Dr. Luis Iván León Ortega & Joel Cazares - Best of the Best in Pediatric Surgery 2025

Chylothorax is associated with significant respiratory morbidity, thoracic cavity compromise, nutritional deficiencies and immunosuppression.

Surgical options for chylothorax include pleurodesis, thoracic duct ligation using an open approach, thoracoscopic surgery and the creation of a pleuroperitoneal shunt.

The study included four patients diagnosed with chylothorax refractory to medical treatment, treated with thoracoscopy using indocyanine green between June 2020 and December 2023.

0.5 milligrams per kilogram of ICG is instilled percutaneously into the inguinal lymph nodes under ultrasound guidance after the anesthetic procedure.

Pneumothorax is induced with a pressure of 6 to 8 millimeters of mercury and a CO2 flow rate of 1 to 2 liters per minute.

Patch pleuritis is frequently observed owing to the presence of chyle or a history of chest tube placement, necessitating adhesion release when required.

Multiple ligation technique with clips at multiple points along the duct trajectory ensures definitive control of any leakage.

Average surgical duration was 75 minutes, ranging from 65 to 85 minutes, with improvement observed as the learning curve progressed.

The causes of chylothorax were two cases of congenital idiopathic chylothorax, one case of pulmonary lymphangiectasia and one iatrogenic case related to pleural decortication performed for complicated pneumonia.

Chylothorax was observed on the right side in three patients and on the left side in one patient.

During follow up, patients demonstrated both clinical and radiological progress with no recurrences and minimal nearly imperceptible scarring.

Identification of the thoracic duct in pediatric patients represents a significant challenge due to anatomical variability among individuals as well as factors such as mediastinitis and patch pleuritis associated with chylothorax.

Intraoperative fluorescence significantly facilitated identification and interruption of the thoracic duct, achieving successful ligation in 100% of cases.

Ultrasound guided installation of ICG directly into the lymph nodes is a safe and effective method for visualizing the thoracic duct.

The use of ICG technology enabled reduction in surgical time without complications, resulting in shorter hospital stays.

For the congenital case, the team opened a window into the pleura, identified the portion of the thoracic duct where leaking occurred, and applied multiple clips to obstruct any branches.

The team uses the Stryker system with the ICG camera 5 millimeters laparoscope.

The ICG dose is 0.5 milligram per kilogram applied around 45 minutes prior to patient positioning and starting the surgery.

Technical factors and platform differences may affect ICG visualization results, as some colleagues do not have the same results.