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. 2010 Dec 13:5:127.
doi: 10.1186/1749-8090-5-127.

Chylothorax after surgery on congenital heart disease in newborns and infants -risk factors and efficacy of MCT-diet

Eva S Biewer  1 , Christoph Zürn, Raoul Arnold, Martin Glöckler, Jürgen Schulte-Mönting, Christian Schlensak, Sven Dittrich
Affiliations

Chylothorax after surgery on congenital heart disease in newborns and infants -risk factors and efficacy of MCT-diet

Eva S Biewer et al. J Cardiothorac Surg. .

Abstract

Objectives: To analyze risk factors for chylothorax in infants after congenital heart surgery and the efficacy of median chain triglyceride diet (MCT). To develop our therapeutic pathway for the management of chylothorax.

Patients and methods: Retrospective review of the institutional surgical database and patient charts including detailed perioperative informations between 1/2000 and 10/2006. Data analyzing with an elimination regression analysis.

Results: Twenty six out of 282 patients had chylothorax (=9.2%). Secondary chest closure, low body weight, small size, longer cardiopulmonary bypass (242 ± 30 versus 129 ± 5 min) and x-clamp times (111 ± 15 versus 62 ± 3 min) were significantly associated with chylothorax (p < 0.05). One patient was cured with total parenteral nutrition (TPN) and one without any treatment. 24 patients received MCT-diet alone, which was successful in 17 patients within 10 days. After conversion to regular alimentation within one week only one chylothorax relapsed. Out of 7 patients primarily not responsive to MCT-diet, 2 were successfully treated by lysis of a caval vein thrombosis, 2 by TPN + pleurodesis + supradiaphragmatic thoracic duct ligation, one by octreotide treatment, and two patients finally died.

Conclusions: Chylothorax may appear due to injury of the thoracic duct, due to venous or lymphatic congestion, central vein thrombosis, or diffuse injury of mediastinal lymphatic tissue in association with secondary chest closure. Application of MCT alone was effective in 71%, and more invasive treatments like TPN should not be used in primary routine. After resolution of chylothorax, MCT-diet can be converted to regular milk formula within one week and with very low risk of relapse.

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Figures

Figure 1
Figure 1
Management of 26 patients with chylothoraces. Chylothoraces were first-line treated with MCT-diet, which was effective in 71%. All patients but one tolerated rapid conversion to regular nutrition formula within 1 week after the chylothorax had disappeared. In 4 patients different additional treatments were effective. Two patients (grey setting box), both with low cardiac output and persistent capillary leackage died with remaining chylothorax despite numerous treatment attempts.
Figure 2
Figure 2
Recommendation for the management of chylothorax. Possibly treatable causes for chylothorax should be ruled out or treated before symptomatic therapy is started. Before more invasive and long-lasting therapies are started, one attempt to treat chylothorax with MCT-diet should be done (efficacy to treat chylothorax is 70% within acceptable treatment period). Abbr.: MCT = fatty acid-free MCT-enriched diet; TPN = total parenteral nutrition.
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