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Duletzke NT, Kiraly LN, Martindale RG. Chylothorax and chylous ascites: Overview, management, and nutrition. Nutr Clin Pract 2023; 38:557-563. [PMID: 36938719 DOI: 10.1002/ncp.10973] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 03/21/2023] Open
Abstract
Chyle leaks of any source or type can cause significant morbidity and mortality. Attention to the anatomy and physiology of the leak, followed by stepwise dietary and pharmacologic management, obviates the need for surgical intervention in a majority of patients. In this article, we review the importance, etiology, anatomy, diagnosis, nutrition and immunologic effects, and options for treatment of chylothorax and chylous ascites based on experience and prior literature. We propose a multidisciplinary approach to optimize these treatments including the primary surgical teams, pharmacists, and dietitians, with reoperation as a last resort to minimize the morbidity of this challenging complication.
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Affiliation(s)
- Nicholas T Duletzke
- Department of Surgery, Oregon Health and Science University, Oregon, Portland, USA
| | - Laszlo N Kiraly
- Department of Surgery, Oregon Health and Science University, Oregon, Portland, USA
| | - Robert G Martindale
- Department of Surgery, Oregon Health and Science University, Oregon, Portland, USA
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2
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Jenkinson AC, McGuinness J, Prendiville T. Octreotide for Acquired Chylothorax in Pediatric Patients Post-Cardiothoracic Surgery for Congenital Heart Disease: A Systematic Review. Pediatr Cardiol 2023; 44:297-305. [PMID: 36255468 DOI: 10.1007/s00246-022-03024-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 10/03/2022] [Indexed: 02/07/2023]
Abstract
Chylothorax is a life-threatening complication post-corrective congenital heart surgery. Octreotide is used for treatment of refractory chylothoraces, with no standardized treatment protocol and a paucity of literature describing its efficacy. Our aim was to provide an update on the safety and efficacy of octreotide for the treatment of refractory chylothoraces in neonatal and pediatric patients' post-corrective congenital heart surgery. We performed a systematic review of PubMed, Medline, CINAHL, and Cochrane Library databases. Only intravenous octreotide treatment was included. A total of 621 patients across 27 studies were included. Studies included were 11 case series, 5 case studies, and 11 retrospective cohort studies. Variation in treatment regimens were reported. Treatment efficacy was reported in 95% (23/27) of studies. Definitions of treatment efficacy were reported in 33% (9/27) of studies. No prospective or randomized control trials were available for inclusion. Octreotide efficacy is widely reported despite a lack of standardization on criteria for treatment initiation or what defines an appropriate response to therapy.Please check and confirm whether the edit made to the article title is in order.Yes.
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Affiliation(s)
- A C Jenkinson
- Department of Cardiology, Children's Heart Centre, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - J McGuinness
- Department of Cardiothoracic Surgery, Children's Heart Centre, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - T Prendiville
- Department of Cardiology, Children's Heart Centre, Children's Health Ireland at Crumlin, Dublin, Ireland. .,Department of Pediatric Cardiology, Children's Heart Centre, Children's Health Ireland at Crumlin Hospital, Dublin, Ireland.
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3
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Subcutaneous octreotide therapy for malignant pleural effusion after pleurodesis with talc powder: a placebo-controlled, triple-blind, randomized trial. Support Care Cancer 2022; 30:9833-9840. [DOI: 10.1007/s00520-022-07440-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 10/27/2022] [Indexed: 11/12/2022]
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4
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Ur Rehman K, Sivakumar P. Non-traumatic chylothorax: diagnostic and therapeutic strategies. Breathe (Sheff) 2022; 18:210163. [PMID: 36337134 PMCID: PMC9584559 DOI: 10.1183/20734735.0163-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 05/31/2022] [Indexed: 12/04/2022] Open
Abstract
Non-traumatic chylothorax refers to accumulation of chyle in the pleural space in the absence of any traumatic disruption to the thoracic duct. Chyle originates from the intestines and is transported via the thoracic duct into systemic circulation. The anatomical course of the thoracic duct is complex with considerable variation; therefore, development of chylothorax is dependent on the site and level of the thoracic duct defect. Non-traumatic chylothorax is associated with a wide range of medical disorders, but malignancy accounts for three-quarters of cases. In up to 9% of cases, the aetiology remains unknown (termed idiopathic chylothorax). Gross appearance of pleural fluid is neither sensitive nor specific enough to diagnose chylothorax; therefore, biochemical analysis of the pleural fluid is required. Pleural fluid triglyceride level >1.24 mmol·L−1 (110 mg·dL−1) with a cholesterol level <5.18 mmol·L−1 (200 mg·dL−1) is diagnostic of chylothorax. In borderline cases, lipoprotein electrophoresis can help confirm the diagnosis by detecting chylomicrons in the pleural fluid. Once the diagnosis of chylothorax is confirmed, the next step is to find the cause and identify the leakage point, for which various lymphatic specific radiological investigations may have an important role. There is paucity of data on the most suitable approach to manage non-traumatic chylothoraces and treatment often depends on the underlying cause. In general, conservative treatment is tried first, usually for a limited time, before considering more invasive measures. A multidisciplinary approach is recommended with close liaison among the respiratory physicians, thoracic surgeons, oncologists, interventional radiologists, dietitians and pharmacists. Non-traumatic chylothorax is associated with a myriad of medical disorders. Lipid analysis of pleural fluid is required to confirm the diagnosis. A multidisciplinary approach is recommended for the effective management of non-traumatic chylothorax. https://bit.ly/3Nssb7n
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Saad D, Makarem A, Fakhri G, Al Amin F, Bitar F, El Rassi I, Arabi M. The use of steroids in treating chylothorax following cardiac surgery in children: a unique perspective. Cardiol Young 2022; 32:1-6. [PMID: 35361290 DOI: 10.1017/s1047951122000750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Chylothorax is the accumulation of chyle fluid in the pleural space. The incidence of chylothorax is quite common post-cardiac surgeries in pediatrics especially in Fontan procedures. Although several treatment lines are known for the management of chylothorax, steroids were scarcely reported as a treatment option. We present a unique case of a 4-year-old child who underwent Fontan procedure and suffered a long-term consequence of chylothorax. The chylothorax only fully resolved after introducing corticosteroids as part of her management. METHODS A literature review about management of chylothorax post-cardiac surgery in children using Ovid Medline (19462021), PubMed, and google scholar was performed. CONCLUSION Conservative management without additional surgical intervention is adequate in most patients. Additionally, somatostatin can be used with variable success rate. However, a few cases mentioned using steroids in such cases. More research and reporting on the use of steroids in the treatment of chylothorax post-cardiac surgeries in children is needed to prove its effectivity. In this article, we describe a case of chylothorax post-Fontan procedure that supports the use of steroids.
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Affiliation(s)
- Dima Saad
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Adham Makarem
- Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ghina Fakhri
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Farah Al Amin
- Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Fadi Bitar
- Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Issam El Rassi
- Department of Cardiothoracic Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mariam Arabi
- Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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Mas E, Borrelli O, Broekaert I, de-Carpi JM, Dolinsek J, Miele E, Pienar C, Koninckx CR, Thomassen RA, Thomson M, Tzivinikos C, Benninga MA. Drugs in Focus: Octreotide Use in Children With Gastrointestinal Disorders. J Pediatr Gastroenterol Nutr 2022; 74:1-6. [PMID: 34508049 DOI: 10.1097/mpg.0000000000003294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
ABSTRACT Octreotide, a somatostatin analogue, has been used for more than 20 years in children with gastrointestinal bleeding, chylothorax or chylous ascites, intestinal lymphangiectasia, pancreatitis, intestinal dysmotility, and severe diarrhoea; however, until now, there is a lack of randomised clinical trials evaluating the efficacy of this compound in childhood. Hence, we aimed to review the literature in order to determine the evidence of its use and safety in children, using PubMed from 2000 to 2021 with the search terms "octreotide" and "children" and "bleeding or chylous ascites or chylothorax or acute pancreatitis or lymphangiectasia or diarrhoea or intestinal dysmotility".
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Affiliation(s)
- Emmanuel Mas
- Unité de Gastroentérologie, Hépatologie, Nutrition, Diabétologie et Maladies Héréditaires du Métabolisme, Hôpital des Enfants, CHU de Toulouse; IRSD, Université de Toulouse, INSERM, INRAE, ENVT, UPS, Toulouse, France
| | - Osvaldo Borrelli
- Department of Paediatric Gastroenterology, Neurogastroenterology and Motility Unit, Great Ormond Street Hospital, London, UK
| | - Ilse Broekaert
- Department of Paediatrics, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - J Martin de-Carpi
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Jernej Dolinsek
- Department of Paediatrics, University Medical Centre Maribor, Maribor, Slovenia
| | - Erasmo Miele
- Department of Translational Medical Science, Section of Paediatrics, University of Naples "Federico II", Naples Italy
| | - Corina Pienar
- Department of Paediatrics, 2 Paediatric Clinic, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | - C Ribes Koninckx
- Paediatric Gastroenterology, La Fe University Hospital, Valencia, Spain
| | - Ruth-Anne Thomassen
- Department of Paediatric Medicine, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Mike Thomson
- Centre for Paediatric Gastroenterology, Sheffield Children's Hospital NHS Foundation Trust, Sheffield, UK
| | - Christo Tzivinikos
- Department of Paediatric Gastroenterology, Al Jalila Children's Specialty Hospital, Dubai, UAE
| | - Marc A Benninga
- Department of Paediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Power R, Smyth P, Donlon NE, Nugent T, Donohoe CL, Reynolds JV. Management of chyle leaks following esophageal resection: a systematic review. Dis Esophagus 2021; 34:doab012. [PMID: 33723611 PMCID: PMC8597908 DOI: 10.1093/dote/doab012] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 01/28/2021] [Accepted: 02/01/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Chyle leakage is an uncommon but potentially life-threatening complication following esophageal resections. The optimal management strategy is not clear, with a limited evidence base. METHODS Searches were conducted up to 31 December 2020 on MEDLINE, Embase, and Web of Science for randomized trials or retrospective studies that evaluated the management of chyle leakage following esophageal resection. Two authors independently screened studies, extracted data, and assessed for bias. The protocol was prospectively registered on PROSPERO (CRD: 42021224895) and reported in accordance with preferred reporting items for systematic reviews and meta-analyses guidelines. RESULTS A total of 530 citations were reviewed. Twenty-five studies, totaling 1016 patients met the inclusion criteria, including two low-quality clinical trials and 23 retrospective case series. Heterogeneity of study design and outcomes prevented meta-analysis. The overall incidence of chyle leak/fistula was 3.2%. Eighteen studies describe management of chyle leaks conservatively, 17 by surgical ligation of the thoracic duct, 5 by pleurodesis, and 6 described percutaneous lymphangiography with thoracic duct embolization or disruption. CONCLUSIONS The evidence base for optimal management of chyle leakage postesophagectomy is lacking, which may be related to its low incidence. There is a paucity of high-quality prospective studies directly comparing treatment modalities, but there is some low-certainty evidence that percutaneous approaches have reduced morbidity but lower efficacy compared with surgery. Further high-quality, prospective studies that compare interventions at different levels of severity are needed to determine the optimal approach to treatment.
