Neonatal Chylothorax and Early Fluid Overload After Cardiac Surgery: Retrospective Analysis of the Neonatal and Pediatric Heart and Renal Outcomes Network Registry (2015-2018).

OBJECTIVES: To evaluate the association between postoperative cumulative fluid balance (FB) and development of chylothorax in neonates after cardiac surgery. DESIGN: Multicenter, retrospective cohort identified within the Neonatal and Pediatric Heart and Renal Outcomes Network (NEPHRON) Registry. SETTING: Twenty-two hospitals were involved with NEPHRON, from September 2015 to January 2018. PATIENTS: Neonates (< 30 d old) undergoing index cardiac operation with or without cardiopulmonary bypass (CPB) entered into the NEPHRON Registry. Postoperative chylothorax was defined in the Pediatric Cardiac Critical Care Consortium as lymphatic fluid in the pleural space secondary to a leak from the thoracic duct or its branches. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of the 2240 NEPHRON patients, 4% ( n = 89) were treated for chylothorax during postoperative day (POD) 2-21. Median (interquartile range [IQR]) time to diagnosis was 8 (IQR 6, 12) days. Of patients treated for chylothorax, 81 of 89 (91%) had CPB and 68 of 89 (76%) had Society of Thoracic Surgeons-European Association for Cardiothoracic Surgery Congenital Heart Surgery 4-5 operations. On bivariate analysis, chylothorax patients had higher POD 1 FB (3.2 vs. 1.1%, p = 0.014), higher cumulative POD 2 FB (1.5 vs. -1.5%, p < 0.001), achieved negative daily FB by POD 1 less often (69% vs. 79%, p = 0.039), and had lower POD 1 urine output (1.9 vs. 3. 2 mL/kg/day, p ≤ 0.001) than those without chylothorax. We failed to identify an association between presence or absence of chylothorax and peak FB (5.2 vs. 4.9%, p = 0.9). Multivariable analysis shows that higher cumulative FB on POD 2 was associated with greater odds (odds ratio [OR], 95% CI) of chylothorax development (OR 1.5 [95% CI, 1.1-2.2]). Further multivariable analysis shows that chylothorax was independently associated with greater odds of longer durations of mechanical ventilation (OR 5.5 [95% CI, 3.7-8.0]), respiratory support (OR 4.3 [95% CI, 2.9-6.2]), use of inotropic support (OR 2.9 [95% CI, 2.0-4.3]), and longer hospital length of stay (OR 3.7 [95% CI, 2.5-5.4]). CONCLUSIONS: Chylothorax after neonatal cardiac surgery for congenital heart disease (CHD) is independently associated with greater odds of longer duration of cardiorespiratory support and hospitalization. Higher early (POD 2) cumulative FB is associated with greater odds of chylothorax. Contemporary, prospective studies are needed to assess whether early fluid mitigation strategies decrease postoperative chylothorax development.

Chylothorax in newborns after cardiac surgery: a rare complication?

The aim of this study was to analyze patients diagnosed with chylothorax after congenital heart disease surgery among a cohort of neonatal patients, comparing the evolution, complications, and prognosis after surgery of patients who were and were not diagnosed with chylothorax, and to analyze possible risk factors that may predict the appearance of chylothorax in this population. Retrospective and observational study included all neonates (less than 30 days since birth) who underwent congenital heart disease surgery in a level III neonatal intensive care department. We included infants born between January 2014 and December 2019. We excluded those infants who were born before 34 weeks of gestational age or whose birth weight was less than 1800 g. We also excluded catheter lab procedures and patent ductus arteriosus closure surgeries. Included patients were divided into two groups depending on whether they were diagnosed with chylothorax or not after surgery, and both groups were compared in terms of perinatal-obstetrical information, surgical data, and NICU course after surgery. We included 149 neonates with congenital heart disease surgery. Thirty-one patients (20.8%) developed chylothorax, and in ten patients (32.3%), it was considered large volume chylothorax. Regarding the evolution of these patients, 22 infants responded to general dietetic measures, a catheter procedure was performed in 9, and 5 of them finally required pleurodesis. Cardiopulmonary bypass, median sternotomy, and delayed sternal closure were the surgical variables associated with higher risks of chylothorax. Patients with chylothorax had a longer duration of inotropic support and mechanical ventilation and took longer to reach full enteral feeds. As complications, they had higher rates of cholestasis, catheter-related sepsis, and venous thrombosis. Although there were no differences in neonatal mortality, patients with chylothorax had a higher rate of mortality after the neonatal period. In a multiple linear regression model, thrombosis and cardiopulmonary bypass multiplied by 10.0 and 5.1, respectively, the risk of chylothorax and have an umbilical vein catheter decreases risk. CONCLUSION: We have found a high incidence of chylothorax after neonatal cardiac surgery, which prolongs the average stay and causes significant morbidity and mortality. We suggested that chylothorax could be an underestimated complication of congenital heart disease surgery during the neonatal period. WHAT IS KNOWN: • Acquired chylothorax in the neonatal period usually appears as a complication of congenital heart disease surgery, being the incidence quite variable among the different patient series (2.5-16.8%). The appearance of chylothorax as a complication of a cardiac surgery increases both mortality and morbidity in these patients, which makes it a quality improvement target in the postsurgical management of this population. WHAT IS NEW: •Most of the published studies include pediatric patients of all ages, from newborns to teenagers, and there is a lack of studies focusing on neonatal populations. The main strength of our study is that it reports, to the best of our knowledge, one of the largest series of neonatal patients receiving surgery for congenital heart disease in the first 30 days after birth. We have found a high incidence of chylothorax after cardiac surgery during the neonatal period compared to other studies. We suggested that chylothorax could be an underestimated complication of congenital heart disease surgery during this period of life.

