Lymphovenous Bypass for the Management of Intractable Chylothorax in Infants: A Novel Surgical Approach to aDevastating Problem
Jason Weissler, Martin Carney, Peter Koltz, L. Scott Levin, Suhail Kanchwala, Stephen Kovach.
University of Pennsylvania, Philadelphia, PA, USA.
BACKGROUND: In the emerging field of lymphedema surgery, clinical initiatives have unveiled new avenues in support of novel microsurgical techniques. Pulmonary lymphangioectasia and traumatic lymphatic disease have traditionally been managed with obliteration of the abnormal lymphatic pathways through surgical ligation or catheter-embolization. However, when traditional treatment modalities fail to achieve chyle leak resolution, opportunities for salvage have been dismal. To date, there have been no descriptions of microsurgical techniques in the algorithm for this devastating problem. Herein, we introduce a lymphaticovenous bypass technique for the management of persistent chylothoraces in infants. METHODS: A single-institution retrospective review was performed in effort to identify patients with clinically-significant persistent chylothoraces. Only patients who failed or were not candidates for embolization were included. Outcome measures included anastomotic patency, resolution of chylothorax, and complication-profile.
RESULTS: Two patients met inclusion criteria, accounting for three operations. The first patient was a 6-week-old male who developed left subclavian vein thrombosis and thoracic duct occlusion following operations to repair his congenital-heart-disease (CHD). Given that the thrombus was not amenable to thrombolysis, and the development of bilateral pleural effusions, a lymphaticovenous anastomosis was performed between the thoracic duct and a small vein in the neck. Lymphangiography 1-week postoperatively revealed patent flow, resolution of chylous ascites, and near complete resolution of collateral flow. The second patient (4-month-old male) suffered a thoracic duct transection during cardiac surgery for CHD. He underwent a lymphaticovenous anastomosis between a lymphatic conduit in the neck and the external jugular vein, which subsequently became obstructed. A successful reoperation was performed 18-days later during which the vein was re-anastomosed to a larger portion of the thoracic duct. Lymphangiography at 2-weeks confirmed patent anastomosis. CONCLUSIONS: Although thoracic duct embolization resolves chylothoraces in nearly three-quarters of patients, there remains a role for lymphovenous surgical bypass using microsurgical technique.
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