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Affiliation(s)
- Robert Power
- National Oesophageal and Gastric Centre, St James's Hospital, Dublin, Ireland
| | - Philip Smyth
- National Oesophageal and Gastric Centre, St James's Hospital, Dublin, Ireland
| | - Noel E Donlon
- National Oesophageal and Gastric Centre, St James's Hospital, Dublin, Ireland
| | - Timothy Nugent
- National Oesophageal and Gastric Centre, St James's Hospital, Dublin, Ireland
| | - Claire L Donohoe
- National Oesophageal and Gastric Centre, St James's Hospital, Dublin, Ireland
| | - John V Reynolds
- National Oesophageal and Gastric Centre, St James's Hospital, Dublin, Ireland
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8
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Jackson S, Jnah AJ. Chylothorax: A Stepwise Approach to Diagnosis and Treatment. Neonatal Netw 2021; 40:386-392. [PMID: 34845089 DOI: 10.1891/11-t-705] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2021] [Indexed: 11/25/2022]
Abstract
Chylothorax, a lymphatic flow disorder characterized by an abnormal circulation of lymph fluid into the pleural cavity, is the most common cause of pleural effusions during the neonatal period. This condition affects 1/15,000 neonates every year. Affected neonates often manifest with respiratory distress, electrolyte imbalances, sepsis, and even immunodeficiencies. Mortality risk is highest among neonates undergoing cardiac surgery as well as those with associated hydrops fetalis. Conservative treatment options include bowel rest with administration of parenteral nutrition, followed with medium-chain triglyceride enteral feedings, and octreotide therapy. Severe or persistent cases require surgical intervention. This can involve a unilateral or bilateral pleurectomy and thoracic duct ligation, with or without pleurodesis. Early identification and successful treatment of this condition is contingent upon awareness of the most current evidence and a timely cross-disciplinary approach to care.
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Resch B, Sever Yildiz G, Reiterer F. Congenital Chylothorax of the Newborn: A Systematic Analysis of Published Cases between 1990 and 2018. Respiration 2021; 101:84-96. [PMID: 34515211 DOI: 10.1159/000518217] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 06/28/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Congenital chylothorax (CCT) of the newborn is a rare entity but the most common cause of pleural effusion in this age-group. We aimed to find the optimal treatment strategy. MATERIAL AND METHODS A PubMed search was performed according to the PRISMA criteria. All cases were analyzed according to prenatal, perinatal, and postnatal treatment modalities and follow-ups. RESULTS We identified 753 cases from 157 studies published between 1990 and 2018. The all-cause mortality rate was 28%. Prematurity was present in 71%, male gender dominated 57%, mean gestational age was 34 weeks, and birth weight was 2,654 g. Seventy-nine percent of newborns had bilateral CCT, the most common associated congenital anomalies with CCT were pulmonary lymphangiectasia and pulmonary hypoplasia, and the most common chromosomal aberrations were Down, Noonan, and Turner syndromes, respectively. Mechanical ventilation was reported in 381 cases for mean 17 (range 1-120) days; pleural punctuations and drainages were performed in 32% and 64%, respectively. Forty-four percent received total parenteral nutrition (TPN) for mean 21 days, 46% medium-chain triglyceride (MCT) diet for mean 37 days, 20% octreotide, and 3% somatostatin; chemical pleurodesis was performed in 116 cases, and surgery was reported in 48 cases with a success rate of 69%. In 462 cases (68%), complete restitution was reported; in 34 of 44 cases (77%), intrauterine intervention was carried out. CONCLUSION Respiratory support, pleural drainages, TPN, and MCT diet as octreotide remain to be the cornerstones of CCT management. Pleurodesis with OK-432 done prenatally and povidone-iodine postnatally might be discussed for use in life-threatening CCT.
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Affiliation(s)
- Bernhard Resch
- Research Unit for Neonatal Infectious Diseases and Epidemiology, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Gülsen Sever Yildiz
- Research Unit for Neonatal Infectious Diseases and Epidemiology, Medical University of Graz, Graz, Austria
| | - Friedrich Reiterer
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
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Cochrane CN, Collin N, Langton Hewer SC. A breathless teenager. Breathe (Sheff) 2021; 17:210027. [PMID: 34295426 PMCID: PMC8291959 DOI: 10.1183/20734735.0027-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 04/15/2021] [Indexed: 11/24/2022] Open
Abstract
A 14-year-old girl presented to hospital with breathlessness and fatigue. On admission she was hypoxaemic with oxygen saturations of 90%, tachycardic with a heart rate of 120 beats·min−1 and tachypnoeic with a respiratory rate of 40–50 breaths·min−1. In children with persistent chylothoraces of unknown origin, intranodal lymphangiography can be used to help identify the source of a leak. This may enable embolisation with glue and coils to enable resolution of the chylothoraces.https://bit.ly/3gskhgJ
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Affiliation(s)
| | - Neil Collin
- Dept of Radiology, Southmead Hospital, Bristol, UK
| | - Simon C Langton Hewer
- Dept of Paediatric Respiratory Medicine, Bristol Royal Hospital for Children, Bristol, UK
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11
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Stange S, Sziklavari Z. [Modern Treatment Options for Postoperative Chylothorax: a Systematic Review]. Pneumologie 2021; 75:439-446. [PMID: 34116575 DOI: 10.1055/a-1172-7288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Chylothorax is a multifactorial complication, usually caused by surgery or traumatic injury, and more rarely by malignant disease. Because of the lack of prospective, randomised trials, the evidence-based treatment rests upon personal experience, but ideally taking into account retrospective analysis. MATERIAL AND METHODS The aim of this review is to provide a comprehensive overview of the currently available modern treatment options. Another aspect is to show their advantages and disadvantages. For this purpose, a literature search was performed using the "PubMed" database. Publications older than ten years were excluded from this review. The literature search employed the keyword "chylothorax". The priority was set on publications including a comparative assessment of treatment approaches. The authors relied on many years of clinical experience to critically analyse and evaluate the treatment options and the given recommendations. RESULTS The success rate of the conservative treatment methods ranges widely, depending on the underlying cause of the disease (3-90 %). Non-invasive or semi-invasive procedures are successful in 50 to 100 % of the cases, also depending on the aetiology. After unsuccessful conservative treatment of operable patients, the standard surgical therapy consists of thoracic duct ligature, which is usually performed thoracoscopically. Alternatively, pleurodesis or the placement of a permanent chest drain (PleurX) or a pleuroperitoneal shunt may be performed. The success rate of these procedures is between 64 and 100 %. The morbidity and mortality rate can reach values up to 25 %. CONCLUSION Treatment of a chylothorax should be started conservatively. Subsequently, a more aggressive therapy may be gradually considered, based on the patient's health and the amount of the secretion. Interventional radiological procedures are safe, successful, and have a legitimate place alongside conservative or surgical treatment. However, they are currently only available in some larger centres.
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Affiliation(s)
- S Stange
- Klinik für Thoraxchirurgie, Regiomed Kliniken GmbH, Sonneberg/Coburg
| | - Z Sziklavari
- Klinik für Thoraxchirurgie, Regiomed Kliniken GmbH, Sonneberg/Coburg
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12
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Treatment of Chylothorax complicating pulmonary resection with hypertonic glucose Pleurodesis. J Cardiothorac Surg 2021; 16:149. [PMID: 34049583 PMCID: PMC8161928 DOI: 10.1186/s13019-021-01462-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 04/05/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To retrospectively assess the efficacy of hypertonic glucose pleurodesis for treatment of chylothorax after pulmonary resection. METHODS Out of a total of 8252 patients who underwent pulmonary resection (at least lobectomy) at department of thoracic surgery, between June 2008 and December 2015, 58 patients (0.7%) developed postoperative chylothorax. All patients received conservative treatment, including thoracic closed drainage, oral fasting, and total parenteral nutrition. RESULTS Conservative treatment was successful in 50 (86.2%) patients, while eight patients [mean age: 58.0 years (range, 45-75)] were treated with hypertonic glucose pleurodesis. All eight patients had undergone operation for lung cancer (four squamous cell carcinomas and four adenocarcinomas). The bronchial stump was covered by pleural flap in three patients. After pleurodesis, three patients developed fever but without empyema; thoracentesis was performed in two patients. The mean time interval between pleurodesis and operation was 4.3 days (range,3-5) days. The average length of stay was 23.1 days (range, 18-31). No recurrent pleural effusion was observed over a mean follow-up duration of 28 months. CONCLUSION Hypertonic glucose pleurodesis performed via the chest drainage tube is a viable treatment option for chylothorax after lung resection, prior to resorting to a thoracoscopic or thoracotomic ductus thoracicus ligation of the thoracic duct leak. It is a simple, safe and efficient modality associated with rapid recovery and less pain.
