Anatomic variability of the thoracic duct in pediatric patients with complex

congenital heart disease

Ji Hyun Bang, Chun Soo Park, Jeong-Jun Park, Tae-Jin Yun

Asan Medical Center, Seoul, Korea

Ji Hyun Bang

Introduction

Introduction

TD mass ligation (TDML) via Rt. thoracotomy

This procedure may NOT be Successful !!

3 treatment failure / 4 TDML Chan et al. ATS 2005

2 treatment failure 2 recurrence / 20 TDML Nath et al. ATS 2009

Standard procedure for chylothorax (regardless of the side of pleral effusion)

Introduction

Hypothesis

Standard treatment failure is attributed to the anatomic

variations of the TD!

Introduction

Reverse course Bilateral course

25-30% of patients have variations in the course of the TD

Persistent Left SVC Chen et al. Clin Anat. 2006

Aberrant Right subclavian artery

Okumura et al. Acta Anat. 1974

Right sided aortic arch

Nathan et al. Acta Anat. 1983

Anatomic variations of the Thoracic duct are associated with

Introduction

To review the outcomes of TDML through right thoracotomy

To determine the risk factors requiring additional left-sided approach

Purpose of the Study

Standard treatment failure necessitate additional left peri-aortic Mass ligation.

Left peri-aortic mass ligation

TDML for Persistent / massive chylothoraxN = 70

Death

N = 3

Additional LT

N = 10

Initial LT

N = 3

Successful resolution

N = 8

Death

N = 2

Successful resolution

N = 3

Successful resolution

N = 54

Initial RT

N = 67RT group

LT group

LT group

OHS for congenital heart diseaseJan, 1992 – Jul, 2014

N = 8,880

RT-group 54 : LT-group 11

Charateristics of Left peri-aortic mass ligation

Initial Left TDML

Age/Wt. Characteristics Diagnosis OperationInterval

(OP-TDML)

PE sid-ed-

ness

Successful resolution

1 5m/2.9kg

Prematurity(GA 23+5wks,

570g)ASD ASD clo-

sure 110 d Left Y

2 13d/3.6kg

Situs inversus, Dextrocardia TGA, VSD ASO, VSD

closure 3 d Left Y

3 7d/3.1kg

Lt. isomerism, Dextrocardia

FSV (c-AVSD, ccTGA, MA) AVVP 11 d Left Y

1st Rt. TDL 2nd Lt. TDL

Age/Wt.(kg)

Diagnosis OperationPreop PE

Op-1st TDML

Interval

Postop PE

1st-2nd TDML In-

terval

Successful resolution

1 12m/8.5 PA with VSDOne-and-a-half repair L(B) 23d L(B) 19d Y

2 10m/8.1 FSV(DORV, MA, PS)

BCS L(B) 20d L(B) 15d Y

3 12d/2.4 CoA with VSDAnterior to-tal repair L(B) 20d L(B) 3d Y

4 9d/2.5 T-B anomaly, Arch hypoplasia

Anterior to-tal repair L(B) 16d L(B) 4d Y

5 14d/2.6 dTGA with VSDASO, VSD

closure R 14d R 7d Y

6 10d/3.2 dTGA with VSDASO, VSD

closure L 11d L 7d Y

7 0d/2.8 Infracardiac TAPVR

TAPVR re-pair R(B) 21d R(B) 2d Y

8 9d/3.4 dTGA with VSDASO, VSD

closure L(B) 14d L(B) 2d Y

VariablesTotal (n=65)

RT group (n=54) LT group (n=11)P

value

Male gender, n (%) 45 (69%) 38 (70%) 7 (64%) 0.73

Age at Op. (days), median (range) 172 (0-1856) 199 (0-1856) 12 (0-351) 0.03

Bwt at Op. (kg), median (range) 6 (1.5-15.3) 6 (1.5-15.3) 3 (2.4-8.5) 0.02

Biochemical nature of pleural effusion

Cholesterol (mg/dl) 40 (10-198) 38 (10-198) 47 (22-69) 0.32

Triglyceride (mg/dl) 237 (18-3565) 234 (18-3565) 297 (36-2187) 0.38

Types of initial operation

Fontan operation, n (%) 8 (12.3) 8 (14.8) 0 (0.0) 0.33

BCS, n (%) 12 (18.5) 11 (20.4) 1 (9.1) 0.67

TOF total correction, n (%) 9 (13.8) 9 (16.7) 0 (0.0) 0.34

Arterial switch operation, n (%) 9 (13.8) 4 (7.4) 5 (45.4) 0.02

TAPVR repair, n (%) 7 (10.8) 6 (11.1) 1 (9.1) 0.66

Aortic arch repair, n (%) 5 (7.7) 4 (7.4) 1 (9.1) 0.27

Rastelli operation, n (%) 3 (4.6) 3 (5.6) 0 (0.0) 0.57

One and a half ventricle repair, n (%) 3 (4.6) 2 (3.7) 1 (9.1) 0.43

Others (n, %) 9 (13.8) 7 (13.0) 2 (18.1) 0.22

CPB time (median and range, min) 117 (21-446) 113 (21-446)140 (60-301)

0.10

ACC time (median and range, min) 51 (0-174) 51 (0-145) 73 (0-174) 0.07

Pre-TDL sidedness of pleural effusion Post-TDL sidedness of pleural effusion

Results

Series10

20

40

60

80

100

120

BothLeftRight

P=0.02

RT group LT group RT group LT groupSeries1

0

20

40

60

80

100

120

BothLeftRight

P=0.001

Results

Pre-TDML drainage of the pleural effusion Post-TDML drainage of the pleural effusion

