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 chylothorax

N = 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 disease

Jan, 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 Operation

Interval

(OP-

TDML)

PE

sided

ness

Successful

resolution

15m/2.9k

g

Prematurity

(GA 23+5wks,

570g)

ASD ASD

closure110 d Left Y

213d/3.6

kg

Situs inversus,

DextrocardiaTGA, VSD

ASO, VSD

closure3 d Left Y

37d/3.1k

g

Lt. isomerism,

Dextrocardia

FSV (c-AVSD,

ccTGA, MA)AVVP 11 d Left Y

1st Rt. TDL 2nd Lt. TDL

Age/Wt.

(kg)Diagnosis Operation

Preop

PE

Op-1st

TDML

Interval

Postop

PE

1st-2nd

TDML Interval

Successful

resolution

1 12m/8.5 PA with VSDOne-and-a-

half repairL(B) 23d L(B) 19d Y

2 10m/8.1FSV(DORV, MA,

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

3 12d/2.4 CoA with VSDAnterior tota

l repair L(B) 20d L(B) 3d Y

4 9d/2.5T-B anomaly,

Arch hypoplasia

Anterior

total repair L(B) 16d L(B) 4d Y

5 14d/2.6 dTGA with VSDASO, VSD

closureR 14d R 7d Y

6 10d/3.2 dTGA with VSDASO, VSD

closureL 11d L 7d Y

7 0d/2.8Infracardiac

TAPVR

TAPVR

repairR(B) 21d R(B) 2d Y

8 9d/3.4 dTGA with VSDASO, VSD

closureL(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

0

20

40

60

80

100

120

Both

Left

Right

P=0.02

RT group LT group RT group LT group

0

20

40

60

80

100

120

Both

Left

Right

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)

P

value

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

physician’s decision

Pleural effusion(drain >50mL/Kg/day)

(Milky drainage)

14 days

Conservative Tx(MCT diet / NPO /

Octreotide/ Pleurodesis)

Pleural effusion

> 50mL/kg/day

7 days

Right

TDML

7 days

Conservative

treatment

Pleural effusion

> 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)

P

value

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

Chyloperitoneum

Age/Wt. Group SVC obstruction Resolution Cause of death

1 16d/2.5kg RT Y N Sepsis

2 30d/2kg RT N NCapillary leak

syndrome

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 removal

Characteristics Total (n=5)

sepsis 2

capillary leak syndrome 2

LCOS 1

Age/Wt. Characteristic Group

SVC

obstructionChyloperitoneum

Cause of death

120d/

1kg

Prematurity

(GA 35+5wks,

960g)

RT N NCapillary leak

syndrome

22d/3.4k

gRT Y Y

Capillary leak

syndrome

37d/2.9k

gNEC LT Y N Sepsis

440mo/1

6.3kgLT Y N Sepsis

519d/

3.2kg

Pulmonary

overflowRT N N LCOS

6 Deaths after chest tube removal

Characteristics Total (n=6)

sepsis 3

capillary leak syndrome 3

Age/Wt. Group SVC obstruction Chyloperitoneum Cause of death

1 6d/ 3kg RT N NCapillary leak

syndrome

2 16d/2.5kg RT Y Y Sepsis

3 30d/2kg RT N YCapillary leak

syndrome

4 7d/3.1kg LT Y NCapillary 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 diagnosis

P-value 0.04