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13
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Mahajan A, Sankhyan P, Boonpheng B. Bilateral Chylothorax and Chylous Ascites: A Rare Presentation of an Uncommon Disorder. Cureus 2021; 13:e14044. [PMID: 33898130 PMCID: PMC8059777 DOI: 10.7759/cureus.14044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We describe the case of a 62-year-old female who presented with gradually progressing abdominal distension and dyspnea. Computed tomography (CT) chest and abdomen revealed large bilateral pleural effusions with large ascites, a mid-abdominal mass, and peritoneal carcinomatosis. Pleural and peritoneal tap revealed chylous fluid, and the biopsy findings from abdominal mass were consistent with follicular lymphoma. We then discuss a review of the literature and diagnoses for bilateral chylothorax and chylous ascites.
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Affiliation(s)
- Akhilesh Mahajan
- Pulmonary Critical Care, Lenox Hill Hospital, New York, USA.,Internal Medicine, East Tennessee State University, Johnson City, USA
| | - Pratyaksha Sankhyan
- Pulmonary Critical Care, East Carolina University, Greenville, USA.,Internal Medicine, East Tennessee State University, Johnson City, USA
| | - Boonphiphop Boonpheng
- Nephrology, University of California Los Angeles, Los Angeles, USA.,Internal Medicine, East Tennessee State University, Johnson City, USA
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14
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Tai HL, Mok TYD, Chao AS, Chu SM, Lien R. Staged Management of Congenital Chylothorax With Hydrops Fetalis: An Insight Into EXIT Related Procedures. Front Pediatr 2021; 9:633051. [PMID: 33681104 PMCID: PMC7925828 DOI: 10.3389/fped.2021.633051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 01/19/2021] [Indexed: 11/21/2022] Open
Abstract
Background: Idiopathic congenital chylothorax is a rare but serious disease. Advancement in perinatal care and the renovated treatment modalities have brought about significant improvement in patient outcome. Objective: To describe the clinical course of severe forms of idiopathic congenital chylothorax, focusing on the development of recent treatment modalities and their impacts. Design: A retrospective cohort by review of medical records in the NICU of a perinatal referral center in Taiwan. Study period was from January 2006 to June 2017. Neonates with the diagnosis of idiopathic congenital chylothorax with non-immune hydrops fetalis were enrolled. Clinical relevant including demographic data, perinatal interventions, post-natal course, and treatment outcome were described and analyzed. Results: Twenty-eight neonatal patients were included. The median gestational age at birth was 34 (range 27-36) weeks and median birth weight was 2,369 (range 1,430-3,608) g. Prenatal intervention was performed in 39.3% of the patients. Besides, 11 out of the 28 neonates developed tension pneumothorax in the first 24 h and 4 (36.4%) of them died. Sepsis was documented in two patients (7.1%). Overall survival rate was 71.4%. There were five patients enrolled during the last 2 years of the study period. EXIT with intubation was performed in two and octreotide was given to four of these most recent neonates, and all of them survived. Conclusion: Recent advances in the management of these neonates, specifically EXIT with intubation and use of octreotide. Both of them improved patient survival in our cohort, but the evidence of impact has yet to be validated.
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Affiliation(s)
- Hung-Lin Tai
- Department of Pediatrics, Saint Paul's Hospital, Taoyuan City, Taiwan.,Division of Neonatalogy, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Tze Yee Diane Mok
- Division of Neonatalogy, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan City, Taiwan.,New Taipei Municipal TuCheng Hospital (Built and Operated by Chang Gung Medical Foundation), New Taipei City, Taiwan
| | - An-Shine Chao
- Department of Obstetrics and Gynecology, Chang Gung Medical Center, Taoyuan City, Taiwan.,School of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Shih-Ming Chu
- Division of Neonatalogy, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan City, Taiwan.,School of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Reyin Lien
- Division of Neonatalogy, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan City, Taiwan.,School of Medicine, Chang Gung University, Taoyuan City, Taiwan
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15
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Vass G, Evans Fry R, Roehr CC. Should Newborns with Refractory Chylothorax Be Tried on Higher Dose of Octreotide? Neonatology 2021; 118:122-126. [PMID: 33494092 DOI: 10.1159/000512461] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 10/20/2020] [Indexed: 12/13/2022]
Abstract
Chylothorax is a rare but life-threatening condition in newborns, often requiring a prolonged hospital stay. To date, no unified guidance exists for best management approach. Octreotide, a somatostatin analogue, has been used to treat neonatal chylothorax due to its effect on the splanchnic circulation and lipid absorption. It is administered either subcutaneously or intravenously; for the latter, a dose range between 1 and 10 µg/kg/h is most commonly used. However, the optimal dose and way of administration remain unclear. Here, we report 2 newborn cases with large volume chylothorax (>500 mL/day), one with congenital chylothorax and one following a repair of a congenital diaphragmatic hernia (post-operative form). In both cases, a significant and sustained reduction in the volume of evacuated chyle was only seen once the dose of intravenous octreotide was increased to 20 µg/kg/h. We suggest that high-dose octreotide can be considered in seemingly refractory cases of neonatal chylothorax.
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Affiliation(s)
- Geza Vass
- Newborn Services, John Radcliffe Hospital, Oxford University Hospitals, NHS Foundation Trust, Oxford, United Kingdom,
| | - Ria Evans Fry
- Newborn Services, John Radcliffe Hospital, Oxford University Hospitals, NHS Foundation Trust, Oxford, United Kingdom
| | - Charles C Roehr
- Newborn Services, John Radcliffe Hospital, Oxford University Hospitals, NHS Foundation Trust, Oxford, United Kingdom.,National Perinatal Epidemiology Unit, Nuffield Department of Population Health, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
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Abstract
Purpose of Review Lymphatic disorders have received an increasing amount of attention over the last decade. Sparked primarily by improved imaging modalities and the dawn of lymphatic interventions, understanding, diagnostics, and treatment of lymphatic complications have undergone considerable improvements. Thus, the current review aims to summarize understanding, diagnostics, and treatment of lymphatic complications in individuals with congenital heart disease. Recent Findings The altered hemodynamics of individuals with congenital heart disease has been found to profoundly affect morphology and function of the lymphatic system, rendering this population especially prone to the development of lymphatic complications such as chylous and serous effusions, protein-losing enteropathy and plastic bronchitis. Summary Although improved, a full understanding of the pathophysiology and targeted treatment for lymphatic complications is still wanting. Future research into pharmacological improvement of lymphatic function and continued implementation of lymphatic imaging and interventions may improve knowledge, treatment options, and outcome for affected individuals.
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17
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Long WG, Cai B, Deng JM, Liu Y, Wang WJ, Luo J. Chemical pleurodesis and somatostatin in treating spontaneous chylothorax in pediatric patients: a retrospective analysis and review of the literature. Transl Pediatr 2020; 9:551-560. [PMID: 32953553 PMCID: PMC7475317 DOI: 10.21037/tp-20-199] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Chylothorax is a rare disease, defined as an abnormal accumulation of chylous lymphatic effusion in thoracic cavity, with a high mortality rate in pediatric patients. At present, there are few studies on the treatment of pediatric chylothorax, and conservative treatments like somatostatin (SST) and pleurodesis are performed empirically. SST has been used for treating pediatric chylothorax over 20 years, and povidone-iodine chemical pleurodesis (PICP) is adopted in recent years with a high cure rate, but both the effect are still uncertain. The safety and efficacy of SST and PICP in treating pediatric chylothorax was compared in this study. METHODS From January 2009 to May 2020, 27 pediatric chylothorax patients who accepted life support, SST and PICP treatment were retrospectively reviewed in this study. Their medical history, clinical manifestations, pleural effusion examinations, treatment methods, effects, and complications were screened. PICP and SST was performed in 19 and 8 children, respectively. Each patient was followed up after discharge from the hospital. RESULTS After admission, chest X-ray and ultrasound diagnosed pleural effusion in 27 patients (18 males and 9 females), including 13 and 6 cases on the left and right side, and 8 cases on both sides. In the pleural effusion, the mean leukocyte count was (9,826±9,482)×106/L, the mean lymphocyte ratio was (84.82±6.58)%, the mean triglyceride content was 7.11±6.63 mmol/L. In PICP and SST group, the mean length of stay was 38.42±19.42 and 35.13±12.72 d (P=0.664), the mean time of thoracic drainage was 24.58±16.34 and 19.63±8.88 d (P=0.440), the mean time of parenteral nutrition was 27.16±18.29 and 25.25±13.52 d (P=0.793), respectively. PICP was performed for 3.16±2.27 times, and SST was used for 14.75±9.08 d with the dosage of 0.5 to 10 µg/kg/hour. After the treatment, all patients in PICP group had mild chest pain and low-grade fever, and 12 cases were observed with transient decrease of oxygen saturation. Eight patients in SST group had nausea and vomit, and 1 child had diarrhea simultaneously. Both were cured by symptomatic treatment, thoracic drainage and discontinuing using SST. Three children were diagnosed with refractory chylothorax and cured by PICP after SST. Pleural effusion in 27 patients was finally absorbed. All of them achieved a clinical cure successfully, and there was no recurrence during discharge follow-up. CONCLUSIONS PICP has a high success rate and few adverse reactions in treating spontaneous chylothorax in pediatric patients, expected to be a new treatment option for pediatric chylothorax after SST.