Chylothorax After Heart Surgery in Children.

Chylothorax is a consequence of a thoracic duct injury that can occur during surgical procedures in patients with congenital heart disease. It is associated with high rates of morbimortality and increased use of clinical and hospital resources. The aim of this study was to evaluate the risk factors, distribution, manifestations, complications, and treatments for chylothorax in patients undergoing cardiac surgery in a tertiary pediatric hospital in southern Brazil. This is a retrospective, quantitative study, in which all medical records (n = 166) of patients with chylothorax after pediatric cardiac surgery between January 2014 and December of 2020 and a matched control group (n = 166) were analyzed. Over the study period, there was an increase in incidence of chylothorax from 4.5% in 2014 to 7.6% in 2020, a trend that has been reported in the literature. After multivariate analysis, the following were identified as risk factors for the diagnosis of chylothorax: genetic syndrome (OR 2.298); prolonged cardiopulmonary bypass time (greater than 120 min) (OR 2.410); fluid overload in the immediate postoperative period (OR 1.110); and SIRS (OR 2.527). Mortality was two times greater (p = 0.021) and there was a higher rate (34.4%) of infection (p < 0.001) in patients who developed chylothorax. In addition, a sensitivity analysis was performed comparing patients with low- and high-output chylothorax (> 20 mL/kg), which confirmed unfavorable outcomes for the latter group. Herein, we show that hemodynamic alterations were important factors for diagnosis. Understanding the risk factors, outcomes, and complications helps early identification and enables the reduction of morbidity and mortality.

Predictors of Prolonged Pleural Effusion After the Extracardiac Fontan Procedure: A 8-Year Single-Center Experience in Resource-Scare Setting.

To date, despite improvement in survival rate following a Fontan operation, postoperative prolonged pleural effusion (PPE) has still remained a confounding complication of this procedure, which significantly contributes to morbidity and prolonged hospitalization. Our study aims to investigate risk factors associated with PPE after the extracardiac Fontan operation. From August 2012 to December 2019, we obtained clinical data from the medical records of 145 consecutive patients who were diagnosed with single-ventricle lesions and received an extracardiac Fontan operation at the E Hospital (Hanoi, Vietnam). PPE was defined as the need for a chest tube for > 14 days. Patients were divided into two groups, those with PPE (n = 29, 20.00%) and those without PPE (n = 116, 80.00%). During the pre-Fontan evaluation, significant differences between two groups were observed in PPE (p = 0.00), chylothorax (p = 0.045), pleurodesis (p = 0.045), position of thoracic and abdominal organs (p = 0.018), atrioventricular (AV) valve regurgitation (p = 0.030), and large aortapulmonary circulation (p = 0.041). During the Fontan evaluation, significant differences among two groups were seen in aortic cross-clamp time (p = 0.04), cardiopulmonary bypass time (p = 0.014), and mean pulmonary artery pressure (PAP) at Fontan (p = 0.0072). In multivariable analysis with logistic regression, a reduced model including independent predictors for PPE was found to be the NYHA class III (OR 4.93, 95% CI 1.19-20.50, p = 0.028), double-outlet right ventricle (DORV) with transposition of great arteries (TGA) (OR 31.00, 95% CI 1.35-711.63, p = 0.032), AV valve regurgitation (OR 70.73, 95% CI 3.28-1523.28, p = 0.007), ventricle-to-pulmonary artery shunt (OR 8.29, 95% CI 1.60-42.78, p = 0.012), PAI (OR 0.98, 95% CI 0.97-0.99, p = 0.002) at pre-Fontan, while, at Fontan, high PAP (OR 1.24, 95% CI 1.01-1.53, p = 0.046) was an independent predictor for PPE. In conclusion, the incidence of PPE was relatively low. The NYHA class III, primary anatomical diagnosis of DORV with TGA, pre-Fontan AV valve regurgitation, the existence of pre-Fontan ventricle-to-pulmonary artery shunt, low pulmonary artery index (PAI), and high PAP in the operation were identified as independent risk factors to predict PPE following a Fontan operation. As prior studies also investigated various risk factors influencing PPE, a preventive strategy that targets these factors combined with previous identified other risk factors might reduce the PPE incidence.

