants with a chylothorax differed from the rest with respect to their duration of oxygen dependence (a median of 28.5 versus 15 days, P < .05) and hospital stay (a median of 5.5 versus 4 weeks, P < .05), but no significant risk factors for the development of a chylothorax were identified.

CONCLUSION

Chylothorax is a relatively common cause of effusion after CDH repair and is associated with increased morbidity.

Postoperative chylothorax in children: differences between vascular and traumatic origin

Twenty-four children with postoperative chylothorax were encountered among 1,264 consecutive thoracic operations over a 7-year period and form the basis of this study. Chylothorax was caused by direct lesion to the thoracic duct or lymphatic vessels in 17 patients and was associated with superior vena cava (SVC) obstruction in seven. Of the latter, five had bilateral chylothorax. Chylothoraces secondary to venous hypertension and thrombosis have a longer interval between operation and diagnosis compared with direct trauma as well as a longer duration and larger volume of chylous drainage. Treatment was entirely nonoperative in 16 patients and operative in 8. Nonoperative treatment consisted of pleural needle aspiration or suction drainage in association with a medium chain triglyceride (MCT) diet (n = 11) or total parenteral nutrition (TPN) after failure of MCT (n = 5). Direct operation on the thoracic duct was performed in 5 patients, four had pleurodesis, and 2 had pleuroperitoneal shunts inserted. All patients were cured of their chylothorax and there were no deaths. Patients with major vein thrombosis were the most difficult to treat. On the basis of this experience, we suggest a step-by-step approach: (1) insertion of chest tube after 3 to 4 pleural punctures; (2) 1-week trial of MCT diet, with intravenous support to correct protein losses; (3) TPN if chylothorax increases or persists with large volumes; (4) Doppler echocardiography or phlebography to rule out obstruction of major thoracic veins; and (5) insertion of TPN line in inferior vena cava in case of such obstruction; and (6) direct surgical approach to the thoracic duct after 4 weeks of unsuccessful nonoperative treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Factors involved in chylothorax following repair of congenital posterolateral diaphragmatic hernia

Chylothorax after repair of congenital posterolateral diaphragmatic hernia has only been reported four times. We add a fifth case and have analyzed these five cases. In all five, the hernia was left sided and a sac was present that was excised. The chylothorax was always left sided. Chylous ascites did not occur. All cases responded to continuous chest drainage without surgical intervention on the thoracic duct or cysterna chyli. All five cases survived.

Primary lymphatic dysplasia in children: chylothorax, chylous ascites, and generalized lymphatic dysplasia

Primary lymphatic "dysplasia", a congenital maldevelopment, interferes with function of the lymphatic system and causes effusion of chyle or lymph into the limbs and pleural or peritoneal cavity. Between 1955 and 1982, 38 Mayo Clinic patients were found to have a chylous effusion or dysplasia of the lymphatic system. In 22, the condition was secondary to surgery or other medical problems and in 16 it was primary. These cases were separated into three categories: chylothorax, chylous ascites, and generalized lymphatic dysplasia. Conservative therapy, such as a restricted fat diet or total parenteral nutrition with repeated thoracentesis or paracentesis, was effective in the children with isolated abnormalities of the lymphatic system (75% resolution rate, no deaths). All five children with documented generalized dysplasia reported in the literature had died; of the three reported here, one has died and two have become progressively worse.