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Affiliation(s)
- Wei-Guang Long
- Department of Chest Wall Surgery, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Bin Cai
- Department of Chest Wall Surgery, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Jian-Ming Deng
- Department of Chest Wall Surgery, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Yang Liu
- Department of Chest Wall Surgery, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Wen-Jie Wang
- Department of Chest Wall Surgery, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Juan Luo
- Department of Chest Wall Surgery, Guangdong Second Provincial General Hospital, Guangzhou, China
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18
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Bacon BT, Mashas W. Chylothorax caused by blunt trauma: Case review and management proposal. Trauma Case Rep 2020; 28:100308. [PMID: 32490128 PMCID: PMC7256325 DOI: 10.1016/j.tcr.2020.100308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2020] [Indexed: 11/17/2022] Open
Abstract
Chylothorax is a potentially devastating complication of lymphatic trauma of the thorax. To date, no recommendations have provided decision making support for prompt definitive treatment. We present a 53 year old male involved in a motor vehicle collision sustaining 9 left rib fractures with flail segments. He was treated non-operatively with a chest tube and no fat diet. A Case report review was performed and a proposed guideline for managing blunt trauma chylothorax in adult patients was developed. In low-output chylothorax, effective initial treatment begins with a no fat diet and chest tube. We propose that a low output leak be defined as <500 mL of initial output or <500 mL/day and can be managed non-operatively in nearly 100% of patients. High output injuries of >1000 mL of initial output will require surgical intervention and should be considered for prompt definitive care.
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Affiliation(s)
- Brandon T. Bacon
- Department of Surgery, University of Missouri-Kansas City, School of Medicine, United States of America
- Department of Surgery, St. Luke's Hospital of Kansas City, MO, United States of America
- Corresponding author at: Truman Medical Center, Department of Surgery, 2301 Holmes Street, Kansas City, MO 64108, United States of America.
| | - Wayne Mashas
- Department of Surgery, St. Luke's Hospital of Kansas City, MO, United States of America
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19
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Shah HA, Rynecki N, Vives MJ, Choi DE, Sambol JT, Sabharwal S. Chylous Leak During Posterior Approach to Juvenile Scoliosis Surgery: A Case Report. JBJS Case Connect 2020; 10:e0100. [PMID: 32224664 DOI: 10.2106/jbjs.cc.19.00100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE We report the first documented case of chylous leak recognized intraoperatively during posterior spinal instrumentation and fusion for juvenile scoliosis in a female patient with a history of thoracotomy and decortication for an empyema. CONCLUSIONS Thoracic duct injury can lead to severe morbidity and mortality because of chylothorax formation. Although chylous leaks are a well-documented complication of the anterior approach to spine surgery, leaks during the posterior approach are rarely reported. When these chylous leaks are recognized intraoperatively, the likelihood of serious complications may be minimized by drain placement before closure.
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Affiliation(s)
- Harsh A Shah
- Department of Orthopaedic Surgery, University of Miami, Miami, Florida
| | - Nicole Rynecki
- Department of Orthopaedic Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Michael J Vives
- Department of Orthopaedic Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Daniel E Choi
- Department of Orthopaedic Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Justin T Sambol
- Department of Cardiothoracic Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Sanjeev Sabharwal
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California
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20
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Liviskie CJ, Brennan CC, McPherson CC, Vesoulis ZA. Propranolol for the Treatment of Lymphatic Malformations in a Neonate - A Case Report and Review of Literature. J Pediatr Pharmacol Ther 2020; 25:155-162. [PMID: 32071591 DOI: 10.5863/1551-6776-25.2.155] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Lymphatic malformations in neonates often manifest as a chylothorax, and although rare, morbidity and mortality can be significant. First-line treatment with medium-chain triglyceride-enriched formulas, or enteric rest with total parenteral nutrition, are not always successful. We describe the case of a premature neonate with trisomy 21 who presented with bilateral pleural effusions and a pericardial effusion that worsened with the initiation of enteral nutrition. Clinical improvement was not seen until the initiation of treatment with oral propranolol at a maximum dosage of 0.5 mg/kg/day divided every 8 hours with extubation 8 days after propranolol initiation. Two case reports have described the use of propranolol in similar patients receiving 2 mg/kg/day; however, our experience is the first to report treatment success at a much lower dose. A review of the literature for alternative medication treatments uncovered numerous case reports and series documenting variable results with incongruent definitions of treatment success in a diverse patient population. The rarity of this disease state makes accrual of patients difficult and more robust treatment data unlikely. Therefore, selection of the optimal adjunctive treatment must be based on individual patient and disease state characteristics as well as safety and efficacy profile of the medication.
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21
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Chandran S, Agarwal A, Llanora GV, Chua MC. Necrotising enterocolitis in a newborn infant treated with octreotide for chylous effusion: is octreotide safe? BMJ Case Rep 2020; 13:13/2/e232062. [PMID: 32051156 DOI: 10.1136/bcr-2019-232062] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Octreotide is a somatostatin analogue used for treating congenital chylothorax and congenital hyperinsulinism in infants. By increasing splanchnic arteriolar resistance and decreasing gastrointestinal blood flow, octreotide indirectly reduces lymphatic flow in chylous effusions.Splanchnic ischaemia following octreotide predisposes infants to necrotising enterocolitis (NEC). Although NEC occurrence in infants treated with octreotide for hyperinsulinaemic hypoglycaemia has been reported widely, its incidence in infants with chylothroax is low. We describe a case of congenital chylothorax in a preterm infant who had poor response to thoracentesis. Although octreotide initiation lead to resolution of chylothorax, he developed NEC. Cessation of octreotide and medical management resulted in rapid resolution of NEC. Since octreotide is generally used as the first-line treatment for chylous effusion, the risk of NEC should be considered, especially when the dosage is increased. Infants on octreotide should be closely observed for early signs and symptoms of NEC to avert surgical emergency.
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Affiliation(s)
- Suresh Chandran
- Department of Neonatology, KK Women's and Children's Hospital, Singapore .,Department of Neonatology, Duke NUS Medical School, Singapore.,Department of Neonatology, NUS Yong Loo Lin School of Medicine, Singapore.,Department of Neonatology, Lee Kong Chian School of Medicine, Singapore
| | - Arpan Agarwal
- Department of Neonatology, KK Women's and Children's Hospital, Singapore.,Department of Neonatology, Duke NUS Medical School, Singapore.,Department of Neonatology, NUS Yong Loo Lin School of Medicine, Singapore
| | | | - Mei Chien Chua
- Department of Neonatology, KK Women's and Children's Hospital, Singapore.,Department of Neonatology, Duke NUS Medical School, Singapore.,Department of Neonatology, NUS Yong Loo Lin School of Medicine, Singapore.,Department of Neonatology, Lee Kong Chian School of Medicine, Singapore
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22
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The use of octreotide in the treatment of chylothorax. JOURNAL OF CONTEMPORARY MEDICINE 2019. [DOI: 10.16899/jcm.661279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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23
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Kim JW, Jin JH, Yoon SW. Povidone-Iodine Pleurodesis for Chylothorax in an Extremely Low Birth Weight Infant. NEONATAL MEDICINE 2019. [DOI: 10.5385/nm.2019.26.4.233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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24
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Bui A, Long CJ, Breitzka RL, Wolovits JS. Evaluating the Use of Octreotide for Acquired Chylothorax in Pediatric Critically Ill Patients Following Cardiac Surgery. J Pediatr Pharmacol Ther 2019; 24:406-415. [PMID: 31598104 DOI: 10.5863/1551-6776-24.5.406] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To evaluate the impact of octreotide on time to resolution of chylothorax compared with conventional therapy. Secondary outcomes include the following: time to reduction of chest tube output by 20%, additional surgeries for chylothorax, hospital length of stay, in-hospital mortality, and adverse drug reactions. METHODS We retrospectively evaluated the efficacy of octreotide vs conventional therapy for treatment postoperative chylothorax in pediatric patients in the cardiac ICU following surgery for congenital heart disease between October 2008 and June 2017. RESULTS Final analysis included 32 patients with chylothorax who met inclusion criteria. Patients who received octreotide had a longer duration of chest tube drainage than those who received conventional therapy (24 vs 9 days, p < 0.001). Resolution of chylothorax was achieved in 13 of 16 (81.3%) octreotide patients and 16 of 16 (100%) conventional patients (p = 0.178). There was a comparable time to reduction by 20% in drainage (6 vs 8 days, p = 0.337). There was no significant correlation between time after starting conventional management and reduction chylous output in either the octreotide or conventional therapy group (p = 0.809, p = 0.107, respectively). However, there was a significant and moderate correlation between octreotide and reduction in a chylous output following initiation of octreotide (R 2 = 0.464, p = 0.021). CONCLUSIONS Octreotide is potentially a safe and effective therapy for treatment in pediatric patients with refractory chylothorax following surgery for congenital heart disease.
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25
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Hermon M, Tenner E, Burda G, Strohmaier W, Schlager G, Golej J. Chylothorax and Chylous-Like Diseases in Children: Clinical Management. Front Pediatr 2019; 7:258. [PMID: 31316953 PMCID: PMC6610320 DOI: 10.3389/fped.2019.00258] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 06/06/2019] [Indexed: 01/30/2023] Open
Abstract
Background: Chylothorax and chylous-like diseases are rare conditions and difficult to treat. But they may represent potentially life-threatening disorders and important causes of morbidity and prolonged hospitalization, especially in critically ill children. Conservative as well as surgical therapeutic management strategies are continuously performed at our institution, however the results have never been evaluated and no guidelines for treatment recommendations have been put into practice so far. The objective of this retrospective study was to present a comprehensive and substantial evaluation of all relevant demographic data from children with the chylothorax and chylous-like diseases and their clinical management. Methods: We retrospectively analyzed data from all children with diagnoses of chylothorax and chylous-like diseases admitted to our pediatric intensive care unit between the years 1999 and 2012. Results: Data of 34 patients were analyzed for this study. Gender distribution (M/F) was almost equal (19/15; 56%/44%). Thirty-one children (91%) developed chylothorax after surgery. Two children (6%) had idiopathic chylothorax and in one child (3%) congenital chylothorax was diagnosed. All study patients (n = 34; 100%) received MBF/MCT therapy. We were quite successful in treating 14 children who received only this therapy, with chest tube output dropping from 100 to 4.7%. But only 11 (32%) children received somatostatin and 7 (20%) children received beta-isodona. Different surgical interventions were performed in 6 patients (17%). All study patients received chest tubes to drain the pleural fluid and hence to relieve the chyle related symptoms. Conclusion: A combination of different conservative therapies was successful in most of our patients. Prevention, early diagnosis and treatment of potential complications may further improve the success rate of conservative therapy especially in patients with postoperative chylothorax. In summary, appropriate therapy of this condition may be lengthy but can prevent significant morbidity and mortality.