Medical Interventions for Chylothorax and their Impacts on Need for Surgical Intervention and Admission Characteristics: A Multicenter, Retrospective Insight.

The incidence of chylothorax is reported from 1-9% in pediatric patients undergoing congenital heart surgery. Effective evidenced-based practice is limited for the management of post-operative chylothorax in the pediatric cardiac intensive care unit. The study characterizes the population of pediatric patients with cardiac surgery and chylothorax who eventually require pleurodesis and/or thoracic duct ligation; it also establishes objective data on the impact of various medical interventions. Data were obtained from the Pediatric Health Information System database from 2004-2015. Inclusion criteria for admissions for this study were pediatric admissions, cardiac diagnosis, cardiac surgery, and chylothorax. These data were then divided into two groups: those that did and did not require surgical intervention for chylothorax. Other data points obtained included congenital heart malformation, age, gender, length of stay, billed charges, and inpatient mortality. A total of 3503 pediatric admissions with cardiac surgery and subsequent chylothorax were included. Of these, 236 (9.4%) required surgical intervention for the chylothorax. The following cardiac diagnoses, cardiac surgeries, and comorbidities were associated with increased odds of surgical intervention: d-transposition, arterial switch, mitral valvuloplasty, acute kidney injury, need for dialysis, cardiac arrest, and extracorporeal membrane oxygenation. Statistically significant medical interventions which did have an impact were specific steroids (hydrocortisone, dexamethasone, methylprednisolone) and specific diuretics (furosemide). These were significantly associated with decreased length of stay and costs. Dexamethasone, methylprednisolone, and furosemide were associated with decreased odds for surgical intervention. These analyses offer objective data regarding the effects of interventions for chylothorax in pediatric cardiac surgery admissions. Results from this study seem to indicate that most post-operative chylothoraxes should improve with furosemide, a low-fat diet, and steroids.

Clinical impacts of magnetic resonance thoracic ductography on preventing postoperative chylothorax after thoracoscopic esophagectomy for esophageal cancer.

PURPOSE: The study aimed to determine whether magnetic resonance thoracic ductography (MRTD) is useful for preventing injury to the thoracic duct (TD) during thoracoscopic esophagectomy and for reducing the incidence of postoperative chylothorax. MATERIALS AND METHOD: A total of 389 patients underwent thoracoscopic esophagectomy between September 2009 and February 2019 in Tokai University Hospital. Of them, we evaluated 228 patients who underwent preoperative MRTD (MRTD group) using Adachi's classification and our novel classification (Tokai classification). Then, the clinicopathological factors of the MRTD group (n = 228) were compared with those of the non-MRTD group (n = 161), and comparative analyses were conducted after propensity score matching (PSM). RESULTS: The TD could be visualized by MRTD in 228 patients. The MRTD findings were divided into 9 classifications including normal findings and abnormal TD findings (Adachi classification vs Tokai classification; 5.3% vs 16.2%). After PSM, both groups consisted of 128 patients. The rate of postoperative chylothorax after thoracoscopic esophagectomy was significantly lower in the MRTD group (0.8%) than in the non-MRTD group (6.3%) (p = 0.036). In the multivariate analysis for risk factors for chylothorax, the independent prognostic factors were preoperative therapy and the presence of MRTD. CONCLUSIONS: This study revealed that MRTD was useful for preventing of chylothorax after thoracoscopic esophagectomy for esophageal cancer.

