Ann Thorac Surg 2006;82:767-768
© 2006 The Society of Thoracic Surgeons
Correspondence
Diaphragmatic Fenestration for Resistant Chlyothorax
Sachin Talwar, MCh,
Shiv Kumar Choudhary, MCh,
Balram Airan, MCh
Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, 110029 India
(Email: shivchoudhary{at}hotmail.com).
To the Editor:
We read with interest the article by Chan and colleagues [1] on postoperative chylothorax in children. Thoracic duct ligation was undertaken in 4 of their patients with failed conservative management. However, in 3 of their 4 patients, the drainage persisted. We concur with them that thoracic duct ligation may reduce the amount of chylous drainage, but may not completely abolish it. The usual finding on thoracotomy at the time of thoracic duct ligation in these patients is a diffuse oozing from the pleural surface rather than a localized leak that renders thoracic duct ligation alone at the level of diaphragm inadequate. In such a setting, we have found that addition of diaphragmatic fenestration may be helpful.
Earlier we published our successful experience with diaphragmatic fenestration using a polypropylene mesh in a 12-year-old patient to manage resistant pleural effusion after univentricular repair [2]. Recently a 5-year-old patient who had undergone a total cavopulmonary connection and had prolonged left-sided chylothorax develop postoperatively was managed successfully by thoracic duct ligation and diaphragmatic fenestration.
After a standard posterolateral thoracotomy through the fifth intercostal space, it was observed that there was diffuse lymphatic ooze from the pleural surface without a discreet lymphatic leak. All the loculi and adhesions were released. The thoracic duct was ligated at the level of the diaphragm. An opening 4 cm x 3 cm was made in the left dome of the diaphragm. An appropriately sized polytetrafluoroethylene patch was taken and multiple 4-mm punch holes were made in the patch. After this the patch was sutured to the margins of the defect in the diaphragm using a continuous polypropylene suture, and the wound was closed after placing a drainage tube. Postoperative recovery was uneventful; the drainage tube was removed on postoperative day 4, and the patient was discharged home. At a 4-month follow-up there was no pleural collection or ascites, and the patient was doing well.
We believe that diaphragmatic fenestration is a useful adjunct to thoracic duct ligation in managing these patients when conventional modes of therapy have failed, as it reduces the amount of chylous drainage with its resultant morbidity, and it also significantly reduces the duration of hospitalization.
 |
References
|
|---|
- Chan EH, Russell JL, Williams WG, Arsdell GS, Coles JG, McCrindle BW. Postoperative chylothorax after cardiothoracic surgery in children Ann Thorac Surg 2005;80:1864-1871.[Abstract/Free Full Text]
- Durariraj M, Sharma R, Choudhary S, Bhan A, Venugopal P. Diaphragmatic fenestration for resistant pleural effusions after univentricular repair Ann Thorac Surg 2002;74:931-932.[Abstract/Free Full Text]
Top
References