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Affiliation(s)
- Michael Hermon
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Medical University of Vienna, Vienna, Austria
| | - Elias Tenner
- ENT-Department, Universitätsklinikum St. Pölten, Sankt Pölten, Austria
| | - Gudrun Burda
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Medical University of Vienna, Vienna, Austria
| | - Wolfgang Strohmaier
- Institut für Molekulare Biowissenschaften, Karl Franzens University Graz, Graz, Austria
| | - Gerald Schlager
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Medical University of Vienna, Vienna, Austria
| | - Johann Golej
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Medical University of Vienna, Vienna, Austria
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26
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Bellini C, Cabano R, De Angelis LC, Bellini T, Calevo MG, Gandullia P, Ramenghi LA. Octreotide for congenital and acquired chylothorax in newborns: A systematic review. J Paediatr Child Health 2018; 54:840-847. [PMID: 29602276 DOI: 10.1111/jpc.13889] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 01/16/2018] [Accepted: 02/12/2018] [Indexed: 12/26/2022]
Abstract
AIM Chylothorax is a rare but life-threatening condition in newborns. Octreotide, a somatostatin analogue, is widely used as a therapeutic option in neonates with congenital and acquired chylothorax, but its therapeutic role has not been clarified yet. METHODS We performed a systematic review to assess the efficacy and safety of octreotide in the treatment of congenital and acquired chylothorax in newborns. Comprehensive research, updated till 31 October 2017, was performed by searching in PubMed, MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL) databases using the MeSH terms 'octreotide' and 'chylothorax'. Both term and preterm newborns with congenital or acquired chylothorax treated with octreotide within the 30th day of life were included. Octreotide treatment was considered effective if a progressive reduction/ceasing in drained chylous effusion occurred. RESULTS A total of 39 articles were included. Octreotide was effective in 47% of patients, with a slight but not significant difference between congenital (30/57; 53.3%) and acquired (9/27; 33.3%) chylothorax (P = 0.10). Marked variation in octreotide regimen was observed. The most common therapeutic scheme was intravenous infusion at a starting dose of 1 μg/kg/h, gradually increasing to 10 μg/kg/h according to the therapeutic response. Side effects were reported in 12 of 84 patients (14.3%). Only case reports were included in this review due to the lack of randomised controlled trials. CONCLUSION Octreotide is a relatively effective and safe treatment option in neonates with chylothorax, especially for the congenital forms.
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Affiliation(s)
- Carlo Bellini
- Neonatal Intensive Care Unit, Neonatal Emergency Transport Service, Department of Mother and Child, Gaslini Children's Hospital, Genoa, Italy
| | - Rita Cabano
- Neonatal Intensive Care Unit, Neonatal Emergency Transport Service, Department of Mother and Child, Gaslini Children's Hospital, Genoa, Italy
| | - Laura C De Angelis
- Neonatal Intensive Care Unit, Neonatal Emergency Transport Service, Department of Mother and Child, Gaslini Children's Hospital, Genoa, Italy
| | - Tommaso Bellini
- Neonatal Intensive Care Unit, Neonatal Emergency Transport Service, Department of Mother and Child, Gaslini Children's Hospital, Genoa, Italy
| | - Maria G Calevo
- Epidemiology, Biostatistics and Committees Unit, Gaslini Children's Hospital, Genoa, Italy
| | - Paolo Gandullia
- Gastroenterology and Digestive Endoscopy Unit, Gaslini Children's Hospital, Genoa, Italy
| | - Luca A Ramenghi
- Neonatal Intensive Care Unit, Neonatal Emergency Transport Service, Department of Mother and Child, Gaslini Children's Hospital, Genoa, Italy
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Costa KM, Saxena AK. Surgical chylothorax in neonates: management and outcomes. World J Pediatr 2018; 14:110-115. [PMID: 29508361 DOI: 10.1007/s12519-018-0134-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 06/13/2017] [Accepted: 07/17/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Postoperative chylothorax occurs due to trauma to lymphatic vessels and can occur after any thoracic procedure. This study reviewed recent literature to evaluate the management and outcomes of surgical chylothorax in neonates. METHODS PubMed database was searched for articles in English, Portuguese and Spanish from 2000 to 2016. Data were collected for surgery, chylothorax management, complications, mortality and length of hospital stay (LOS). RESULTS Twenty studies offered 107 neonates: congenital diaphragmatic hernia (CDH) (n = 76, 71%), cardiac malformations (n = 25, 23.4%), esophageal atresia (n = 5, 4.7%) and CDH + extralobar sequestration (n = 1, 0.9%). Medium-chain triglycerides (MCT) was the initial treatment in 52 neonates (48.6%), prednisolone + MCT in one (0.9%), total parenteral nutrition in 51 patients (47.7%), and three patients (2.8%) did not require any treatment. Octreotide and somatostatin were used as second or third line treatment in 25 neonates (23.4%), and 15 neonates (14%) underwent 17 surgeries, including thoracic duct ligation (TDL) (n = 9); pleurodesis (n = 3) (2 patients required TDL); TDL + pleurodesis (n = 2), and TDL + placement of hemostat (n = 1). Complications due to the chylothorax were reported in 27 neonates (25.2%): hypoalbuminemia + hyponatremia (n = 18), hypoalbuminemia (n = 4), hypoalbuminemia with cutaneous flushing as colateral effect of somatostatin (n = 1), loose stool after somatostatin use (n = 1), pneumonia (n = 1), congestive heart failure + hypernatremia (n = 1), and hyponatremia (n = 1). There were 21 deaths (19.6%) and median LOS was 53.4 days (30-93.1 days). CONCLUSIONS Conservative management is appropriate as initial treatment for neonatal postsurgical chylothorax. Octreotide and somatostatin are safe in neonates and surgical approach should be considered in prolonged leaks.
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Affiliation(s)
- Karina Miura Costa
- Department of Pediatric Surgery, Chelsea Children's Hospital, Chelsea and Westminster Hospital NHS Foundation Trust, Imperial College London, London, UK
- Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Amulya Kumar Saxena
- Department of Pediatric Surgery, Chelsea Children's Hospital, Chelsea and Westminster Hospital NHS Foundation Trust, Imperial College London, London, UK.
- Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil.
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28
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Bellini C, De Angelis L, Cabano R, Ramenghi LA. Letter to the editor. J Pediatr Surg 2018; 53:580. [PMID: 29277468 DOI: 10.1016/j.jpedsurg.2017.10.062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 10/20/2017] [Indexed: 01/31/2023]
Affiliation(s)
- Carlo Bellini
- Neonatal Intensive Care Unit, IRCCS Gaslini Children's Hospital, Genoa, Italy.
| | - Laura De Angelis
- Neonatal Intensive Care Unit, IRCCS Gaslini Children's Hospital, Genoa, Italy
| | - Rita Cabano
- Neonatal Intensive Care Unit, IRCCS Gaslini Children's Hospital, Genoa, Italy
| | - Luca A Ramenghi
- Neonatal Intensive Care Unit, IRCCS Gaslini Children's Hospital, Genoa, Italy
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29
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Kumar TKS, Balduf K, Boston U, Knott-Craig C. Diaphragmatic fenestration for refractory chylothorax after congenital cardiac surgery in infants. J Thorac Cardiovasc Surg 2017; 154:2062-2068. [PMID: 28916211 DOI: 10.1016/j.jtcvs.2017.08.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 07/14/2017] [Accepted: 08/09/2017] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Medically refractory chylous pleural effusion after congenital heart surgery is associated with significant morbidity and mortality, especially in infants. We reviewed our experience with diaphragmatic fenestration procedure in this group of patients. METHODS A retrospective chart review of all patients who had diaphragmatic fenestrations for chylous effusion at our institution over a 2-year period was performed. RESULTS A total of 9 diaphragmatic fenestration procedures were performed in 8 patients who had failed medical management of chylous pleural effusions. All procedures except 1 were performed on the right side. The median age at time of procedure was 4.6 months (range, 3 weeks to 14 months). The average time between primary congenital cardiac surgery and fenestration was 26 days (range, 4-53 days). Three patients had single ventricle repair. Average time of chest tube removal after procedure was 4 days. Average time to extubation was 3 days. All patients but 1 were able to advance to full feedings without reaccumulation of chylous effusion within 12 days. No complications developed in the patients. Recurrent effusion over a median follow-up period of 19 months did not develop in the patients. CONCLUSIONS Diaphragmatic fenestration is an effective and safe strategy for management of persistent chylous effusions after congenital cardiac surgery.
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Affiliation(s)
- T K Susheel Kumar
- Department of Pediatric Cardiothoracic Surgery, Le Bonheur Children's Hospital and University of Tennessee Health Science Center, Memphis, Tenn.
| | - Kaitlin Balduf
- Department of Pediatric Cardiology, Le Bonheur Children's Hospital and University of Tennessee Health Science Center, Memphis, Tenn
| | - Umar Boston
- Department of Pediatric Cardiothoracic Surgery, Le Bonheur Children's Hospital and University of Tennessee Health Science Center, Memphis, Tenn
| | - Christopher Knott-Craig
- Department of Pediatric Cardiothoracic Surgery, Le Bonheur Children's Hospital and University of Tennessee Health Science Center, Memphis, Tenn
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Czobor NR, Roth G, Prodán Z, Lex DJ, Sápi E, Ablonczy L, Gergely M, Székely EA, Gál J, Székely A. Chylothorax after pediatric cardiac surgery complicates short-term but not long-term outcomes-a propensity matched analysis. J Thorac Dis 2017; 9:2466-2475. [PMID: 28932552 DOI: 10.21037/jtd.2017.07.88] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND The occurrence of postoperative chylothorax in children with congenital heart disease is a rare and serious complication in cardiac intensive care units (ICUs). The aim of our study was to identify the perioperative characteristics, treatment options, resource utilization and long term complications of patients having chylothorax after a pediatric cardiac surgery. METHODS Patients were retrospectively assessed for the presence of chylothorax between January 2002 and December 2012 in a tertiary national cardiac center. Occurrence, treatment options and long term outcomes were analyzed. Chylothorax patients less than 2 years of age were analyzed using propensity-matched statistical analysis in regard to postoperative complications after discharge. RESULTS During the 10-year period, 48 patients had chylothorax after pediatric cardiac surgery. The highest incidence was observed on the second postoperative day (7 patients, 14.6%). Seven patients (14.6% of the chylothorax population) died. During the follow up period, 5 patients had additional thromboembolic complications (2 had confirmed thrombophilia). Eleven patients had a genetic abnormality (3 had Down's syndrome, 3 had Di-Giorge's syndrome, 1 had an IgA deficiency and 4 had other disorders). During the reoperations (49 cases), no chylothorax occurred. After propensity matching, the occurrence of pulmonary failure (P=0.001) was significantly higher in the chylothorax group, and they required prolonged mechanical ventilation (P=0.002) and longer hospitalization times (P=0.01). After discharge, mortality and neurologic and thromboembolic events did not differ in the matched groups. CONCLUSIONS Chylothorax is an uncommon complication after pediatric cardiac surgery and is associated with higher resource utilization. Chylothorax did not reoccur during reoperations and was not associated with higher mortality or long-term complications in a propensity matched analysis.
