胸骨正中切開による上行弓部大動脈置換術後の乳び胸に対する手術

Surgical Treatment for Postoperative Chylothorax after Aortic Arch Replacement via Median Sternotomy

乳び胸は胸部外科手術後に起こりうる合併症として知られているが，その治療方針は確立されていない．重症・難治例では，低栄養や免疫機能の低下から敗血症などの重大な合併症を引き起こすおそれがあり1），予後の改善には的確な診断と治療が必要である．保存的治療で軽快しない場合，最終的に外科的再手術を考慮せざるをえないが，その適応・タイミングを判断するのは容易でない2）．われわれは，胸骨正中切開による再弓部大動脈置換術後に発症した乳び胸に対し，比較的すみやかに再手術を決断し，乳び瘻を閉鎖して良好な結果を得たので，文献的考察を加えて報告する．

Postoperative chylothorax is known as a possible complication after thoracic surgery, but no treatment strategy has been established. We report a case of successful surgical treatment for postoperative chylothorax after redo aortic arch replacement via median sternotomy. A 48-year-old man, who had undergone redo aortic arch replacement for aortic pseudoaneurysm due to prosthetic vascular graft infection, developed postoperative chylothorax. Despite the conservative treatment with fasting and administration of octreotide for 4 days, there was no effect on reduction in drainage. Surgical repair was performed on postoperative day 13. About 3 hours before surgery, milk was administered from the nasogastric tube to make the drainage milky. After median re-sternotomy, a stump of the thoracic duct was clearly identified and exposed in the posterior mediastinum, and the thoracic duct was easily closed by clipping. There was no recurrence of chylothorax and oral intake was re-started on day 2. Early operation might be effective against postoperative chylothorax.