Asian Cardiovasc Thorac Ann 2001;9:243-245
© 2001 Asia Publishing EXchange Pte Ltd
Management of Post-Fontan Chylothorax With Non-Valved Silastic Conduit
Vikram Jitendra, FRCS,
D Bhaktavatsala Reddy, MD,
M P Naresh Kumar, MS
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Department of Cardiovascular Diseases Harvey Heart Hospitals Ltd Chennai, Tamil Nadu, India
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For reprint information contact: M P Naresh Kumar, MS Tel: 91 44 823 4209 Fax: 91 44 822 1355 Department of Cardiovascular Diseases, Harvey Heart Hospitals Ltd, 20 Pycrofts Garden Road, Nungambakkam, Chennai, Tamil Nadu 600006, India.
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Abstract
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A non-valved silastic pleuroperitoneal shunt and omentoplasty were used to treat persistent chylothorax and chylopericardium in a 2-year-old boy who had undergone a Fontan operation.
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INTRODUCTION
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Chylothorax complicating cardiac surgery is well documented.1 It can vary in presentation from a self-limiting postoperative complication to one of severe debilitation leading to septicemia and death. The treatment options for chylothorax are as varied as its causes.2–4 The mainstay of treatment has been conservative management consisting of repeated pleurocentesis or tube thoracostomy combined with nutritional manipulations, both enteral and parenteral.5 Chemical pleurodesis has been a useful adjunct after successful drainage in such situations. Surgical procedures to correct chylothorax have also been used in certain resistant cases. Pleural peritoneal shunting using a valved conduit (Denver shunt) has been successful in managing this condition.6
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CASE REPORT
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A 2-year-old boy presenting with severe cyanosis, was investigated by echocardiography and cardiac catheter-ization. These revealed a complex cyanotic heart defect in the form of dextrocardia with situs inversus universalis, left-sided superior and inferior venae cavae, large atrial and ventricular septal defects, 2 atrioventricular valves, single ventricle of indeterminate morphology with an anterior subaortic rudimentary outflow chamber, trans-posed great arteries with anterior aorta and posterior pulmonary root, moderately severe pulmonary valve stenosis, and confluent and well-developed pulmonary arterial branches. Considering the complex intracardiac anatomy, protected pulmonary circulation, and well-developed pulmonary arterial tree, it was decided to perform a cavopulmonary diversion, despite the young age. Surgery was performed through a midline sternotomy under general anesthesia. After systemic heparinization and high aortic and bicaval cannulation, the patient was placed on cardiopulmonary bypass. Under moderate hypothermia and cold blood potassium cardioplegic arrest, total cavopulmonary connection was performed using the Fontan principle. The child was weaned off bypass with minimal inotropic support and central venous pressure of approximately 10 cm H2O. Pleural, pericardial, and peritoneal cavities were electively drained with tubes. The patient was extubated within 2 hours of the procedure and made a rapid recovery. The drainage tubes were left in place for 5 days despite minimal or no drainage. On the 7th postoperative day, he was discharged from the hospital with clear chest radiographs and no evidence of pericardial or peritoneal fluid collection by echo-cardiography. He was maintained on limited fluid intake and a regular diuretic regime.
One week after discharge, the patient was readmitted with breathlessness and decreased urine output. Chest radiography and echocardiography revealed bilateral pleural and pericardial fluid collection (Figure 1A
). Drainage tubes were inserted in the pleural and pericardial cavities under general anesthesia. The right pleural and pericardial tubes were removed on the 3rd day as there was no further drainage. However, the left pleural drainage increased in volume and became opalescent. Analysis of the fluid revealed it to be chyle with a high content of cholesterol, triglycerides, and chylomicrons. It pro-gressively increased in volume until it averaged 400 to 500 mL per 24 hours. This continued for 14 days during which the child was put on a diet rich in medium-chain triglycerides, with no decrease in chylous output. He lost weight and became irritable. Echocardiography revealed additional fluid collection in the pericardial cavity. Since conservative measures were not effective, surgery was decided. Under general anesthesia, the peritoneum was opened through a subxiphoid approach, and the greater omentum was mobilized. The pericardial cavity was drained through the same incision and the mobilized omentum was inserted into the pericardial cavity in the form of an omentoplasty. A large inferior window was also made in the central tendon, draining the pericardium into the peritoneal cavity. Through a small incision in the anterior axillary line in the 5th interspace, one end of a non-valved silastic tube (Lifemed, Los Angeles, CA, USA) of 2.62 mm in diameter was introduced into the left pleural cavity, and the other end was tunneled sub-cutaneously into the peritoneal cavity and anchored to the subcutaneous tissue. After this procedure, the child was put back on a normal diet. He was comfortable with no evidence of dyspnea. Chest radiography revealed no fluid collection in the pericardial and pleural cavities (Figure 1B) and this was confirmed by echocardiography. The child was discharged from hospital 3 days later and followed up as an outpatient every 3rd day. Initially, there was mild to moderate abdominal wall edema, but no evidence of pleural, pericardial, or peritoneal fluid collection as assessed by echocardiogram and abdominal ultrasound examination. Gradually, the abdominal wall edema subsided. One year after insertion of the pleuro-peritoneal shunt, the child was alert, active, and eating normally, with no evidence of collection of fluid.
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Figure 1. (A) Chest radiograph on the 10th postoperative day, showing bilateral pleural and pericardial effusions. (B) After insertion of a non-valved silastic tube between the left pleural and peritoneal cavities, with a pericardial window.
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DISCUSSION
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Chylothorax by definition is fluid enriched with cho-lesterol, triglycerides, and chylomicrons, unlike pseudochylothorax that contains only cholesterol. Chylothorax is known to occur idiopathically and can also complicate cardiothoracic surgical procedures.1,7 Management of chylothorax has been essentially either conservative, surgical, or a combination of both. Conservative manage-ment consists of repeated aspirations, tube thoracostomy, and a modified diet based on medium-chain triglycerides, with or without parenteral nutrition. Use of somatostatin and inhaled nitric oxide has also been reported.6 Prolonged and excessive drainage of chyle can lead to malnutrition, immunodepression, and septicemia. Therefore, it is advisable to intervene surgically when conservative measures fail.8 Surgical options include talc pleurodesis, pleurectomy, direct ligation of leaking lymphatics by an open surgical or thoracoscopic approach, and pleuro-peritoneal shunting.2,3,8
In our patient, conservative measures failed, necessitating a surgical solution keeping in mind the abnormal anatomy, complicated cardiac surgical repair, progressive clinical deterioration and financial implications. Therefore, we opted for a pleuroperitoneal shunt. Due to lack of availability of a Denver valved shunt or its equivalent, we decided to use a silastic non-valved tube as the shunt conduit. The ease of insertion, good drainage characteris-tics, and excellent functioning of this simple shunt recommends it as a potential therapeutic technique for similar situations.
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REFERENCES
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Abstract
INTRODUCTION
