Biewer Eva S, Zürn Christoph, Arnold Raoul, Glöckler Martin, Schulte-Mönting Jürgen, Schlensak Christian, Dittrich Sven
Department of Pediatric Cardiology, University of Erlangen-Nuernberg, Erlangen, Loschgestraße 15, 91054 Erlangen, Germany.
J Cardiothorac Surg. 2010 Dec 13;5:127. doi: 10.1186/1749-8090-5-127.
To analyze risk factors for chylothorax in infants after congenital heart surgery and the efficacy of median chain triglyceride diet (MCT). To develop our therapeutic pathway for the management of chylothorax.
Retrospective review of the institutional surgical database and patient charts including detailed perioperative informations between 1/2000 and 10/2006. Data analyzing with an elimination regression analysis.
Twenty six out of 282 patients had chylothorax (=9.2%). Secondary chest closure, low body weight, small size, longer cardiopulmonary bypass (242 ± 30 versus 129 ± 5 min) and x-clamp times (111 ± 15 versus 62 ± 3 min) were significantly associated with chylothorax (p < 0.05). One patient was cured with total parenteral nutrition (TPN) and one without any treatment. 24 patients received MCT-diet alone, which was successful in 17 patients within 10 days. After conversion to regular alimentation within one week only one chylothorax relapsed. Out of 7 patients primarily not responsive to MCT-diet, 2 were successfully treated by lysis of a caval vein thrombosis, 2 by TPN + pleurodesis + supradiaphragmatic thoracic duct ligation, one by octreotide treatment, and two patients finally died.
Chylothorax may appear due to injury of the thoracic duct, due to venous or lymphatic congestion, central vein thrombosis, or diffuse injury of mediastinal lymphatic tissue in association with secondary chest closure. Application of MCT alone was effective in 71%, and more invasive treatments like TPN should not be used in primary routine. After resolution of chylothorax, MCT-diet can be converted to regular milk formula within one week and with very low risk of relapse.
分析先天性心脏病手术后婴儿乳糜胸的危险因素及中链甘油三酯饮食（MCT）的疗效。制定我们治疗乳糜胸的方案。
回顾机构手术数据库和患者病历，包括2000年1月至2006年10月期间详细的围手术期信息。采用逐步回归分析进行数据分析。
282例患者中有26例发生乳糜胸（=9.2%）。二次胸廓关闭、低体重、体型小、体外循环时间较长（242±30 vs 129±5分钟）和x夹闭时间较长（111±15 vs 62±3分钟）与乳糜胸显著相关（p<0.05）。1例患者通过全胃肠外营养（TPN）治愈，1例未接受任何治疗。24例患者仅接受MCT饮食，其中17例在10天内成功。在一周内转换为常规饮食后，只有1例乳糜胸复发。在7例最初对MCT饮食无反应的患者中，2例通过腔静脉血栓溶解成功治疗，2例通过TPN+胸膜固定术+膈上胸导管结扎术治疗，1例通过奥曲肽治疗，2例患者最终死亡。
乳糜胸可能由于胸导管损伤、静脉或淋巴充血、中心静脉血栓形成或与二次胸廓关闭相关的纵隔淋巴组织弥漫性损伤而出现。单独应用MCT治疗有效率为71%，在初始常规治疗中不应使用如TPN等更具侵入性的治疗方法。乳糜胸消退后，MCT饮食可在一周内转换为常规奶粉，复发风险极低。