Prophylactic thoracic duct ligation is associated with poor prognosis and regional lymph node relapse in esophageal squamous cell carcinoma.

OBJECTIVES: The ligation of thoracic duct interrupts the normal lymphatic circulation. Whether the ligation of thoracic duct would affect tumor recurrence and patient survival is unclear. METHODS: The correlations between prophylactic thoracic duct ligation (PLG) and prognosis were examined in patients with esophageal squamous cell carcinoma. Patients who received Ivor Lewis or McKeown esophagectomy with systemic lymph node dissection and R0 resection between 2003 and 2013 in Sun Yat-sen University Cancer Center were included in the study. RESULTS: A total number of 473 and 462 were included in the PLG group and non-prophylactic thoracic duct ligation (NPLG) group, respectively. The PLG group had a lower 5-year survival rate (48.2% vs 61.6%, P < .001). After a 1:1 propensity score matching, 874 cases (437 pairs) were included and the survival analysis showed that PLG was associated with worse 5-year cumulative survival of 48.6% vs 61.6% in those patients without ligation (P < .001). The multivariate analysis revealed that PLG was an independent factor for poor prognosis after esophagectomy (hazard ratio, HR = 1.56; 95% confidence interval, 95% CI, 1.26-1.93, P < .001). Additionally, PLG was associated with regional lymph node relapse (P = .015). CONCLUSIONS: PLG should not be performed routinely if no sign of thoracic duct rupture or tumor invasion were identified.

Prophylactic ligation of the thoracic duct branch prevents chylothorax after pulmonary resection for right lung cancer.

PURPOSE: Chylothorax is a rare and challenging complication of thoracic surgery. Whereas most current studies focus on postoperative treatment and preventative measures for esophageal cancer surgery, the current study investigates the impact of prophylactic ligation of the thoracic duct branch on postoperative chylothorax after pulmonary resection for right lung cancer. METHODS: The subjects of this retrospective study were 1165 patients who underwent right pulmonary resection and mediastinal lymph-node dissection in our department between January 2015 and August 2019. Those who underwent prophylactic ligation of the thoracic duct branch after 4R lymph-node dissection were assigned to group A (n = 475), and those who did not were assigned to group B (n = 690). The incidence of postoperative chylothorax, the success rate of conservative treatment, the postoperative hospital stay, and the chest drainage volume were recorded and compared statistically between the two groups. RESULTS: The incidence of postoperative chylothorax was significantly lower in group A than in group B (0.84% vs. 2.90%, p = 0.015). Patients who had a chylothorax in group A had a significantly shorter postoperative hospital stay, less mean drainage volume per day, and less total drainage than those in group B (7.25 ± 0.50 days vs. 11.00 ± 2.81 days, p = 0.003; 0.64 ± 0.04 L vs. 0.80 ± 0.09 L, p = 0.003; 4.64 ± 0.40 L vs. 8.82 ± 2.84 L; p = 0.002). The success rate of conservative treatment was higher in group A than in group B, but the difference was not significant (100% vs. 75.0%, p = 0.544). CONCLUSION: Performing prophylactic ligation of the thoracic duct branch during right pulmonary resection and mediastinal lymph-node dissection is an effective and safe method of preventing postoperative chylothorax.

Incidence of Postoperative Chylothorax Following Congenital Heart Surgery in Pediatric Patients: A Single-Center Experience.

BACKGROUND: Although postoperative chylothorax following congenital heart surgery occurs rarely, it is associated with substantial morbidity and mortality. The incidence of postoperative chylothorax has been reported as 2% to 5%. Therefore, we aimed to evaluate the incidence of postoperative chylothorax at our center and compared our results with those of other studies. METHODS: Between January 2009 and December 2018, there were 2,515 congenital heart repair surgeries performed at our center. Thirty-six patients with postoperative chylothorax were enrolled in this study, and their medical records retrospectively were reviewed. We calculated the overall and surgery-specific incidences. We compared the data of the medical management group with those of the surgical management group. RESULTS: The overall incidence of postoperative chylothorax was 1.4%. The incidence was highest for patients who underwent vascular ring repair (3/32). Moreover, the incidence was higher for single ventricle-related procedure than bi-ventricle-related procedures (5.6% versus 1.0%, P < .0001). Chylothorax was predominantly found on the left side (20/36). Among these cases, six patients died; three of these six were in the surgical management group. CONCLUSIONS: The postoperative chylothorax incidence at our center was comparable to those of other centers. However, a reasonable protocol for postoperative chylothorax management to improve outcomes is necessary.

