Invited Commentary

Abstract

Postoperative chylothorax is a complication or consequence after cardiac operations in infants and children in a variety of situations. For example, surgery on the aortic arch, such as repair of arch stenosis, coarctation, or patent ductus arteriosus, places the thoracic duct or its tributaries at risk for injury and the complication of chylothorax. Alternatively, the creation of a superior cavopulmonary connection or a Fontan pathway may lead to elevated systemic venous pressure with a consequence of lymph leakage through the interconnected lymphatic vessels. Other causes of postoperative chylothorax include superior central venous thrombosis and diastolic heart dysfunction, both of which also elevate systemic venous pressure. In some circumstances, more than one cause of chyle accumulation in a thorax may be involved. Hence, establishing the precipitant for a chylothorax and directing treatment at the specific cause can be challenging. Adding to the complexity of this problem are the sequelae from the fluid losses into the extravascular space, such as intravascular volume depletion, electrolyte imbalances, protein losses, coagulopathy, malnutrition, and immunosuppression. The volume of fluid sequestered within the pleural space or ongoing losses drained into a tube will affect the severity of these secondary problems and contribute to the morbidity and mortality associated with chylothorax. Current treatment strategies for chylothorax, including parenteral nutrition through central venous access, tube thoracostomy drainage, and mechanical ventilation, all compound the risks for infection and venous thrombosis in these patients. Therefore, prompt recognition of chylothorax, determination of its cause, and institution of effective treatment are paramount to successful outcomes with this difficult postoperative problem. A good first step in addressing postoperative chylothorax is to have heightened awareness for its presence and to begin treatment soon after its development before the sequelae occur. This approach was used by Yeh and colleagues in this report [1Yeh J. Brown E.R. Kellogg K.A. et al.Utility of a clinical practice guideline in treatment of chylothorax in the postoperative congenital heart patient.Ann Thorac Surg. 2013; 96: 930-937Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar]. By use of a directed clinical practice guideline, attention was drawn to the problem of chylothorax so that a treatment algorithm could be started. Although there are limitations to this study, including its retrospective design and the inconsistent use of pleural fluid analysis to determine whether the effusion was chylous, prompt attention to this problem seems to have contributed to improved outcomes compared with those in patients cared for before the introduction of the practice guideline. The benefits of early diagnosis and intervention identified in this report, including earlier time to diagnosis, decreased lengths of stay in the intensive care unit and the hospital, less mechanical ventilation, fewer days with drainage tubes and central venous catheters, and less time without enteral nutrition, will all likely contribute to less morbidity and mortality if these results are confirmed in prospective randomized trials. Utility of a Clinical Practice Guideline in Treatment of Chylothorax in the Postoperative Congenital Heart PatientThe Annals of Thoracic SurgeryVol. 96Issue 3PreviewChylothorax after congenital heart surgery is a common complication with associated morbidities, but consensus treatment guidelines are lacking. Variability exists in the duration of medical treatment and timing for surgical intervention. Full-Text PDF