VariablesTotal (n=65)

RT-group (n=54)

LT-group(n=11)

Pvalue

Dextrocardia 6 (9.2%) 3 (5.6%) 3 (27.3%) 0.05

Atrial situs 0.23

Solitus 58 (89.2%) 49 (90.7%) 9 (81.8%)

Rt. isomerism 3 (4.6%) 3 (5.6%) 0 (0.0%)

Lt. isomerism 3 (4.6%) 2 (3.7%) 1 (9.1%)

Inversus 1 (1.5%) 0 (0.0%) 1 (9.1%)

Bilateral SVC 10 (15.4%) 7 (13.0%) 3 (27.3%) 0.22

Great arterial relationship 0.08

Normal 42 (64.6%) 38 (70.4%) 4 (36.4%)

d-TGA 9 (13.8%) 5 (9.3%) 4 (36.4%)

l-TGA 5 (7.7%) 4 (7.4%) 1 (9.1%)

side by side 9 (13.8%) 7 (13.0%) 2 (18.2%)

Rt. descending aorta 7 (10.8%) 5 (9.3%) 2 (18.2%) 0.34

Aberrant Rt.SCA 4 (6.2%) 3 (5.6%) 1 (9.1%) 0.53

Risk factor analyses for left sided approach

Variables OR 95%CIP

valueOR 95%CI

P value

Abnormal Atrial situs 2.18 0.37-13.00 0.39

GA malposition 3.81 0.98 - 14.78 0.05

Dextrocardia 6.38 1.09 – 37.25 0.04 6.38 1.09 – 37.25 0.04

Bilateral SVC 2.52 0.53 – 11.82 0.24

CPB times 1.004 0.99 – 1.01 0.21

OP Body Weight 0.88 0.73 – 1.07 0.21

OP age 0.99 0.99 – 1.001 0.21

Conclusion

Standard right TDML for chylothorax is frequently

unsuccessful.

In case of standard treatment failure, Left peri-

aortic mass ligation could be considered.

Scheme of Treatment

Open heart surgery for congenital heart disease

10 days

Pleural fluid analysis (TG>110mg/dl) Buttiker et al.

According to physi-cian’s decision

Pleural effu-sion(drain >50mL/Kg/day)(Milky drainage)

14 days

Conservative Tx(MCT diet / NPO / Octreotide/ Pleu-rodesis)

Pleural effu-sion > 50mL/kg/day

7 days

Right TDML

7 days

Conserva-tive treat-ment

Pleural effu-sion > 50mL/kg/day

Left TDML

Pleurodesis

• Chemical pleurodesis – 13 / 65 patients

preop - 3 pts (median: 13, range: 3-16)

intraop - 6 pts

postop - 4 pts (median:13.5, range: 5-19)

minocyclin 10mg/kg * 1-3 cycle

• Mechanical pleurodesis – 14 / 65 patients

SVC obstruction or stenosis

Variables OR 95%CI P value

SVC obstruction 3.8 0.88-16.6 0.07

Risk factors for left sided approach

VariablesTotal (n=65)

Right TDL (n=54)

Left TDL(n=11)

Pvalue

SVC obstruction 11 (16.9%) 7 (13.0%) 4 (36.4%) 0.08

ChyloperitoneumAge/Wt. Group SVC obstruction Resolution Cause of death

1 16d/2.5kg RT Y N Sepsis

2 30d/2kg RT N N Capillary leak syn-drome

3 40mo/12kg RT N Y Alive

4 12d/2.4kg LT N Y Alive

5 47d/3.2kg RT N Y Alive

6 23d/3.2kg RT N Y Alive

7 0d/2.8kg LT N Y Alive

8 9d/ 3.4kg LT Y Y Alive

Efficacy and Safety of Thoracic duct ligation

Characteristics Number of patients

(N=70)

Chylothorax resolution 65

Death before chest tube removal 5

In-hospital death after chylothorax resolution 6

Recurrence 0

Chyloperitoneum 9

Chylopericardium 13

5 Deaths before chest tube removalCharacteristics Total (n=5)

sepsis 2

capillary leak syndrome 2

LCOS 1

Age/Wt. Characteristic GroupSVC ob-struction Chyloperitoneum Cause of death

1 20d/ 1kg

Prematurity(GA 35+5wks,

960g)RT N N Capillary leak

syndrome

2 2d/3.4kg RT Y Y Capillary leak

syndrome

3 7d/2.9kg NEC LT Y N Sepsis

4 40mo/16.3kg LT Y N Sepsis

5 19d/ 3.2kg

Pulmonary overflow RT N N LCOS

6 Deaths after chest tube removalCharacteristics Total (n=6)

sepsis 3

capillary leak syndrome 3

Age/Wt. Group SVC obstruction Chyloperitoneum Cause of death

1 6d/ 3kg RT N N Capillary leak syndrome

2 16d/2.5kg RT Y Y Sepsis

3 30d/2kg RT N Y Capillary leak syndrome

4 7d/3.1kg LT Y N Capillary leak syndrome

5 9d/ 2.5kg LT N N Sepsis

6 14d/2.6kg LT Y N Sepsis

Results

Open heart surgery for congenital heart disease

Start

10 (2 - 86) d

13 (0 – 34) d

Right TDML

Left TDML

Total

RT

LT

9 (2 - 74) d

10 (4 – 86) d

9 (2 - 74) d

7 (2 -34) d 7 (2 - 19) d

0.78

Chylothorax diag-nosis

P-value

0.04