Chylothorax after Repair of Congenital Diaphragmatic Hernia in a Neonate: Usefulness of Conservative Management

Tadao Okada, Shohei Honda, Hisayuki Miyagi, Masashi Minato, Akinobu Taketomi

Department of Gastroenterological Surgery I, Graduate School of Medicine, Hokkaido University, Sapporo, Japan.
Department of Pediatric Surgery, Hokkaido University Hospital, Sapporo, Japan.

DOI: 10.4236/ss.2012.32018                

Abstract

Aim: Chylothorax is a recognized complication after surgery for congenital diaphragmatic hernia (CDH) in a neonate. Management strategies for chylothorax include cessation of enteral feedings, repeated aspiration, chest drainage, and total parenteral nutrition. It is important to determine which is the better plan for treatment of chylothorax after repair of CDH. The authors report successful management by use of the MCT diet for a neonate with chylothorax after repair of CDH. Case: A male infant weighing 3.0 kg was delivered by cesarean section at 38 weeks of gestation and intubated immediately after birth. Prenatal ultrasonography had disclosed left-sided posterolateral diaphragmatic hernia. After stabilization, surgery was performed via a left-sided transverse supra-abdominal incision. The unfixed colon, small bowel, stomach, and spleen were reduced from the chest with little difficulty. A hernia sac was not present and the left-sided posterolateral diaphragm showed a defect 3.5 cm × 2.0 cm in width. The child was fed via a nasogastric tube starting on postoperative day 4 and dyspnea disappeared. Plain chest X-ray on postoperative day 7 showed left pleural radioopacity. A specimen of the chest drainage examined on postoperative day 10 was typical of lymph, with a triglyceride level of 328 mg/dl. The chest drainage was dark yellowish, and a medium-chain triglyceride formula was used until postoperative day 30, by which time the effusion has disappeared. Discussion: Chylothorax after repair of CDH may be a transient disorder that will resolve after a period of diminished flow through the thoracic lymphatics.

Keywords

Chylothorax; Congenital Diaphragmatic Hernia; Chest Drainage; Algorithm

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	V. Kavvadia, A. Greenough, M. Davenport, J. Karani and H. Nicolaidesk, “Chylothorax after Repair of Congenital Diaphragmatic Hernia—Risk Factors and Morbidity.” Journal of Pediatric Surgery, Vol. 33, No. 3, 1998, pp. 500-502. doi:10.1016/S0022-3468(98)90097-5
[2]	X. Liu, M. Ashtari, J. C. Leonidas and Y. Chan, “Magnetic Resonance Imaging of the Fetus in Congenital Intrathoracic Disprders: Preliminary Observations,” Pediatric Radiology, Vol. 31, No. 6, 2001, pp. 435-439. doi:10.1007/s002470100450
[3]	H. L. M. Van Straaten, L. J. Gerards and T. G. Krediet, “Chylothorax in the Neonatal Period,” European Journal of Pediatrics, Vol. 152, No. 1, 1993, pp. 2-5. doi:10.1007/BF02072505
[4]	A. Macy, R. W. Thomas and E. F. Robert, “Successful Use of Somatostatin in a Case of Neonatal Chylothorax,” Journal of Pediatric Surgery, Vol. 38, No. 7, 2003, pp. 1106-1107. doi:10.1016/S0022-3468(03)00205-7
[5]	A. Goyal, N. P. Smith, E. C. Jesudason, S. Kerr and P. D. Losty, “Octreotide for Treatment of Chylothorax after Repair of Congenital Diaphragmatic Hernia,” Journal of Pediatric Surgery, Vol. 38, No. 8, 2003, pp. E19-E20. doi:10.1016/S0022-3468(03)00294-X
[6]	S. Mercer, “Factors Involved in Chylothorax Following Repair of Congenital Posterolateral Diaphragmatic Hernia,” Journal of Pediatric Surgery, Vol. 21, No. 9, 1986, pp. 809-811. doi:10.1016/S0022-3468(86)80374-8
[7]	S. Naik, A. Greenough, Y. Zhang and M. Davenport, “Prediction of Morbidity during Infancy after Repair of Congenital Diaphragmatic Hernia,” Journal of Pediaticr Surgery, Vol. 31, No. 12, 1996, pp. 1651-1654. doi:10.1016/S0022-3468(96)90040-8
[8]	G. Stringel, S. Mercer and J. Bass, “Surgical Management of Persistent Chylothorax in Children,” Canadian Journal of Surgery, Vol. 27, No. 6, 1984, pp. 543-546.
[9]	M. T. Longaker, J. M. Laberge, J. Dansereau, J. C. Lanfer, T. M. Crombleholme, P. W. Callen, M. S. Golbus and M. R. Harrison, “Primary Fetal Hydrothorax: Natural History and Management,” Journal of Pediatric Surgery, Vol. 27, No. 6, 1989, pp. 573-576. doi:10.1016/S0022-3468(89)80509-3
[10]	M. L. Paes and H. Powell, “Chylothorax: An Update,” British Journal of Hospital Medicine, Vol. 51, No. 9, 1994, pp. 482-490.