Cardiothoracic Surgery: Student/Resident Case Report Poster - Cardiac and Thoracic Surgery |

Integral Management of Cerebrospinal-Pleural Fistula Secondary to Patent Ductus Arteriosus Ligation Surgery FREE TO VIEW

Carlos Latorre Dávila, MD; Diana Yepez-Ramos, MD; Walid Dajer-Fadel, MD; Serafín Ramírez-Castañeda, MD; Octavio Calderon, MD; Kleber Gonzalez Echeverria, MD
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Hospital General de Mexico, Ciudad de Mexico, Mexico

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):58A. doi:10.1016/j.chest.2016.08.065
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SESSION TITLE: Student/Resident Case Report Poster - Cardiac and Thoracic Surgery

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: We report one case of subarachnoid-pleural fistula of a girl who had a thoracic surgery for patent ductus arteriosus ligation by left posterolateral thoracotomy approach. She experienced postoperative pleural effusion, which confirmed to be a cerebrospinal fluid fistula. Subarachnoid-pleural fistula is a rare complication seen in cardiothoracic surgery for chest wall, lung or spine operations for neoplastic disease caused by disruption of the costovertebral angle anatomy, exposing the subarachnoid space to the pleural cavity that prompted this report.

CASE PRESENTATION: A 7-year-old girl weighing 19.5 kilograms who had a patent ductus arteriosus ligation by a left posterolateral thoracotomy through on the 4th intercostal space. A chest drain left in place, the clinical parameters were stable and the patient was translated extubated to the PICU. There was 150 ml of blood stain fluid in the first 48 hours which continued to be in the range of 160-250 ml for the next 7 days by which it became watery an very clear. On the 8th day began with symptoms of fever and intermitent headaches. Water seal was left in passive suction. The conservative management included bedrest for one week, flat head position, broad-spectrum antibiotics, and no suction on chest tube with unsuccessful outcome. Because of that, the surgical treatment was indicated.

DISCUSSION: One of the approaches to reach the PDA is by thoracotomy through the 3rd or 4th intercostal space using a costal retractor but if the open of the space is large can produce disruption of the costovertebral junction and lead to the formation of a leak of CSF. Because of this, at the end of the patent ductus arteriosus ligation is recommended that the patients should be ventilated to increased intrathoracic pressure; this maneuver is helpful intraoperatively for early recognition of SPF for timely repair because spontaneous closure seldom occurs and is unlikely to heal spontaneously.

CONCLUSIONS: In our case because of the age and the quantity of the drain during the time the patient was in bed, and after the conservative management which included subarachnoid drainage, rest in bed with head in flat position, no suction on chest tube, antibiotics coverage, and drugs to decrease CSF production like acetazolamide and omeprazole, with unsuccessful result because the chest tube continued with a drainage between 150 - 200 ml per day we decided the surgical treatment.

Reference #1: Shamji MF, Sundaresan S, Da Silva V, Seely J, Shamji FM. Subarachnoid-Pleural Fistula: Applied Anatomy of the Thoracic Spinal Nerve Root. Int Sch Res Notices. 2011;2011:8.

Reference #2: Shimizu K, Otarii Y, Ibe T, Kawashima O, Kamiyoshihara M, Morishita Y. Successful treatment of subarachnoid-pleural fistula using pericardial fat pad and fibrin glue after chest wall resection for lung cancer. Jpn J Thorac Cardiovasc Surg. 2005;53:93-96.

Reference #3: Mokri B. Intracranial hypertension after treatment of spontaneous cerebrospinal fluid leaks. Mayo Clin Proc 2002;77:1241-1246.

DISCLOSURE: The following authors have nothing to disclose: Carlos Latorre Dávila, Diana Yepez-Ramos, Walid Dajer-Fadel, Serafín Ramírez-Castañeda, Octavio Calderon, Kleber Gonzalez Echeverria

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