Anesth Analg 2001;93:96-97
© 2001 International Anesthesia Research Society
PEDIATRIC ANESTHESIA
The Successful Management of Thoracoscopic Thoracic Duct Ligation in a Compromised Infant with Targeted Lobar Deflation
Masahiko Takahashi, MD*,
Yoshimochi Kurokawa, MD
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Hiroaki Toyama, MD*,
Ryuichi Hasegawa, MD*, and
Yasuhiko Hashimoto, MD*
*Departments of Anesthesiology and Emergency Medicine and Surgery, Tohoku University Postgraduate Medical School, Sendai, Japan
Address correspondence and reprint requests to Masahiko Takahashi, MD, Assistant Professor, Department of Anesthesiology and Emergency Medicine, Tohoku University Postgraduate Medical School, 1-1 Seiryo, Aoba-ku, Sendai 980-8574, Japan. Address e-mail to m-takaha{at}mail.cc.tohoku.ac.jp
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Abstract
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Implications: We describe the successful management of thoracoscopic thoracic duct ligation in a 2.5-kg compromised infant by using selective lobar-bronchial blockade. The technique reduces the risk of intraprocedural physiologic impairment, allowing the benefits of otherwise minimally invasive thoracoscopic procedures, even when the conditions of children are severely compromised.
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Introduction
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Thoracoscopic surgery has been increasingly used for pediatric patients because it is minimally invasive (1). In children, surgical access has been conventionally accomplished by the total collapse of the ipsilateral lung via blocking (2,3) or intubation (4,5) of the main stem bronchus. However, one-lung ventilation in infants and small children is often a clinical challenge, especially when the patient’s respiratory and cardiovascular condition is compromised.
Recently, we reported a technique for collapsing selected lobes, rather than a total single lung, in children (6). In this case report, we describe the successful use of this technique for thoracoscopic thoracic duct ligation in a 2.5-kg infant with congenital heart disease.
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Case Report
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A 16-day-old girl (3.2 kg) developed chylothorax after correction of an interrupted aortic arch. Persistent pleural effusion with continuous drainage of chyle (100–150 mL/day) resulted in hemodynamic depression, respiratory distress, and malnutrition. She was referred to us for thoracic duct ligation on day 34 after surgery. Her body weight had decreased to 2.5 kg. For surgical access, video-assisted thoracic surgery, rather than conventional open thoracotomy, was selected because we anticipated massive pleural adhesion, compromised immune function, and an impaired wound-healing process in this patient. Under anesthesia with fentanyl, midazolam, and vecuronium, pressure-limited ventilation was established via a previously maintained 4.5-mm-inner-diameter uncuffed endotracheal tube. Her trachea was reintubated with a double-access-port tube of the same size that we previously reported for pediatric selective-lung ventilation (7). This device, fabricated by combining two conventional tracheal tubes, provides independent access for both ventilation and the bronchial-blocking maneuver. To reach the thoracic duct, we first applied left one-lung ventilation by blocking the right main bronchus with a 4F Fogarty catheter. However, the total collapse of the right lung profoundly depressed her hemodynamics (mean arterial pressure <30 mm Hg) and gas exchange (pH 7.00, PaO2/fraction of inspired oxygen [FIO2] 88 mm/Hg, and PaCO2 106 mm Hg). Therefore, we decided to attempt a more selected deflation of the lobe despite the fact that we had no previous experience in such low-body-weight children. Details of this technique have been described elsewhere (6). In this case, briefly, the 4F Fogarty balloon was carefully advanced to the lower lobar bronchus under fiberoptic (2.2-mm-outer-diameter) inspection. The blocking of the right lower lobe was accomplished via the inflation of the balloon with a minimal volume of air (0.8 mL). The effectiveness of the lower-lobar blocking was fiberoptically confirmed (Fig. 1). These procedures were completed without interrupting ventilation. Ventilation of the left lung and the right upper and middle lobes stabilized her physiologic condition (pH >7.25, PaO2/FIO2 >250 mm Hg, PaCO2 <60 mm Hg, and mean arterial pressure >40 mm Hg) while enabling sufficient surgical access (Fig. 2). The intrathoracic procedures were successfully completed in 115 min. The pleural effusion disappeared and the chest drains were removed 2 days later. Unfortunately, malnutrition and low cardiac performance interfered with her recovery, and she died from intestinal perforation 2 mo later.
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Figure 1. Fiberoptic view of a 4F Fogarty balloon placed in the right lower lobar bronchus of a 2.5-kg infant.
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Figure 2. Thoracoscopic view during the thoracic duct ligation in a 2.5-kg infant. The selective deflation of the right lower lobe provides adequate surgical access.
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Discussion
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Recent advances in thoracoscopic techniques have enabled surgeons to perform intrathoracic surgery in small infants. Preservation of the ventilation and pulmonary circulation by using video-assisted thoracic surgery may prevent physiologic impairment even in small children whose general condition is severely compromised. This report has demonstrated such a case.
For precise blocking of the targeted lobe, fiberscope-aided introduction and alignment of the blocker are necessary. These maneuvers need to be used while maintaining sufficient ventilation to avoid possible hypoxemia. By using the techniques described here and in detail elsewhere (6), we easily placed a Fogarty balloon into the right lower lobar bronchus and achieved blockade of the right lower lobe. The advantage of a Fogarty catheter for these procedures is that various sizes are available and the catheter can be controlled with a guidewire.
Although postoperative bronchoscopic examination revealed no significant injury in her bronchi, the relative vulnerability of the bronchial wall in small children may increase the risk of bronchial laceration or perforation by a blocker. Accordingly, the careful introduction of the catheter and inflation of the balloon with a minimal volume of air are important. It should be noted that a Fogarty catheter is still less than ideal for this specific use because of its expense, high-pressure balloon, and lack of a suction port. Therefore, the development of a more sophisticated bronchial blocker is needed.
Thoracoscopic procedures have been developed to reduce the invasiveness of thoracic and chest-wall surgery. However, the risk associated with the conventional one-lung ventilation may impede the application of such procedures for small children whose general condition is compromised. The targeted lobar blocking described here will afford such patients the potential benefits of thoracoscopic surgery.
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References
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Takahashi M, Horinouchi T, Kato M, Hashimoto Y. Double-access-port endotracheal tube for selective lung ventilation in pediatric patients. Anesthesiology 2000; 93: 308–9.[ISI][Medline]
Accepted for publication February 27, 2001.
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Abstract
Introduction
