Find best premium and Free Joomla templates at GetJoomlaTemplatesFree.com

Chylothorax after primary repair of esophageal atresia and tracheo-esophageal fistula: successful management by biological fibrin glue

Dhua A. K., Ratan S. K., Aggarwal S. K.
Department of Pediatric Surgery, Maulana Azad Medical College, Delhi

 

Correspondence

AK Dhua, MD
B1 Plot no 724, Shakti khand IV, Indirapuram, Ghaziabad
Uttarpradesh 201010, India
Mob No: 9871568690
E mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

Abstract
We report a newborn that developed right sided chylothorax after repair of an esophageal atresia with tracheo-esophageal fistula. The chylothorax was treated successfully by fibrin glue application.

Key words: chylothorax, esophageal atresia, fibrin glue

 

Introduction

Chylothorax, as a complication of surgery for esophageal atresia is rare. We report a newborn that developed right sided chylothorax after repair of an esophageal atresia (AE) with tracheo-esophageal fistula (TEF). The chylothorax was treated successfully by fibrin glue application.

Case Report

A preterm (34 weeks) male baby underwent a primary repair of esophageal atresia with tracheo-esophageal fistula through a standard 4th space extra-pleural approach on the right chest at another hospital. The operation was reportedly uneventful. An intercostal chest drain and a trans-anastomotic tube were placed. On the 8th day the patient developed respiratory distress with decreased air entry in the right hemi thorax. Chest radiograph showed radiopaque shadow on the right hemithorax suggestive of effusion (fig. 1). Chest tube revealed white milky fluid. A diagnosis of anastomotic leak was suspected and conservative management was followed for the next 17 days. Feeds were continued through the trans-anastomotic tube, but the chest tube continued draining. On the 26th day a re-exploration was planned because of failed conservative treatment. However, on parents request the baby was referred to us for further management.

7.1.20

Figure 1. Effusion in the right hemi thorax

Patient was admitted in NICU. She weighed 1030g (fig. 2). Patient was hemodynamically stable. A chest tube, which was removed earlier, was reinserted and started draining serous fluid. Blood investigations showed Hb 13 g/dl, leucocytes 15000/ml. A sepsis screen was positive. Gavage feeding was started. The following day the output from the chest tube increased and it became cloudy. Biochemical analysis of the fluid showed 661.5 mg/dl of Triglycerides against a serum triglyceride level of 104.5 mg/dl. A diagnosis of chylothorax was made. The baby had already received Ceftriaxone and Meropenem. Meropenem was continued. Blood culture did not grow any organism. For the next four days the chest drain produced more than 70 ml fluid per day. Prolonged starvation could not be resorted to as the baby was already in a catabolic phase. Total parenteral nutrition was not considered useful as the child had already spent almost four weeks in the hospitals and was on antibiotics for nearly the entire period; septic complications of TPN were thought to be too risky.

7.1.21

Figure 2. Clinical aspect at admission at NICU

Right postero-lateral thoracotomy under GA was performed on the 7th day of admission. A transpleural approach was used. The anastomosis was intact. Clear lymphatic fluid was leaking from the mediastinum diffusely below the anastomosis. No clear leaking point could be identified. Two milliliters of fibrin sealant was applied over the mediastinum. The clot covered the entire mediastinum and the lymphatic leak stopped. A chest tube of size 10Fr was left and the thorax closed. Post operatively the baby was electively ventilated for three days. The chest drain produced 10 ml serous fluid in the first 24 hours but remained dry subsequently.

Gavage feeding was started on the fifth post operative day and gradually increased to bring the baby on full enteral feeds on the 10th day. The chest tube was then removed. Chest radiograph showed both lungs inflated (fig. 3). Weight gain was documented. However, the baby became oxygen dependent. She required to be put on a ventilator as she would not maintain saturation on spontaneous breathing. A flexible bronchoscopy revealed tracheo-bronchomalcia. An aortopexy was planned but the child developed pneumonitis and septicemia and expired 45 days after our surgery.

7.1.22

Figure 3. Thoracic X ray at day 10 post-operative

Discussion

Chylothorax is the accumulation of lymphatic fluid in the pleural space that usually occurs after injury to the thoracic duct (surgery or trauma) or in association with various medical conditions including neoplasm, lymphatic abnormality or a congenital abnormality [1, 2]. With the increasing complexity of cardiothoracic surgery in infants and children, post-operative chylothorax has become the most common cause of chylothorax in tertiary pediatric hospitals and an important cause of morbidity and prolonged hospitalization [3].

