THE MANAGEMENT OF CHYLOTHORAX CHYLOPERICARDIUM FOLLOWING PEDIATRIC CARDIAC-SURGERY - A 1O-YEAR EXPERIENCE

We reviewed the management of 25 cases of chylothorax/chylopericardium (CT/CP) in 24 patients (9 females, 15 male; 3 days to 11-years-old) f ollowing 1605 cardiothoracic procedures (incidence of 1.5%) between Ja nuary 1984 and December 1993 at our institution. The surgical procedur es preceding the occurrence of lymph leak included ligation of patent ductus arteriosus (6 patients), coarctation/double aortic arch repairs (3), complex intracardiac repairs (11), and systemic to pulmonary shu nts (5). There were 3 CPs and 22 CTs. All of the patients were initial ly treated nonsurgically with diet modification using either total par enteral nutrition (TPN) or enteral low fat solid food or enteral eleme ntal diet supplemented with intravenous lipid emulsion. Twenty-one cas es (84%) responded to conservative therapy. Of those, 15 had TPN as th e initial treatment; the average duration of lymph leak was 13.7 (rang e 7 to 30) days and the average maximal lymph leak was 39.4 (range 15 to 130) mL/kg per day. The other six cases had low-fat enteral diet as the initial treatment, four resolved completely. Two with high-centra l venous pressure had to be switched to TPN prior to complete resoluti on. The average duration of lymph leak in this subgroup was 30 (range 12 to 56) days with the average maximal lymph leak was 30.1 (range 8.5 to 59) mL/kg per day. Excluding these two cases, the average lymph le ak of the rest of the group was very compatible to the TPN group of 15 days. Lymphocytopenia and hyponatremia were frequently seen during CT /CP (47.6% and 43%, respectively). Two recurrent CTs in this group wer e easily treated with reinstitution of low fat diet in one and TPN the other. Four remaining patients required surgical interventions (retho racotomy and ligation of lymph fistulae in 2, application of fibrin gl ue to the site of leakage in 1, 1 patient underwent four thoracotomies for persistent CT) for failed initial medical therapy. The mean peak daily lymph loss was 131.2 (range 68.4 to 216) mL/kg which was signifi cantly higher than that of the conservative group (36.2 mL/kg, p < 0.0 01). Three (75%) had complete cessation of lymph drainage after surger y. We concluded that the majority of CT/CP following surgery for conge nital heart diseases could safely be treated without surgical interven tions by diet manipulations with acceptable inherent morbidity. Patien ts with high-central venous pressure should be managed early with TPN and bowel rest. Enteral low-fat diet used in appropriately selected pa tients appeared to be as effective in controlling lymph leak as TPN. S urgical ligation of severed lymphatics was indicated for few cases wit h excessive lymph loss.