Incidence and Nutritional Management of Chylothorax after Surgery for Congenital Heart Diseases in Children.

BACKGROUND: Chylothorax is caused by thoracic lymphatic system injury that leads to lymph extravasates in the thoracic cavity. Cardiac surgery was the most common cause. Reports comparing therapeutic effects between enteral nutrition (EN) with medium-chain triglycerides (MCT) and total parenteral nutrition (TPN) are few and inconsistent. Our study aimed to analyze the incidence of chylothorax in children in our hospital and optimum nutritional management modalities. METHODS: We retrospectively reviewed the medical records of children admitted to our hospital with a diagnosis of chylothorax from 2014 to 2018. We analyzed the incidence of chylothorax, therapeutic effectiveness, and cost effectiveness of EN with MCT or TPN. RESULTS: 136 patients with chylothorax after surgery for congenital heart disease (CHD) were identified from 172 patients with chylothorax (79.07%); chylothorax occurred in 5.62% of all 2420 congenital heart disease surgeries that were performed during that period. Tetralogy of Fallot (TOF), ventricular septal defect (VSD), and double-outlet right ventricle (DORV) were the most common primary diagnoses. Fontan surgery, TOF repair, and VSD repair were the most common primary procedures. We enrolled 45 patients with cured chylothorax. Nutrition support costs in the EN with MCT group (n = 28) were significantly lower than in the TPN group (n = 17) (P = .000). Time to resolution and time to removal of the drainage tube were shorter in EN with MCT versus TPN (P = .003), and the length of hospital stay was shorter (P = .032). There were no significant differences between the 2 groups in time from admission to surgery, postoperative days before diagnosing chylothorax, or length of PICU stay (P > .05). CONCLUSIONS: The therapeutic effects of EN with MCT were significantly better than those of TPN, with lower costs. Therefore, we suggest that EN with MCT be chosen first to treat chylothorax caused by surgery with mild chest drainage volume when gastrointestinal tract function is allowed.

Postoperative Chylothorax after Modified Radical Neck Dissection for Thyroid Carcinoma: A Missable Rare Complication of Thyroid Surgery.

Background and objectives: Currently, few studies have been conducted on postoperative chylothorax, specifically in total thyroidectomy with modified radical neck dissection (MRND) in papillary thyroid carcinoma patients. This study provides the actual incidence, etiology, and clinical features of postoperative chylothorax and reports the clinical outcomes after treatment, which were dependent upon the severity of the complications. Materials and Methods: The medical charts of 111 papillary thyroid cancer (PTC) patients who underwent total thyroidectomy with modified radical neck dissection from January 2016 to December 2018 were reviewed retrospectively. The results were compared in three groups: the no chylothorax group, the subclinical (asymptomatic) group, and the clinical (symptomatic) group. Results: Chylothorax occurred in 23 patients (20.7%, 23/111). Nineteen (82.6%, 19/23) were subclinical chylothorax cases, which implies a small amount of chyle leakage with no respiratory symptoms. Four (17.4%, 4/23) were clinical, meaning they had either respiratory symptoms, such as dyspnea, desaturation, or a large amount of chylothorax in the images. The incidence was significantly higher in patients who underwent left modified radical neck dissection, and this corresponds to the side in which chylothorax occurred. There were also statistical differences in the drainage color, peak amount, or drain removal time. Conclusions: Postoperative chylothorax is a rare complication following neck dissection. However, it can be fatal if the condition progresses. Therefore, patients who undergo total thyroidectomy with modified radical neck dissection, especially on the left side, should be monitored for respiratory symptoms, and serial chest x-ray images obtained.

An international survey of the nutrition management of chylothorax: a time for change.