Conservative treatment includes keeping the child starved or giving enteral MCT (medium chain triglycerides) with or without intravenous alimentation. This treatment had failed in our baby. Initial misdiagnosis (as a leak) resulted in a delay of about 2 weeks in instituting aggressive conservative management of chylothorax. During this period the baby had lost weight and had become septic. Therefore, a prolonged medical management was not considered worthwhile. Components of usual surgical treatment are: treatment of the underlying cause, decreasing chyle production, draining and obliterating the pleural space, suture closure of thoracic duct or application of sealing agents, providing appropriate fluid and nutritional replacement, and instituting necessary respiratory care.

The timing of surgical management is controversial and depends on the etiology of the chylothorax and the patient’s overall condition [4]. Usually, surgical therapy is reserved for cases with persistent and/or high volume lymph leak not resolved within 4 weeks of conservative management. Various surgical procedures have been described including direct ligation of the thoracic duct [5] pleurodesis with different agents including application of fibrin glue to putative sites of leaks [6, 7] and placement of a pleuro-peritoneal shunt [8, 9].Congenital chylothorax has been successfully treated by fibrin glue [10]. A management scheme of postoperative chylothorax for children has been described in detail by Panthongviriyakul and Bines [11].

Among all surgical options, application of fibrin glue appears to be an attractive option in high risk re-operative cases like neonates. It is quick, safe, effective and easy for the novice. Its efficacy has been shown in postoperative chylothorax cases. Nguyen and Tchervenkov [7] in 1994 have reported successful application of fibrin glue in a 600g premature neonate. Chylothorax had developed following a cardiovascular operation. There are scanty reports in English literature on the use of fibrin glue for chylothorax in neonates as a complication of oesophageal atresia repair. Rifai et al [12] in 2003 successfully treated chylothorax in a post surgical case of esophageal atresia by a combination of argon beam coagulation of the mediastinum and fibrin glue application. Ours is perhaps the only case treated solely by Fibrin Glue.

Conclusion

High index of suspicion is necessary for diagnosing chylothorax in postoperative effusions developing after thoracic surgeries. The diagnosis may be confused with anastomotic leak in EA/TEF. Prompt treatment should be initiated with conservative methods. At surgery it is unlikely that a solitary leak site would be found. The leak is likely to be diffuse. Application of topical Fibrin Glue seems a safe and easy approach.

 

 

References

1. Doerr CH, Allen MS, Nichols FC III, Ryu JH. Etiology of chylothorax in 203 patients. Mayo Clin Proc 2005; 80: 867–70.

2. Beghetti M, La Scala G, Belli D, Bugmann P, Kalangos A, Le Coultre C. Etiology and management of pediatric chylothorax. J Pediatr 2000; 136: 653–8.

3. Le Coultre C, Oberhansli I, Mossaz A, Bugmann P, Faidutti B, Belli DC. Postoperative chylothorax in children: differences between vascular and traumatic origin. J Pediatr Surg 1991; 26: 519–23.

4. Paul S, Altorki NK, Port JL, Stiles BM, Lee PC. Surgical management of chylothorax. Thorac Cardiovasc Surg 2009; 57(4):226-8.

5. Patterson GA, Todd TR, Delarue NC, Ilves R, Pearson FG, Cooper JD. Supradiaphragmatic ligation of the thoracic duct in intractable chylous fistula. Ann. Thorac. Surg 1981; 32: 44–9.

6. Stenzl W, Rigler B, Tscheliessnigg KH, Beitzke A, Metzler H. Treatment of postsurgical chylothorax with fibrin glue. Thorac Cardiovasc Surg 1983; 31: 35–6.

7. Nguyen D, Tchervenkov CI. Successful management of postoperative chylothorax with fibrin glue in a premature neonate. Can J Surg 1994; 37:158–60.

8. Azizkhan RG, Canfield J, Alford BA, Rodgers BM. Pleuroperitoneal shunts in the management of neonatal chylothorax. J Pediatr Surg 1983;18: 842–50.

9. Rheuban KS, Kron IL, Carpenter MA, Gutgesell HP, Rodgers BM. Pleuroperitoneal shunts for refractory chylothorax after operation for congenital heart disease. Ann Thorac Surg 1992; 53: 85–7.

10. Mathur NB, Singh B, Kumar A, Aggarwal SK. Successful Treatment of Congenital Chylothorax Using Fibrin Glue. Indian J Pediatr 2009; 76:758.

11. Panthongviriyakul C, Bines JE. Post-operative chylothorax in children: an evidence-based management algorithm. J Paediatr Child Health 2008; 44(12):716-21.

12. Rifai N, Sfeir R, Rakza T, Alameh J, Besson R, Lequien P, Storme L. Successful management of severe chylothorax with argon plasma fulguration and fibrin glue in a premature infant. Eur J Pediatr Surg 2003; 13(5):324-6.