Thoracoscopic Approach of Bilateral Chylothorax

Abstract

Introduction: Chylothorax is a relatively common complication of pediatric cardiac surgery. Although reaching a diagnosis is simple, management is a challenge and consensus is lacking. We report the case of a 10 days old, female newborn, who presented with bilateral chylothorax after surgical correction of congenital transposition of the great vessels and showed no response to medical therapy for a period of 1 month. Materials and Methods: A full-term newborn infant with prenatal diagnosis of transposition of the great vessels underwent arterial switch surgery at 10 days of life, which required two revisions because of bleeding. The patient evolved with a bilateral chylothorax and mechanical ventilation and inotropic medications were required. A neck CT scan showed thrombosis of the right and left internal jugular veins and the right cerebral venous sinus. Multiple conservative treatment measures were implemented. Bilateral pleural fluid was drained, a fat-restricted oral diet supplemented with medium chain triglycerides was instituted, followed later by total parenteral nutrition and intravenous administration of octreotide. Notwithstanding, the chylothorax persisted and, finally, a video-assisted thoracic duct ligation with bilateral pleurodesis was planned and performed, as shown in this video. Once in the operating room, endotracheal intubation was placed and the patient was situated in 3/4 prone position. Three trocars were inserted into the right chest: one on the mid-axillary line at the level of the third intercostal space, the second one on the posterior axillary line at the level of the fifth intercostal space, and the third one on the scapular line, at the eighth intercostal space level. A 5 mmHg CO2 pneumothorax was created to collapse the right lung. Using a 3.8 mm arthroscope with a wide angle lens, dissecting forceps, and a 3 mm aspiration cannula, multiple fibrin partitions were released, and abundant chyle that was trapped in them was drained. After the right pleural cavity was unified, the thoracic duct was identified. It was composed of a main and an accessory trunk that were both dissected, clamped, and sectioned with 5 mm polymer ligating clips. The esophagus was entirely dissected. The thoracic aorta was dissected too, until a particular area of the mediastinal pleura was found, allowing passage to the left hemithorax. Fibrin cysts and partitions were released and chylous content was evacuated, unifying the left pleural cavity. Finally, talcum powder was spread homogeneously on the parietal and the visceral membranes of both pleural cavities and a 12F pleural drainage was placed in each hemithorax. Results and Conclusions: The patient showed improvement and the chylothorax has not reappeared. Video-assisted surgery of refractory cases of bilateral chylothorax is feasible and can be performed safely and effectively using one-sided thoracoscopy. No competing financial interests exist. Runtime of video: 2 mins 14 secs