Successful Management of Postoperative Chylothorax in a Neonate after Coarctation Repair

This is a 3.8 kg, 6-day old neonate whose initial presentation was a cardiogenic shock secondary to ductal closure. Upon admission, prostaglandins was initiated and the neonate was stabilized. Echocardiography and Computed tomography scan showed critical coarctation with severe arch hypoplasia and a paramembranous ventricular septal defect. One-stage repair via median sternotomy was performed where an extended end-to-end repair of the aortic coarctation was performed with pulmonary homograft patch augmentation of the anastomosis anteriorly, in addition to closure of the ventricular septal defect. The chest was closed 24 hours later and chest drains were removed 72 hours later. The initial postoperative course was uneventful till the 10th postoperative day where a significant right sided effusion was noticed on the chest x-ray. A right-sided chest tube was placed with drainage of clear serous fluids. Due to the large amount of daily drainage, analysis of the pleural fluid was performed and confirmed elevated triglycerides and chylomicrons levels in the fluid. Initial conservative measures included nothing per os status, total parenteral nutrition and octreotide infusion. We proceeded with extubation of the child as planned on the 14th postoperative day. There was no improvement in the chest tube drainage (200 ml/day). Decision was made to proceed to the operating room for thoracic duct ligation.

After induction of general endotracheal anesthesia, and placement of the routine monitoring lines, 0.9 mg of indocyanine green was injected subcutaneously in each groin (0.3 mg/site, three injection /groin) and the groin was gently massaged. The child was then positioned in the left lateral decubitus position and the right chest was entered through a right lateral thoracotomy along the 6th intercostal space. The right lung was retracted and the posterior mediastinum was exposed. The thoracic duct was identified easily in the space between the aorta, azygous vein and the spine. This was greatly facilitated with the hand-held near-infrared probe and the injected indocyanine green. The duct was doubly ligated and a segment was resected and sent for pathological examination which confirmed absence of a muscle layer. Topical pleurodesis was performed with Doxycycline and a chest drain was placed and the incision was closed in the standard fashion. The child was extubated in the operating room.

The remaining postoperative course was uneventful. The drainage from the chest tube was significantly less. Breast milk feeding was initiated 48 hours later and the chest tube was removed 72 hours later. The child was discharged about a month after the initial procedure.

This demonstrates the usefulness of intraoperative fluorescence angiography using indocyanine green to facilitate thoracic duct localization and ligation with high degree of accuracy and success.

We are not aware of similar reports in neonates after cardiac surgery. The technique is safe and reproducible and may have the potential to change timing of intervention in such challenging cases which may have the potential to shorten the hospital stay and decrease morbidities.

References

1. Vecchiato M, Martino A, Sponza M, Uzzau A, Ziccarelli A, Marchesi F, Petri R. Thoracic duct identification with indocyanine green fluorescence during minimally invasive esophagectomy with patient in prone position. Dis Esophagus. 2020 May 25:doaa030.
2. Chakedis J, Shirley LA, Terando AM, Skoracki R, Phay JE.Identification of the Thoracic Duct Using Indocyanine Green During Cervical Lymphadenectomy. Ann Surg Oncol. 2018 Nov;25(12):3711-3717
3. Shirotsuki R, Uchida H, Tanaka Y, Shirota C, Yokota K, Murase N, Hinoki A, Oshima K, Chiba K, Sumida W, Hayakawa M, Tainaka T. Novel thoracoscopic navigation surgery for neonatal chylothorax using indocyanine-green fluorescent lymphography.
4. J Pediatr Surg. 2018 Jun;53(6):1246-1249

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