INTRODUCTION: Although chylothorax is an uncommon complication following paediatric cardiothoracic surgery, it has significant associated morbidities and increased in-hospital mortality, as well as results in higher costs. A lack of prospective evidence or consensus guidelines for management of chylothorax further hinders optimal management. The aim of this survey was to characterise variations in practice in the management of chylothorax and to identify areas for future research. MATERIALS AND METHODS: A descriptive, observational survey investigating conservative management practices of chylothorax was distributed internationally to health-care professionals in paediatric intensive care and cardiology units. The survey investigated five domains: the first providing general information about health-care professionals and four domains focusing on clinical practice including diet composition and duration. RESULTS: In total, sixty-four health-care professionals completed the survey, representing 38 organisations from 16 countries. The respondents were dietitians (80%), physicians (19%), and nurses (1%). In Australia and New Zealand, management was most commonly directed by physicians' preference (67%) as compared to unit protocols in Europe (67%), United States of America (67%), and Other regions (55%). Dietitians in Australia/New Zealand, United Kingdom, and Ireland followed the most restrictive diet therapy recommending <5 g long chain triglyceride fat per day (p < 0.00001). The duration of diet therapy significantly varied between regions: Australia/New Zealand: 4 weeks (36%) and 6 weeks (43%); Europe: 4 weeks (25%) and 6 weeks (57%); and North America: 4 weeks (18%) and 6 weeks (75%) (p < 0.00001). CONCLUSIONS: This survey highlights international variations in practice in the management of chylothorax, particularly with respect to treatment duration and dietary fat restriction. Future research should include a multi-centre randomised controlled trial to inform evidence-based practice and reduce morbidity, particularly poor growth.

The usefulness of three-dimensional video-assisted thoracoscopic esophagectomy in esophageal cancer patients.

BACKGROUND: The three-dimensional video-assisted (3D-VA) system is known to provide depth perception and the precise measurement of anatomical spaces, unlike the two-dimensional video-assisted (2D-VA) system. However, the advantages of the 3D-VA system in thoracoscopic esophagectomy remains unclear. METHODS: We retrospectively analyzed data from 104 patients who underwent thoracoscopic esophagectomy for esophageal cancer from 2016 to 2017. We performed thoracic esophagectomy using either the 2D-VA or 3D-VA system during this period. Whenever the 3D-VA system was available in our surgical center, we performed 3D-VA thoracoscopic esophagectomy. Perioperative parameters, including operation times, blood loss, the number of dissected lymph nodes, postoperative complications, and the duration of postoperative hospital stays, were compared between the 2D-VA and 3D-VA system groups. RESULTS: There were 51 and 53 patients in the 2D-VA and 3D-VA system groups, respectively. Preoperative parameters, including age, sex, tumor location, clinical stage and the distribution of preoperative treatment, were not significantly different between the groups. Although intraoperative blood loss did not differ between the two groups, operation times were significantly shorter in the 3D-VA system group than the 2D-VA system group (P = 0.023). The number of dissected mediastinal lymph nodes was similar in both groups. The incidences of postoperative complications, including pneumonia, recurrent nerve palsy, anastomotic leakages and chylothorax, were similar between the groups. The duration of postoperative hospital stays was also comparable between the groups. CONCLUSIONS: An introduction of 3D-VA endoscopy into minimally invasive esophagectomies may contribute to the shortening of the duration of thoracoscopic procedures.

Predictive Factors for Central Line-Associated Bloodstream Infections in Pediatric Cardiac Surgery Patients With Chylothorax.

OBJECTIVES: To assess the prevalence of central line-associated bloodstream infections in pediatric patients with and without chylothorax after cardiac surgery and identify risk factors that predict those patients at highest risk for developing a central line-associated bloodstream infection. DESIGN: Retrospective single-center cohort study. SETTING: A PICU located within a tertiary-care academic pediatric hospital. PATIENTS: All pediatric patients admitted to the PICU after cardiac surgery between 2008 and 2014. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We identified 1,191 pediatric cardiac surgery patients in the study time frame, of which 66 (5.5%) had chylothorax. Patients with chylothorax were more likely to have a central line-associated bloodstream infection (23% vs 3.8%; p < 0.001). Patients with both chylothorax and central line-associated bloodstream infection had longer durations of central venous catheter, higher Risk Adjustment Congenital Heart Surgery score, longer PICU stay, and higher mortality compared with patients with chylothorax who did not have a central line-associated bloodstream infection. Multivariable analysis identified higher Risk Adjustment Congenital Heart Surgery score, longer duration of central venous catheter, and higher chest tube output at 24 hours after initiating treatment for chylothorax to be predictive of increased central line-associated bloodstream infection risk in patients with chylothorax. CONCLUSIONS: The prevalence of central line-associated bloodstream infection is higher in pediatric patients with chylothorax after heart surgery. In patients with chylothorax, complexity of surgery, central venous catheter duration, and chest tube output are associated with increased risk for developing a central line-associated bloodstream infection. Using this knowledge will allow us to identify patients at increased risk for central line-associated bloodstream infections and to focus extra prevention efforts on them.

