초록접수 현황
| 14F-239 | 구연 발표 |
Anatomic Variations of Thoracic Duct in Pediatric Patients with Complex Congenital Heart Disease
방지현, 김상화, 박천수, 박정준, 윤태진
¹Division of Pediatric Cardiac Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
Background : Thoracic duct (TD) mass ligation through right thoracotomy, regardless of the side of pleural effusion, is the standard procedure for the treatment of chylothorax. However, this procedure may not be successful, necessitating additional left peri-aortic mass ligation. We hypothesized that failure of right side approach may be attributable to the anatomical variation of the course of TD .
Methods : Among the 8,880 children who underwent open heart surgery for congenital heart disease between 1992 and 2014, 70 patients (70/8880, 0.8%) developed massive chylothorax and underwent TD mass ligation. Median age at cardiac surgery was 164 days (range, 0 day- 70 months). Diagnosis of chylothorax was confirmed 8.5 days (range, 2 to 118 days) after initial operation, and initial TD ligation was performed after a median duration of 31 days (range: 7-120 days) of medical treatment with a maximal drainage of 52 mL/kg/day (range, 14 to 259 mL/kg/day). Chylothorax resolved after right-side approach in most of patients (group 1, n=51) while additional left thoracotomy was required in 16 patients. In 3 patients with left chylothorax, left thoracotomy was initially performed. Thus, a total of 19 patients had left thoracotomy (group 2). Demographic data, cardiac morphology, atrial situs, characteristics of chylous drainage, and postoperative outcomes were compared between the two groups.
Results : In cardiac morphology, patients in group 2 were more likely to have dextrocardia (21.1% vs. 3.9%, p=0.04), left isomerism (15.8% vs. 5.9%, p=0.02), situs inversus (15.8% vs. 3.9%, p=0.02) and abnormal great artery relationships (L-TGA, 15.8% vs. 5.9%, p=0.02: side by side, 15.8% vs. 3.9%, p=0.02). Initial drainage site of chylothorax, Incidence of right arch, right descending aorta, left superior vena cava, congenital esophageal anomaly were similar in both groups. There was no 30 days mortality, but 18 patients (20%) died during follow-up. Excluding 11 patients who died before chest tube removal, there was a gradual decrease in drainage after TD ligation, and chest tubes were eventually removed in 20 days (range, 4 to 79 days). After adjustment, both groups of patients showed a similar risk of death at 1 year (hazard ratio [HR]: 1.15; 95% CI: 0.4 to 3.2; p = 0.78). On multiple logistic regression analysis, peripheral leak syndrome (RR 38.6 [95% CI 10.2 to 148.2], p<0.001) and postoperative low cardiac output (RR 111.1 [95% CI 18.8-660.4], p<0.0001) were identified as risk factos for death after TD ligation.
Conclusion : The course of thoracic duct course may be variable in pediatric patients with complex congenital heart disease. Left peri-aortic mass ligation should be considered in chylothorax refractory to right side TD mass ligation, especially in patients with abnormal atrial situs, dextrocardia, and great artery malposition.
Methods : Among the 8,880 children who underwent open heart surgery for congenital heart disease between 1992 and 2014, 70 patients (70/8880, 0.8%) developed massive chylothorax and underwent TD mass ligation. Median age at cardiac surgery was 164 days (range, 0 day- 70 months). Diagnosis of chylothorax was confirmed 8.5 days (range, 2 to 118 days) after initial operation, and initial TD ligation was performed after a median duration of 31 days (range: 7-120 days) of medical treatment with a maximal drainage of 52 mL/kg/day (range, 14 to 259 mL/kg/day). Chylothorax resolved after right-side approach in most of patients (group 1, n=51) while additional left thoracotomy was required in 16 patients. In 3 patients with left chylothorax, left thoracotomy was initially performed. Thus, a total of 19 patients had left thoracotomy (group 2). Demographic data, cardiac morphology, atrial situs, characteristics of chylous drainage, and postoperative outcomes were compared between the two groups.
Results : In cardiac morphology, patients in group 2 were more likely to have dextrocardia (21.1% vs. 3.9%, p=0.04), left isomerism (15.8% vs. 5.9%, p=0.02), situs inversus (15.8% vs. 3.9%, p=0.02) and abnormal great artery relationships (L-TGA, 15.8% vs. 5.9%, p=0.02: side by side, 15.8% vs. 3.9%, p=0.02). Initial drainage site of chylothorax, Incidence of right arch, right descending aorta, left superior vena cava, congenital esophageal anomaly were similar in both groups. There was no 30 days mortality, but 18 patients (20%) died during follow-up. Excluding 11 patients who died before chest tube removal, there was a gradual decrease in drainage after TD ligation, and chest tubes were eventually removed in 20 days (range, 4 to 79 days). After adjustment, both groups of patients showed a similar risk of death at 1 year (hazard ratio [HR]: 1.15; 95% CI: 0.4 to 3.2; p = 0.78). On multiple logistic regression analysis, peripheral leak syndrome (RR 38.6 [95% CI 10.2 to 148.2], p<0.001) and postoperative low cardiac output (RR 111.1 [95% CI 18.8-660.4], p<0.0001) were identified as risk factos for death after TD ligation.
Conclusion : The course of thoracic duct course may be variable in pediatric patients with complex congenital heart disease. Left peri-aortic mass ligation should be considered in chylothorax refractory to right side TD mass ligation, especially in patients with abnormal atrial situs, dextrocardia, and great artery malposition.
책임저자: 윤태진
울산대학교 의과대학 서울아산병원 흉부외과학교실
연락처 : 방지현, Tel: 02-3010-1853 , E-mail : mibbi@naver.com
