Kahraman Doğan, Keskin Gökhan, Khalil Emced, Dogan Omer Faruk
Department of Cardiovascular Surgery, Gaziantep University School of Medicine, Gaziantep, Turkey.
Department of Cardiology, Amasya University School of Medicine, Amasya, Turkey.
Heart Surg Forum. 2020 Feb 27;23(1):E081-E087. doi: 10.1532/hsf.2655.
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.
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.
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.
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.
乳糜胸或假性乳糜胸是成人及小儿心脏手术后的严重并发症。本研究介绍了我们在心脏手术后乳糜胸方面的10年临床经验。
2008年1月至2019年2月期间，在2家三级诊所进行了4896例心血管手术，其中小儿年龄组有416例患者（8.4%）。在47例患者（22例成人和20例小儿患者，4.8%）中检测到乳糜胸和假性乳糜胸。5例成年患者出现假性乳糜胸。27例患者左侧出现胸腔积液（64.2%）。所有患者胸腔积液中的乳糜微粒量均显著。此外，蛋白质和乳酸脱氢酶水平>2.9 g/dL。所有患者胸腔积液中的胆固醇水平>2.49 mmol/L。平均潜伏期为8天（范围3.1至63.1天）。对于乳糜胸的治疗，在重症监护病房中，23例患者（15例成人和8例小儿）使用生长抑素或作为生长抑素类似物的奥曲肽。生长抑素或奥曲肽以0.3至4 μg/(kg·h-1)的剂量静脉内或皮下给药。在进行胸膜固定术或导管结扎术前对药物治疗耐药的患者中，我们使用地塞米松作为类固醇与生长抑素联合使用。11例患者（8例成人和3例小儿）进行了经典化学胸膜固定术联合纤维蛋白胶。作为最后一种选择，7例患者进行了手术导管结扎。
未观察到死亡或发病情况。23例患者通过药物治疗在24.2±11.3天内乳糜胸得到改善（48.9%）。除经典方法外，我们还成功地使用纤维蛋白胶进行了胸膜固定术。保守治疗的平均持续时间为27.1天（范围11至39天）。出院后，2名儿童出现乳糜胸复发，并进行了胸导管手术结扎。导管结扎期间及之后未出现并发症。
根据我们的临床经验，在小儿心血管手术的心脏手术后，乳糜胸并非极为罕见的并发症。许多乳糜胸患者可通过药物治疗和饮食调整进行治疗。包括给予类固醇在内的药物治疗可能是诊断后立即采取的首要治疗策略。经典化学胸膜固定术联合纤维蛋白胶可在早期应用。胸导管手术结扎应被视为最后的治疗选择。
