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Postoperative chylothorax in children: differences between vascular and traumatic origin
C Le Coultre1, I Oberhänsli, A Mossaz
1Clinique Universitaire de Chirurgie Pédiatrique et de Pédiatrie, Geneva, Switzerland.
Insights
This study analyzed 24 pediatric cases of postoperative chylothorax, finding nonoperative management effective for most. A structured approach is proposed for treating this rare complication after thoracic surgery.
Area of Science:
- Pediatric Surgery
- Thoracic Surgery
- Critical Care Medicine
Background:
- Postoperative chylothorax is a rare but significant complication following thoracic operations in children.
- It can result from direct injury to the thoracic duct or secondary to superior vena cava (SVC) obstruction.
Purpose of the Study:
- To evaluate the outcomes of different treatment strategies for pediatric postoperative chylothorax.
- To propose a stepwise management algorithm for this condition.
Main Methods:
- Retrospective analysis of 24 children with postoperative chylothorax over a 7-year period.
- Review of treatment modalities including nonoperative (dietary management, pleural drainage) and operative interventions.
- Categorization of chylothorax causes (direct injury vs. SVC obstruction).
Main Results:
- All 24 patients were successfully treated without mortality.
- Nonoperative management was successful in 16 patients, utilizing medium chain triglyceride (MCT) diets or total parenteral nutrition (TPN).
- Chylothorax associated with SVC obstruction and thrombosis proved more challenging to manage.
Conclusions:
- A step-by-step management approach, starting with conservative measures and progressing to surgical intervention if necessary, is recommended.
- Early diagnosis and appropriate management are crucial for favorable outcomes in pediatric postoperative chylothorax.
- The proposed algorithm aims to optimize treatment efficacy and minimize complications.
Abstract:
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)