Effect of Prophylactic Thoracic Duct Ligation in Reducing the Incidence of Postoperative Chylothorax during Esophagectomy: A Systematic Review and Meta-analysis.

OBJECTIVES: There is no consensus on the effectiveness of prophylactic thoracic duct ligation (PLG) in esophagectomy for reducing the incidence of postoperative chylothorax. We performed a systemic review and meta-analysis to study its efficacy. METHODS: A systemic review of the publications was performed on three databases to identify all the relevant literature on comparative outcomes of PLG and nonprophylactic thoracic duct ligation (NPLG). The primary end point was the incidence of postoperative chylothorax. RESULTS: Seven studies with comparative data on PLG (n = 2,178) versus NPLG (n = 3,048) were identify from the current publications. Comparison showed no significant difference between PLG and NPLG on the incidence of postoperative chylothorax (relative risk = 0.431; 95% confidence interval, 0.186 to 1.002; p = 0.050). CONCLUSIONS: Although some studies showed that PLG during the esophagectomy was effective to lower the incidence of postoperative chylothorax, no evidence was observed in the present meta-analysis. Further research is warranted to validate the findings.

Chylothorax following paediatric cardiac surgery: a case-control study.

OBJECTIVES: The aims of this study were to investigate risk factors for the development of postoperative chylothorax following paediatric congenital heart surgery and to investigate the impact of a management guideline on management strategies and patient outcome. METHODS: All patients with chylothorax following cardiac surgery at the Royal Children's Hospital, Melbourne, over a 48-month period beginning in January 2008 were identified. A control group, matched for age, date of surgery, and sex, was identified. To investigate potential risk factors, univariable and multivariable logistic regression models were constructed with paired analysis. To examine the effect of a standardised management protocol, data before and after the implementation of the guideline were compared. RESULTS: In total, 121 cases of chylothorax were identified, with 121 controls, matched for age at surgery, date of surgery, and sex. The incidence of chylothorax was 5.23%. Increasing surgical complexity (univariable OR 0.17 for the least complex versus the most complex group, p=0.02), closed-heart surgeries (OR 0.07 for open versus closed, p<0.001), and redo chest incisions (OR 10.0 for redo versus virgin, p<0.001) were significantly associated with chylothorax. The standardised management protocol had no significant impact on either drainage duration or management strategy. CONCLUSIONS: We have replicated the previously reported association between surgical complexity and chylothorax risk, and have shown, for the first time, that redo chest openings are also associated with a significantly increased risk. The implementation of a standardised management protocol in our institution did not result in a significant change in either chylothorax drainage duration or management strategy.

The outcomes and prognostic factors of fetal hydrothorax associated with trisomy 21.

OBJECTIVES: To determine the characteristics, outcomes, and prognostic factors of fetal hydrothorax (FHT) with trisomy 21. METHODS: A nationwide survey was conducted on FHT fetuses with trisomy 21 delivered after 22 weeks' gestation between January 2007 and December 2011 at perinatal centers. RESULTS: The 91 cases of FHT with trisomy 21 included 28 (30.8%) diagnosed in utero and 63 (69.2%) diagnosed after birth. The natural remission rate was 6.6% (6/91). Thoracoamniotic shunting was performed in 14.3% (13/91) of cases. The survival rates of the hydropic, nonhydropic, and total cases were 47.0% (31/66), 84.0% (21/25), and 57.1% (52/91), respectively. The crude odds ratio for death was 8.2 (p = 0.003) for fetuses diagnosed at 26-30 weeks of gestational age (vs ≥30 weeks), 5.9 (p = 0.003) for hydrops, 4.0 (p = 0.04) for bilateral pleural effusion, 0.68 (p = 0.42) for associated cardiovascular anomalies, and 2.1 (p = 0.26) for thoracoamniotic shunting (vs no fetal therapy). CONCLUSIONS: The prognosis of FHT with trisomy 21 was not very poor, but it was still worse than that of primary FHT. Hydrops, an early gestational age at the diagnosis and bilateral effusion, but not associated anomalies, were risk factors for death. Fetal therapy showed no survival benefit for FHT with trisomy 21. © 2017 John Wiley & Sons, Ltd.

Management and outcome of cervical versus intrathoracic manifestation of cervical anastomotic leakage after transthoracic esophagectomy for cancer.