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Affiliation(s)
| | - György Roth
- School of PhD Studies, Semmelweis University, Budapest, Hungary
| | - Zsolt Prodán
- Department of Pediatric Cardiac Surgery, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary
| | - Daniel J Lex
- School of PhD Studies, Semmelweis University, Budapest, Hungary
| | - Erzsébet Sápi
- Department of Anesthesiology and Pediatric Intensive Care, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary
| | - László Ablonczy
- Department of Anesthesiology and Pediatric Intensive Care, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary
| | - Mihály Gergely
- Department of Anesthesiology and Pediatric Intensive Care, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary
| | - Edgar A Székely
- Department of Anesthesiology and Pediatric Intensive Care, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary
| | - János Gál
- Department of Anesthesiology and Intensive Care, Semmelweis University, Budapest, Hungary
| | - Andrea Székely
- Department of Anesthesiology and Pediatric Intensive Care, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary.,Department of Anesthesiology and Intensive Care, Semmelweis University, Budapest, Hungary
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Yin R, Zhang R, Wang J, Yuan L, Hu L, Jiang S, Chen C, Cao Y. Effects of somatostatin/octreotide treatment in neonates with congenital chylothorax. Medicine (Baltimore) 2017; 96:e7594. [PMID: 28723800 PMCID: PMC5521940 DOI: 10.1097/md.0000000000007594] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The influence of somatostatin/octreotide treatment on outcomes of neonates with congenital chylothorax remains controversial. We retrospectively reviewed our experience with somatostatin/octreotide therapy in neonates with this very rare disease.Fourteen neonates with congenital chylothorax who were treated with somatostatin (3.5-7 μg/kg/h, before 2016) or octreotide (1-6 μg/kg/h, after January 2016), along with traditional management between 2013 and 2016, were retrospectively reviewed in this observational study. Their daily volumes of pleural drainage and parameters of respiratory support were recorded, and the potential side effects of somatostatin/octreotide were screened.Four patients (28.6%) had a unilateral presentation of pleural effusion, whereas 10 patients (71.4%) had a bilateral presentation. Twelve patients (85.7%) survived until discharge without later recurrence or death, whereas 2 patients (14.3%) died within the first 3 days after birth. Somatostatin/octreotide treatment was maintained for a median period of 6 days (range 1-16 days). The chest tube was removed after a median duration of 14 days (range 2-51 days), and no patient needed pleurodesis or thoracic duct ligation surgery. The average daily drain output within 3 days post-treatment (median 62 mL, range 10-651 mL) was significantly lower than that before treatment (median 133 mL, range 70-620 mL) (P = .002). The need for ventilation support was reduced in most patients (85.7%) after the initiation of somatostatin/octreotide therapy. No serious side effects were identified.Somatostatin/octreotide treatment reduced pleural drainage and respiratory support without significant side effects. Further randomized controlled studies with more patients are necessary to ascertain the benefits of somatostatin/octreotide in neonates with congenital chylothorax.
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Hasanali ZS, O'Hara C. Visual Diagnosis: A 7-week-old Boy with Tachypnea and Poor Feeding. Pediatr Rev 2017; 38:e6-e9. [PMID: 28148713 DOI: 10.1542/pir.2016-00003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Zainul S Hasanali
- Division of Pediatric Hospital Medicine, Penn State Hershey Medical Center, Hershey, PA
| | - Christopher O'Hara
- Division of Pediatric Hospital Medicine, Penn State Hershey Medical Center, Hershey, PA
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Aljazairi AS, Bhuiyan TA, Alwadai AH, Almehizia RA. Octreotide use in post-cardiac surgery chylothorax: a 12-year perspective. Asian Cardiovasc Thorac Ann 2016; 25:6-12. [DOI: 10.1177/0218492316682670] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Background Chylothorax following cardiothoracic surgery is a rare condition in pediatric patients with significant morbidity and mortality. Pharmacological management with octreotide suggests possible efficacy; however, current evidence is inadequate. The objective of this study was to assess the safety and efficacy of octreotide as a therapeutic option in this clinical setting. Methods This was a 12-year single-center retrospective cohort study of all patients (birth to 18-years old) who received octreotide for management of post-cardiac surgery chylothorax between January 2003 to August 2015. The primary efficacy endpoint was resolution of chylothorax, categorized as complete (<2 mL·kg−1·day−1), partial (based on physician’s judgement), or failed. The primary safety endpoint was any significant adverse drug reaction leading to discontinuation of octreotide therapy. Of the 46 patients identified as receiving octreotide for post-cardiac surgery chylothorax, 29 were included in efficacy and safety analyses. Results Resolution of chylothorax was achieved in 62% (complete in 28%, partial in 34%) of the total sample. The 38% who did not respond to octreotide therapy required thoracic duct ligation. The mean initial dose and duration of octreotide was 4 ± 3 µg·kg−1·h−1 and 10 ± 5 days, respectively. Besides minor side-effects including transient hyperglycemia (45%), abdominal distension (3%), and tachycardia (>150 beats·min−1; 10%), no patient developed a significant side-effect that required discontinuation of therapy. Conclusions Pharmacological management of post-cardiac surgery induced chylothorax with octreotide shows promising benefits with an acceptable safety profile.
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Affiliation(s)
- Abdulrazaq Sheikh Aljazairi
- Division of Pharmaceutical Care, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia Both Abdulrazaq Aljazairi Sheikh and Tauhid Ahmed contributed equally to establish co-authorship
| | - Tauhid Ahmed Bhuiyan
- Division of Pharmaceutical Care, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia Both Abdulrazaq Aljazairi Sheikh and Tauhid Ahmed contributed equally to establish co-authorship
| | - Abdullah Hasan Alwadai
- Division of Pharmaceutical Care, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia Both Abdulrazaq Aljazairi Sheikh and Tauhid Ahmed contributed equally to establish co-authorship
| | - Rayd Abdulaziz Almehizia
- Division of Pharmaceutical Care, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia Both Abdulrazaq Aljazairi Sheikh and Tauhid Ahmed contributed equally to establish co-authorship
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Efficacy of octreotide against chylothorax following lateral neck dissection for thyroid cancer: A case report. Int J Surg Case Rep 2016; 21:107-10. [PMID: 26963261 PMCID: PMC4802334 DOI: 10.1016/j.ijscr.2016.02.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Revised: 02/04/2016] [Accepted: 02/20/2016] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Postsurgical chylothorax is a rare complication of cervical dissection for thyroid cancer. We report that octreotide, a synthetic analog of somatostatin, is effective in treating chylothorax after thyroid carcinoma surgery. PRESENTATION OF CASE The patient was a 48-year-old woman who presented to our institution complaining of a left anterior cervical mass. We diagnosed this as thyroid papillary carcinoma and performed a subtotal excision of the thyroid gland with left cervical lymph node dissection. The patient developed dyspnea, and a chest X-ray revealed bilateral chylothorax on Day 4 post-surgery. Octreotide was administered since bilateral chylothorax was noted. A marked decrease in chyle effusion was noted just 3 days after starting octreotide, and after a total of 9 days of treatment, there were no further signs of chylous effusion. DISCUSSION Octreotide is effective against postsurgical chylothorax; however, if there are no signs of improvement, we believe surgical treatment should be considered. CONCLUSION Octreotide should be administered first to treat postsurgical chylothorax before surgical treatment is considered.
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Hawkes CP, Adzick NS, Palladino AA, De León DD. Late Presentation of Fulminant Necrotizing Enterocolitis in a Child with Hyperinsulinism on Octreotide Therapy. Horm Res Paediatr 2016; 86:131-136. [PMID: 26867223 PMCID: PMC4982848 DOI: 10.1159/000443959] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 01/12/2016] [Indexed: 12/12/2022] Open
Abstract
Congenital hyperinsulinism (HI) is the most common cause of persistent hypoglycemia in infants and children. In cases of diazoxide-unresponsive HI, alternative medical and surgical approaches may be required to reduce the risk of hypoglycemia. Octreotide, a somatostatin analog, often has a role in the management of these children, but a dose-dependent reduction in splanchnic blood flow is a recognized complication. Necrotizing enterocolitis (NEC) has been reported within the first few weeks of initiating predominantly high doses of octreotide. We describe the case of an infant with Beckwith-Wiedemann syndrome and diazoxide-unresponsive HI, who had persistent hypoglycemia after two pancreatectomy surgeries. She developed NEC 2 months after beginning octreotide therapy at a relatively low dose of 8 µg/kg/day. This complication has occurred later, and at a lower dose, than has previously been described. We review the case and identify the known and suspected multifactorial risk factors for NEC that may contribute to the development of this complication in patients with HI.
