心内直视手术后乳糜心包和乳糜胸的治疗

目的:总结心内直视手术后乳糜心包或乳糜胸的治疗经验,探讨其发病机制及治疗方法。方法:我院1980～2000年间2250例体外循环心内直视手术中3例术后并发乳糜心包/乳糜胸(0.13％),3例均为法洛四联症,都经胸骨正中径路施行根治术,术后不同时期并发乳糜心包和乳糜胸。结果:全组先行非手术治疗,1～3周后引流量无减少即行手术治疗,1例经再次手术治愈。另2例术后仍有乳糜胸,再经非手术治疗痊愈。结论:乳糜心包和/或乳糜胸是心内直视手术后十分少见而治疗相当棘手的并发症。常因丢失大量营养物质而导致营养障碍及水电失衡等并发症。术中损伤前纵隔淋巴侧支循环以及术后右心功能不全,静脉压升高影响淋巴回流是造成乳糜漏的主要原因。治疗乳糜心包/乳糜胸目前尚无最佳措施,因手术治疗效果不确切,本文强调非手术治疗为首选。非手术治疗的原则:①减少乳糜流量,补充营养物质,维持正氮平衡。本组采用低脂,高蛋白,高糖饮食以及中链甘油三酯(MCT)饮食,收到良好效果;②持续通畅的引流,促进肺膨胀。淋巴管瘘口愈合依赖于周围胸膜组织粘连,故负压吸引以及高渗糖冲洗纵隔及胸腔均有助于瘘口愈合;③强心,扩管,利尿,改善右心功能,降低静脉系统及淋巴系统压力,从而减少乳糜反流是不容忽视的重要措施。

Management of Chylopericardium and Chylothorax after OPen-heart Surgery

Objective To explore the pathogenesis and therapeutic way of chylopericardium and chylothorax. Methods Of 2250 patients who underwent open- heart surgery in our hospital from 1980 to 2000, 3(0.13%) developed chylopericardium and chylothorax after the radical operation for tetralogy of Fallot (TOF). The conservative therapy was used, and then reoperation for treatment of the unabated drainage performed in the 3 patients with chylopericardium and chylothorax. The clinical data of the 3 patients were analysed retrospectively. Results Of the 3 patients with chylopericardium and chylothorax, 1 was cured by reoperau'on following the conservative therapy and 2 by another conservative therapy after the reoperation. Conclusions Most cases of the chylopericardium and chylothorax, which are uncommon following the radical operation for TOF, may be conservatively treated. Favorable results will be expected if total gut rest, intravenous hypernutrition, effective drainage and decreasing right - side cardiac pressure are used.