The aim of this study was to evaluate management strategies and related outcomes for cervical versus intrathoracic manifestation of cervical anastomotic leakage after transthoracic esophagectomy for cancer with gastric conduit reconstruction. Patients with esophageal cancer undergoing transthoracic esophagectomy with cervical anastomosis from October 2003 to December 2014 were identified from a prospectively acquired database. Management strategies and related outcomes among patients with anastomotic leakage confined to the neck were compared to patients with intrathoracic manifestation of anastomotic leakage. From a total of 286 patients, leakage of the cervical anastomosis occurred in 60 patients (21%) at a median time of 7 days after esophagectomy. Leakage was confined to the neck in 23 of 60 patients (38%), whereas 37 of 60 patients (62%) presented with intrathoracic spread. Leakages with intrathoracic manifestation were more frequently accompanied by a positive SIRS score compared to leakages confined to the neck (73% vs. 35%, respectively; P = 0.004). Drainage of the anastomotic leakage through the neck wound was effective in all of 23 patients (100%) with cervical manifestation. In patients with intrathoracic manifestation, mediastinal drainage through the neck was successful in 15 of 37 patients (41%), whereas 22 patients (59%) required an intervention through the thoracic cavity. Compared to patients with leakage confined to the neck, patients with intrathoracic manifestation showed prolonged intensive care unit (ICU) stay (median 6 vs. 2 days, respectively; P = 0.001), hospital stay (median 34 vs. 19 days, respectively; P < 0.001), and time to oral intake (32 vs. 23 days, respectively; P = 0.018). Intrathoracic manifestation of cervical anastomotic leakage occurs in more than half of patients with anastomotic leakage after transthoracic esophagectomy for cancer. A SIRS reaction should raise the suspicion of intrathoracic spread of leakage. Intrathoracic manifestation can be managed effectively by mediastinal drainage through the neck in 41% of patients, but a reintervention through the thoracic cavity is required in 59%. Intrathoracic manifestation of leakage results in prolonged ICU/hospital stay and delays time to oral intake compared with leakage confined to the neck.

Chylothorax after esophagectomy for cancer: impact of the surgical approach and neoadjuvant treatment: systematic review and institutional analysis.

BACKGROUND: Esophagectomy is a challenging operation with considerable potential for postoperative complications, including chylothorax. METHODS: Because no randomized controlled trial or metaanalysis is available to clarify the incidence of chylothorax in esophageal cancer surgery, the authors analyzed their own institutional data for 1,856 patients and performed a systematic review using the MEDLINE database (9,794 patients) to identify risk factors, compare success rates of therapeutic approaches, and investigate long-term outcomes. RESULTS: The overall institutional chylothorax rate was 2 % (n = 39). Reoperation was performed for 69 % of the patients. No significant difference was noted between the transthoracic and transhiatal approaches. Regression analysis showed neoadjuvant treatment (odds ratio [OR], 0.302; p = 0.001) and tumor type (OR, 0.304; p = 0.002) to be independent risk factors. The systematic review included 12 studies. Chylothorax occurred for 2.6 % of the patients. Treatment favored reoperation in five studies (70-100 %) and a conservative approach in four studies (58-72 %), with equal mortality rates. No significant difference was found between the transthoracic and transhiatal approaches. CONCLUSION: Chylothorax rates are low in high-volume centers (2-3 %). No significant difference was noted between the transthoracic and transhiatal approaches. Neoadjuvant treatment and tumor type were shown to be independent risk factors. Treatment concept (reoperation vs conservative treatment) did not affect long-term survival.

Lymph or Chyle Leak After Neck Dissection in Patients With Thyroid Carcinoma: Results of a Study on 1724 Patients.

BACKGROUND: To discuss the prevention and treatment of lymph or chyle leak following neck dissection in patients with thyroid carcinoma. METHODS: A total of 1724 patients with thyroid carcinoma received neck dissection in the Sun Yat-sen University Cancer Center between November 2009 and October 2014. The incidence and management of leak were analyzed. RESULTS: A total of 92 (5.34%) patients developed leak, 28 (1.62%) developed lymph leak, 59 (3.42%) developed chyle leak, and 5 (.29%) developed chylothorax. Medical management to stop postoperative lymph or chyle leak included pressure dressing, reoperation, fasting, or low-fat diet therapy. CONCLUSIONS: Lymph or chyle leak may occur in thyroid carcinoma patients who underwent neck dissection. Clinicians should alert to leak when there were IV + VI region lymph node metastasis and should become aware of chylothorax after pressure dressing. A careful identification and ligation of lymphatic duct may be an effective way to avoid lymph or chyle leak.