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Affiliation(s)
- Colin Patrick Hawkes
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - N Scott Adzick
- Division Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew A Palladino
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Diva D De León
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Gupta A, Singh T. Octreotide in malignant chylothorax: a case report. BMJ Support Palliat Care 2015; 6:122-4. [DOI: 10.1136/bmjspcare-2015-000933] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 11/12/2015] [Indexed: 01/31/2023]
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Scottoni F, Fusaro F, Conforti A, Morini F, Bagolan P. Pleurodesis with povidone-iodine for refractory chylothorax in newborns: Personal experience and literature review. J Pediatr Surg 2015; 50:1722-5. [PMID: 25969129 DOI: 10.1016/j.jpedsurg.2015.03.069] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 03/03/2015] [Accepted: 03/31/2015] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Refractory chylothorax is a severe clinical issue, particularly in neonates. Conventional primary approach is based on diet with medium-chain fatty acids and/or total parenteral nutrition. In nonresponders, proposed second line treatments include chemical or surgical pleurodesis, thoracic duct ligation, pleuroperitoneal shunting and pleurectomy but none of these have been shown to be superior to other in terms of resolution rate and safety. Our aim is to report our experience on povidone-iodine use for chemical pleurodesis in newborn infants with chylothorax unresponsive to conservative treatment. Our aim is to report our experience on povidone-iodine use for chemical pleurodesis in newborn infants with chylothorax unresponsive to conservative treatment. METHODS Since 2013, povidone-iodine pleurodesis was attempted in all patients with persistent chylothorax who failed conservative treatment (no response to at least 10 days of total parenteral nutrition and maximum dosage of intravenous octreotide). Pleurodesis consisted in the injection of 2 ml/kg of a 4% povidone-iodine solution inside the pleural space, leaving the pleural tube clamped for the subsequent 4 hours. RESULTS Five patients were treated with chemical pleurodesis of persistent chylothorax. Four of 5 patients had their pleural effusion treated by one single povidone-iodine infusion. Median time for resolution was 4 days. A patient with massive superior vena cava thrombosis did not benefit from pleurodesis. None of the patients experienced long term side effects of the treatment. CONCLUSION Our data suggest that povidone-iodine pleurodesis may be considered a safe and effective option to treat refractory chylothorax in newborns.
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Affiliation(s)
- Federico Scottoni
- Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Fabio Fusaro
- Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Andrea Conforti
- Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Francesco Morini
- Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Pietro Bagolan
- Medical and Surgical Neonatology, Bambino Gesù Children's Hospital, Rome, Italy.
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Testoni D, Hornik CP, Neely ML, Yang Q, McMahon AW, Clark RH, Smith PB. Safety of octreotide in hospitalized infants. Early Hum Dev 2015; 91:387-92. [PMID: 25968047 PMCID: PMC4450124 DOI: 10.1016/j.earlhumdev.2015.04.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 04/21/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Octreotide is used off-label in infants for treatment of chylothorax, congenital hyperinsulinism, and gastrointestinal bleeding. The safety profile of octreotide in hospitalized infants has not been described; we sought to fill this information gap. METHODS We identified all infants exposed to at least 1 dose of octreotide from a cohort of 887,855 infants discharged from 333 neonatal intensive care units managed by the Pediatrix Medical Group between 1997 and 2012. We collected laboratory and clinical information while infants were exposed to octreotide and described the frequency of baseline diagnoses, laboratory abnormalities, and clinical adverse events (AEs). RESULTS A total of 428 infants received 490 courses of octreotide. The diagnoses most commonly associated with octreotide use were chylothorax (50%), pleural effusion (32%), and hypoglycemia (22%). The most common laboratory AEs that occurred during exposure to octreotide were thrombocytopenia (47/1000 infant-days), hyperkalemia (21/1000 infant-days), and leukocytosis (20/1000 infant-days). Hyperglycemia occurred in 1/1000 infant-days and hypoglycemia in 3/1000 infant-days. Hypotension requiring pressors (12%) was the most common clinical AE that occurred during exposure to octreotide. Necrotizing enterocolitis was observed in 9/490 (2%) courses, and death occurred in 11 (3%) infants during octreotide administration. CONCLUSION Relatively few AEs occurred during off-label use of octreotide in this cohort of infants. Additional studies are needed to further evaluate the safety, dosing, and efficacy of this medication in infants.
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Affiliation(s)
- Daniela Testoni
- Duke Clinical Research Institute, Durham, NC, United States; Division of Neonatal Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Christoph P Hornik
- Duke Clinical Research Institute, Durham, NC, United States; Department of Pediatrics, Duke University, Durham, NC, United States
| | - Megan L Neely
- Duke Clinical Research Institute, Durham, NC, United States; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, United States
| | - Qinghong Yang
- Duke Clinical Research Institute, Durham, NC, United States
| | - Ann W McMahon
- Office of Pediatric Therapeutics, Food and Drug Administration, Silver Spring, MD, United States
| | - Reese H Clark
- Pediatrix-Obstetrix Center for Research and Education, Sunrise, FL, United States
| | - P Brian Smith
- Duke Clinical Research Institute, Durham, NC, United States; Department of Pediatrics, Duke University, Durham, NC, United States.
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Snow BD, Salcedo ES, Galante JM, Greenholz SK. Traumatic tension chylothorax in a child: A case report. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2015. [DOI: 10.1016/j.epsc.2015.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Bender B, Murthy V, Chamberlain RS. The changing management of chylothorax in the modern era. Eur J Cardiothorac Surg 2015; 49:18-24. [PMID: 25732972 DOI: 10.1093/ejcts/ezv041] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 01/14/2015] [Indexed: 01/30/2023] Open
Abstract
Initial conservative therapy is applied to all cases of chylothorax (CTx) with expected excellent outcomes. The indication for aggressive surgical treatment of early CTx remains uncertain and requires rigorous scientific scrutiny. Lymphangiography and lymphoscintigraphy are useful to localize the leak and assess thoracic duct patency as well as to differentiate partial from complete thoracic duct transection. The aetiology of the CTx, flow rate and patient condition dictate the preferred management. Octreotide/somatostatin and etilefrine therapy is highly efficacious in the conservative management of CTx. For patients in whom conservative management fails, those who are good surgical candidates, and those in whom the site of the leak is well identified, surgical repair and/or ligation using minimally invasive techniques is highly successful with limited adverse outcomes. Similarly, if the site of the chylous effusion cannot be well visualized, a thoracic duct ligation via video-assisted thoracic surgery is the gold standard approach. A pleuroperitoneal or less often a pleurovenous shunt is a final option and may be curative in some patients.
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Affiliation(s)
- Bradley Bender
- Saint George's University School of Medicine, Grenada Department of Internal Medicine, Hahnemann University Hospital, Philadelphia, PA, USA
| | - Vijayashree Murthy
- Department of Surgery, Saint Barnabas Medical Center, Livingston, NJ, USA
| | - Ronald S Chamberlain
- Saint George's University School of Medicine, Grenada Department of Surgery, Saint Barnabas Medical Center, Livingston, NJ, USA Department of Surgery, Rutgers University, New Jersey Medical School, Newark, NJ, USA
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Bialkowski A, Poets CF, Franz AR. Congenital chylothorax: a prospective nationwide epidemiological study in Germany. Arch Dis Child Fetal Neonatal Ed 2015; 100:F169-72. [PMID: 25480460 DOI: 10.1136/archdischild-2014-307274] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Congenital chylothorax (CCT) is a rare disease of unknown aetiology. Treatment approaches vary; none has been evaluated prospectively. OBJECTIVE To prospectively determine incidence, treatment and outcome of infants with CCT born in Germany in 2012. DESIGN CCT was defined as non-traumatic chylous pleural effusion within 28 days after birth. As part of the Surveillance Unit for Rare Pediatric Conditions in Germany (Erhebungseinheit für seltene pädiatrische Erkrankungen in Deutschland), all paediatric departments (n=432) received monthly reporting cards to notify the study centre of CCT cases, which were analysed based on anonymised questionnaires and discharge summaries. Data are shown as median (range) or n/N. RESULTS Of 37 cases reported, 28 met inclusion criteria. Questionnaires and/or discharge summaries were available for 27/28. Assuming complete reporting, the incidence of CCT was 1:24 000. Nine infants suffered from proven or suspected syndromal anomalies, most frequently Noonan syndrome (5/9). Postnatally, 23 required mechanical ventilation, 3 continuous positive airway pressure; only 1 had no respiratory support. 17 infants were treated with inotropes/vasopressors, 25 required pleural drainage for 11 (1-36) days. In 13 infants, enteral feeds were withheld initially; 25 received medium-chain triglyceride diet at some time, 9 were treated with octreotide or somatostatin. 18 infants survived without, 6 with sequelae attributable to the underlying disorder; 3 infants died (median age at death 37 (2-144) days). Duration of hospital stay in survivors was 51 (20-127) days. Infants treated with octreotide or somatostatin had similar outcomes compared with those not treated. CONCLUSIONS Based on this small observational study, CCT seems to have a favourable prognosis if not associated with genetic disorders.
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Affiliation(s)
- Anja Bialkowski
- Department of Neonatology, University Children's Hospital of Tübingen, University of Tübingen, Tübingen, Germany
| | - Christian F Poets
- Department of Neonatology, University Children's Hospital of Tübingen, University of Tübingen, Tübingen, Germany
| | - Axel R Franz
- Department of Neonatology, University Children's Hospital of Tübingen, University of Tübingen, Tübingen, Germany Center for Pediatric Clinical Studies, University Children's Hospital of Tübingen, University of Tübingen, Tübingen, Germany
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Abstract
Chylothorax, the accumulation of chyle in the pleural space, is a relatively rare cause of pleural effusion in children. It can cause significant respiratory morbidity, as well as lead to malnutrition and immunodeficiency. Thus, a chylothorax requires timely diagnosis and treatment. This review will first discuss the anatomy and physiology of the lymphatic system and discuss various causes that can lead to development of a chylothorax in infants and children. Then, methods of diagnosis and treatment will be reviewed. Finally, complications of chylothorax will be reviewed.
