Peripheral Lymphovenous Shunting Followed by Thoracic Duct Ligation for Refractory Postoperative Chylothorax in a Premature Infant: A Case Report

A premature male infant born at 33+4 weeks of gestation (2.45 kg) developed refractory high-output chylothorax after arterial switch operation for d-transposition of the great arteries. Despite maximal conservative management, including fat-restricted enteral feeding, total parenteral nutrition, and octreotide infusion, chest tube output remained persistently elevated and was accompanied by failure to gain weight. As an adjunctive measure, peripheral lymphatic bypass surgery with lymphovenous and lymph node-to-vein anastomoses (LVA/LNVA) was performed in the lower extremity and groin. Following shunting, peripheral genital and limb edema improved, and objective clinical parameters supported partial physiologic stabilization during the interval before definitive intervention. However, thoracic drainage re-escalated and hemodynamic and nutritional instability persisted, leading to thoracic duct ligation. Following ligation, chest drainage declined durably, all tubes were removed, and the patient demonstrated catch-up weight gain without systemic lymphedema, protein-losing complications, or procedure-related adverse events. This case supports a step-up strategy in which peripheral lymphatic bypass surgery, including inguinal lymph node-to-vein anastomosis (LNVA) and lower-extremity lymphaticovenous anastomosis (LVA), serve as adjunctive stabilizing measures in premature infants with refractory postoperative chylothorax, while timely thoracic duct ligation remains essential for definitive resolution of persistent central leakage.