Anatomic variability of the thoracic duct in pediatric patients with complex congenital heart disease

Thoracic duct mass ligation (TDML) through a right thoracotomy (RT), regardless of the side of the pleural effusion, is a standard procedure for chylothorax that is refractory to medical treatment. This procedure may be unsuccessful in patients with complex congenital heart disease, which necessitates additional left thoracotomy (LT) for left periaortic mass ligation. We hypothesized that failure of the right-sided approach is attributable to the anatomic variation of the path of the thoracic duct.

Of the children who underwent surgery for congenital heart disease between 1992 and 2014, a total of 70 of 8880 (0.8%) underwent TDML by RT (n = 57) or LT (n = 13; LT after RT in 10, and primary LT in 3).

Persistent chylothorax was successfully resolved in 65 patients (65 of 70; 93%) within 15 days (2-79 days) after the first or second TDML; 5 patients died with a chest-tube(s) in situ. After excluding mortality without chest-tube removal, we sought to identify the risk factor(s) necessitating LT in 65 patients (RT group: 54; LT group: 11). On logistic regression analysis, the LT group was more likely to have dextrocardia (odds ratio: 6.38; 95% confidence interval: 1.09-37.25; P = .04). The incidence of abnormal atrial situs, great arterial malposition, right descending thoracic aorta, and bilateral superior vena cavae were comparable in the 2 groups.

The path of the thoracic duct may vary in pediatric patients with complex congenital heart disease. Left periaortic mass ligation should be considered in patients with chylothoraces that persist after the right-sided approach, especially in patients with dextrocardia.