anatomic variability of the thoracic duct in pediatric patients with complex congenital heart...
TRANSCRIPT
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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
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Ji Hyun Bang
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Introduction
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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)
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Introduction
Hypothesis
Standard treatment failure is attributed to the anatomic
variations of the TD!
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Introduction
Reverse course Bilateral course
25-30% of patients have variations in the course of the TD
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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
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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.
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Left peri-aortic mass ligation
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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
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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
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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
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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
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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
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Results
Pre-TDML drainage of the pleural effusion Post-TDML drainage of the pleural effusion
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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
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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
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Conclusion
Standard right TDML for chylothorax is frequently
unsuccessful.
In case of standard treatment failure, Left peri-
aortic mass ligation could be considered.
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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
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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
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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
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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
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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
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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
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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
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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