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Affiliation(s)
- James D Tutor
- Program in Pediatric Pulmonary Medicine, University of Tennessee Health Science Center; Le Bonheur Children's Hospital; and St. Jude Children's Research Hospital, Memphis, Tennessee
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Schild HH, Strassburg CP, Welz A, Kalff J. Treatment options in patients with chylothorax. DEUTSCHES ARZTEBLATT INTERNATIONAL 2013; 110:819-26. [PMID: 24333368 PMCID: PMC3865492 DOI: 10.3238/arztebl.2013.0819] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Revised: 10/02/2013] [Accepted: 10/02/2013] [Indexed: 12/23/2022]
Abstract
BACKGROUND Chylothorax arises when lymphatic fluid (chyle) accumulates in the pleural cavity because of leakage from lymphatic vessels. It is most commonly seen after thoracic surgery (in 0.5% to 1% of cases) and in association with tumors. No prospective or randomized trials have yet been performed to evaluate the available treatment options. METHOD This review is based on a selective search of the PubMed database for pertinent publications from the years 1995 to 2013. Emphasis was laid on articles that enabled a comparative assessment of treatment options. RESULTS Initial conservative treatment (e.g., parenteral nutrition or a special diet) succeeds in 20% to 80% of cases. When such treatment fails, the standard approach up to the present has been to treat surgically, e.g., with ligation of the thoracic duct, pleurodesis, or a pleuroperitoneal shunt. The success rates of such procedures have ranged from 25% to 95%. Most of the patients undergoing such procedures are severely ill; complication rates as high as 38% have been reported, with mortality as high as 25%. In more recent publications, however, morbidity and mortality were lower. Interventional radiological treatments, such as percutaneous thoracic duct embolization or the percutaneous destruction of lymphatic vessels, succeed in about 70% of cases and lead to healing in up to 80% of cases, even after unsuccessful surgery. The complication rate of percutaneous methods is roughly 3%. CONCLUSION Interventional radiological procedures have now taken their place alongside conservative treatment and surgery in the management of chylothorax, although they are currently available in only a small number of centers.
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Affiliation(s)
- Hans H Schild
- Department of Radiology, University Hospital of Bonn
| | | | - Armin Welz
- Clinic and Policlinic of Cardiac Surgery, University Hospital of Bonn
| | - Jörg Kalff
- Clinic and Policlinic of General, Visceral, Thoracic, and Cardiovascular Surgery, University Hospital of Bonn
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Yeh J, Brown ER, Kellogg KA, Donohue JE, Yu S, Gaies MG, Fifer CG, Hirsch JC, Aiyagari R. Utility of a clinical practice guideline in treatment of chylothorax in the postoperative congenital heart patient. Ann Thorac Surg 2013; 96:930-6. [PMID: 23915583 DOI: 10.1016/j.athoracsur.2013.05.058] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2013] [Revised: 05/08/2013] [Accepted: 05/17/2013] [Indexed: 12/27/2022]
Abstract
BACKGROUND Chylothorax after congenital heart surgery is a common complication with associated morbidities, but consensus treatment guidelines are lacking. Variability exists in the duration of medical treatment and timing for surgical intervention. METHODS After institution of a clinical practice guideline for management of postoperative chylothorax at a single center, pediatric cardiothoracic intensive care unit (ICU) in June 2010, we retrospectively analyzed 2 cohorts of patients: those with chylothorax from January 2008 to May 2010 (early cohort; n=118) and from June 2010 to August 2011 (late cohort; n=45). Data collected included demographics, cardiac surgical procedure, treatments for chylothorax, bloodstream infections, hospital mortality, length of hospitalization, duration of mechanical ventilation, and device utilization. RESULTS There were no demographic differences between the cohorts. No differences were found in octreotide use or surgical treatments for chylothorax. Significant differences were found in median times to chylothorax diagnosis (9 in early cohort versus 6 days in late cohort, p=0.004), ICU length of stay (18 vs 9 days, p=0.01), hospital length of stay (30 vs 23 days, p=0.005), and total durations of mechanical ventilation (11 vs 5 days, p=0.02), chest tube use (20 vs 14 days, p=0.01), central venous line use (27 vs 15 days, p=0.001), and NPO status (9.5 vs 6 days, p=0.04). CONCLUSIONS Institution of a clinical practice guideline for treatment of chylothorax after congenital heart surgery was associated with earlier diagnosis, reduced hospital length of stay, mechanical ventilation, and device utilization for these patients.
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Affiliation(s)
- Jay Yeh
- Division of Pediatric Cardiology, Department of Cardiac Surgery, University of Michigan, C.S. Mott Children's Hospital Ann Arbor, Michigan 48109-4204, USA
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Pontarelli E, Goodhue C, Merritt R, Anselmo D. Chylous ascites following Kasai portoenterostomy: Case study and review of the literature. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2013. [DOI: 10.1016/j.epsc.2013.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Rivera-Beltrán S, Ortíz VN, Díaz R, Hernández JA. Transabdominal ligation of the thoracic duct with pericardial-peritoneal shunting in a case of primary idiopathic chylous pericardial effusion. J Pediatr Surg 2013; 48:1434-7. [PMID: 23845644 DOI: 10.1016/j.jpedsurg.2013.04.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2012] [Revised: 03/17/2013] [Accepted: 04/09/2013] [Indexed: 01/30/2023]
Abstract
Primary chylous pericardial effusion is a rare entity with few cases reported so far. We report a case of idiopathic etiology in a previously healthy 16-year-old boy. The patient presented with intermittent chest pain and dizziness caused by a chronic pericardial effusion. An echocardiogram revealing a pericardial effusion and open pericardiocentesis with a drainage of approximately of 500 ml of chylous fluid established the diagnosis. Patient had no history of trauma, cardiac surgery, central insertion of subclavian catheters or blunt injury. Computed tomography ruled out malignancies in the abdomen and chest. Clinical, laboratory and radiological investigations for the possible underlying cause of the condition were not determined. Management with a dietary regimen consisting of a medium-chain triglyceride-rich diet, octreotide pharmacological treatment and initial subxiphoid resection with pericardial tube drainage was unsuccessful. Surgical approach was required consisting of pericardio-peritoneal window with trans-abdominal ligation (clipping) of the thoracic duct above the diaphragm. Postoperative outcome was uneventful and there was a rapid recovery after surgical management.
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Choo YM, Lim CT. Treatment of congenital chylothorax with octreotide in a hydropic preterm infant. Paediatr Int Child Health 2013; 33:116-9. [PMID: 23925288 DOI: 10.1179/2046905512y.0000000030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Congenital chylothorax is rare in preterm infants. While most cases respond to conservative treatment, a few require surgery. Treatment with intravenous octreotide has been reported to have varying success in preterm infants. A fetus was diagnosed with bilateral hydrothoraces at 29 weeks of gestation and repeated thoracocentesis was performed antenatally to allow growth of the lungs. She was delivered electively at 32 weeks by caesarean section. Hydrops fetalis was confirmed and chest tubes were inserted bilaterally soon after birth. Intravenous octreotide was commenced on day 4 of life, titrated to a maximum of 10 μg/kg/hr for a total of 28 days. Hydrothorax resolved at day 30 and total parenteral nutrition was given for a total of 37 days. She was successfully extubated on day 40 of life and discharged on day 80. On review at 6 months of age, she was thriving and developing normally.
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Affiliation(s)
- Yao Mun Choo
- Department of Paediatrics, University Malaya, Kuala Lumpur, Malaysia.
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Tidder J, Pang CL. A staged management of prolonged chylothorax in a patient with yellow nail syndrome. BMJ Case Rep 2012; 2012:bcr-2012-006469. [PMID: 23125296 DOI: 10.1136/bcr-2012-006469] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Spontaneous chylothorax remains an unusual condition with diverse aetiologies and non-unified management strategies. Owing to the rarity of the condition, the evidence of management remains from case reports and limited retrospective studies. This case represents a difficult-to-manage chylothorax secondary to yellow nail syndrome with initial failure of both surgical and conservative treatment methods. Pleurovenous shunting represents a surgical management approach allowing the patient to live with and control an ongoing chyle leak.
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Affiliation(s)
- James Tidder
- Department of Thoracic Surgery, Norfolk and Norwich University Hospital, UK.
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Abstract
Chylothorax refers to the accumulation of chyle in the pleural cavity. Although rare, it is the most frequent cause of pleural effusion in the neonatal period. Its incidence is estimated at one in 15,000 neonates. The causes of chylothorax are multiple, and there are several major types of chylothorax defined by origin, ie, traumatic (and iatrogenic) chylothorax, medical (spontaneous) chylothorax, and congenital chylothorax. A case of neonatal chylothorax following surgery for esophageal atresia and our therapeutic approach to this entity are presented. Conservative therapy with total enteral nutrition and drainage were sufficient. Treatment for chylothorax is essentially medical, ie, pleural drainage, removal of dietary fats, treatment of any medical cause, and use of drugs to reduce production of chyle. In the event of failure or reappearance of a large effusion, surgical treatment is needed.
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Affiliation(s)
- Amina Barkat
- National Reference Center in Neonatology and Nutrition, Children's Hospital, Rabat, Morocco
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Octreotide infusion for malignant duodenal obstruction in a 12-year-old girl with metastatic peripheral nerve sheath tumor. J Pediatr Hematol Oncol 2012; 34:e292-4. [PMID: 22735881 DOI: 10.1097/mph.0b013e318257dd4c] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Malignant bowel obstruction is a common complication of some adult malignancies. In childhood cancer, malignant bowel obstruction is relatively rare. Octreotide, an analogue of the hormone somatostatin, has been shown to be an effective treatment for this condition in adults. However, explicit description of its use for this indication in children was not discovered in the pediatric literature by this group of authors. The following report is that of a 12-year-old female who had copious bilious emesis secondary to malignant obstruction of the distal duodenum, which abated after treatment with a continuous intravenous octreotide infusion.
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