Lymphovenous Anastomosis for the Treatment of Chylothorax in Infants: A Novel Microsurgical Approach to a Devastating Problem

Plastic and Reconstructive Surgery - Tập 141 Số 6 - Trang 1502-1507 - 2018
Jason M. Weissler1,2,3,4,5,6,7,8,9,10,11,12,13,14,15, Eugenia H. Cho1,2,3,4,5,6,7,8,9,10,11,12,13,14,15, Peter F. Koltz1,2,3,4,5,6,7,8,9,10,11,12,13,14,15, Martin J. Carney1,2,3,4,5,6,7,8,9,10,11,12,13,14,15, Maxim Itkin1,2,3,4,5,6,7,8,9,10,11,12,13,14,15, Pablo Laje1,2,3,4,5,6,7,8,9,10,11,12,13,14,15, L. Scott Levin1,2,3,4,5,6,7,8,9,10,11,12,13,14,15, Yoav Dori1,2,3,4,5,6,7,8,9,10,11,12,13,14,15, Suhail Kanchwala1,2,3,4,5,6,7,8,9,10,11,12,13,14,15, Stephen J. Kovach1,2,3,4,5,6,7,8,9,10,11,12,13,14,15
1Coding perspective for this article is on page 1506.
2Disclosure: The authors have no financial interest to declare in relation to the content of this article.
3From the Division of Plastic Surgery and the Department of Orthopaedic Surgery, University of Pennsylvania Health System
4Philadelphia, Pa.
5Presented at the 2018 American Society for Reconstructive Microsurgery Annual Meeting, in Phoenix, Arizona, January 13, through 16, 2018.
6Received for publication June 2, 2017
7Stephen J. Kovach, M.D., Division of Plastic Surgery, University of Pennsylvania Health System, 3400 Civic Center Boulevard, Philadelphia, Pa. 19104, [email protected]
8Supplemental digital content is available for this article. Direct URL citations appear in the text
9The first two authors contributed equally to this work.
10accepted December 14, 2017.
11simply type the URL address into any Web browser to access this content. Clickable links to the material are provided in the HTML text of this article on the Journal’s website (www.PRSJournal.com).
12the Department of Bioengineering, University of Pennsylvania
13the Department of Radiology, Section of Interventional Radiology, Hospital of the University of Pennsylvania
14the Division of Cardiology, Children’s Hospital of Philadelphia/Hospital of the University of Pennsylvania Center for Lymphatic Imaging and Interventions, Children’s Hospital of Philadelphia.
15the Division of General, Thoracic and Fetal Surgery, Children’s Hospital of Philadelphia

Tóm tắt

Summary:

With the expanding horizon of microsurgical techniques, novel treatment strategies for lymphatic abnormalities are increasingly reported. Described in this article is the first reported use of lymphovenous anastomosis surgery to manage recalcitrant chylothoraces in infants. Chylothorax is an increasingly common postoperative complication after pediatric cardiac surgery, with a reported incidence of up to 9.2 percent in infants. Although conservative nutritional therapy has a reported 70 percent success rate in this patient population, failed conservative management leading to persistent chylothorax is associated with a significant risk of multisystem complications and mortality. Once conservative medical strategies are deemed unsuccessful, surgical or radiologic interventions, such as percutaneous thoracic duct embolization or ligation, are often attempted. However, these procedures lack high-level evidence in the infant population and remain a challenge, given the small size of the lymphatic vessels. As such, we report our experience with performing lymphovenous anastomoses in two infants who had developed refractory chylothoraces secondary to thoracic duct injury following cardiac surgery for congenital cardiac anomalies. In addition, this article reviews the relevant pathophysiology of chylothoraces, current treatment algorithm following failed conservative management, and potential role of the microsurgeon in the multidisciplinary management of this life-threatening problem. As part of the evolving microsurgery frontier, physiologic operations, such as lymphovenous anastomosis, may have a considerable role in the management of refractory pediatric chylothoraces. In our experience, lymphovenous anastomosis can restore normal lymphatic circulation within 1 to 2 weeks, liberate patients from mechanical ventilation, and enable expeditious return to enteral feeding.

 CLINICAL QUESTION/LEVEL OF EVIDENCE:

Therapeutic, V.

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Plastic and Reconstructive Surgery

Tập 141 Số 6

1502-1507

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