Octreotide in the treatment of neonatal postoperative chylothorax: report of three cases and literature review

Risk factors and early outcomes of chylothorax following congenital cardiac surgery: A single-center experience

Background

This study aims to investigate the incidence and risk factors for chylothorax and to evaluate the effect of chylothorax on the early postoperative outcomes following congenital cardiac surgery.

Methods

A total of 1,053 patients (606 males, 447 females; median age: 12 months; range, 3 days to 48 years) who underwent surgery for congenital heart disease at our institute between January 2018 and December 2019 were retrospectively analyzed. Patients with chylothorax were identified and the data of this cohort was compared with the entire study population. Following the diagnosis of chylothorax, a standardized management protocol was applied to all patients.

Results

Of 1,053 patients operated, 78 (7.4%) were diagnosed with chylothorax. In the univariate analysis, younger age, peritoneal dialysis, preoperative need for mechanical ventilation, surgical complexity, delayed sternal closure, high vasoactive inotrope score in the first 24 h after operation, residual or additional cardiac lesions which required reoperations were found to be the risk factors for chylothorax (p<0.05). In the multivariate analysis, the correlation persisted with only younger age, infections, and peritoneal dialysis requirement (p<0.05). In the chylothorax group, ventilation times were longer, and re-intubation and infection rates were higher (p<0.05). Although the length of intensive care unit and hospital stay was significantly longer in this patient group, there was no significant association between the development of chylothorax and in-hospital mortality (p>0.05).

Conclusion

Chylothorax following congenital cardiac surgery is a significant problem which prolongs the length of hospital stay and increases the infection rates. Complex cardiac pathologies which require surgery at early ages and re-operations are risk factors for chylothorax. Although there is no consensus on the most optimal therapeutic strategy, standardizing the management protocol may improve the results.

A late presenting left-sided congenital diaphragmatic hernia repair complicated by postoperative chylothorax: A case report

Management of chylothorax after repair of late presenting congenital diaphragmatic hernia is debatable. Conservative management in the form of close monitoring of chylous output with nutritional support appears convincing to surgery.

Octreotide Use in Neonates: A Case Series

Background and Objective

Octreotide is a somatostatin analogue and has been used off-label for a variety of conditions. There are no specific guidelines for the use of octreotide in neonates and its safety and efficacy have not been systematically evaluated. The objective of this study is to present our experience of using octreotide therapy in neonates.

Methods

This is a retrospective study of neonates who received octreotide therapy during their hospital stay over a 15 years period (2003–2017) in a tertiary neonatal centre. The demographic details and indications of octreotide therapy including time of initiation, route, dose, duration and adverse effects of therapy were noted. The clinical course following octreotide administration was also analysed.

Results

Eleven neonates received octreotide therapy during the study period, of which nine had chylothorax and two had chylous ascites. Resolution of the chylous effusion with octreotide therapy was achieved in 4 out of 11 (36.3%) of the cases. The median duration of octreotide therapy in cases with successful resolution was 17.5 days. With the exception of minor side effects such as hyperglycaemia, none of the patients had any significant side effects that required discontinuation of therapy.

Conclusion

Octreotide was used safely as an adjunctive therapy for the treatment of chylothorax and chylous ascites in neonates. However, larger prospective controlled trials are required to establish the optimal dose, time of initiation, duration and efficacy of octreotide therapy in neonates.

Octreotide for congenital and acquired chylothorax in newborns: A systematic review

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.

Novel thoracoscopic navigation surgery for neonatal chylothorax using indocyanine-green fluorescent lymphography

BACKGROUND

Postoperative chylothorax after surgery for esophageal atresia/tracheoesophageal fistula (TEF) is a rare but serious complication, especially in neonates. This study aimed to identify the thoracic duct and ligate chylous leakage sites, using thoracoscopic navigation of an indocyanine-green (ICG)-based near-infrared (NIR) fluorescence imaging system.

METHODS

From November 2014 to April 2017, thoracoscopic intraoperative ICG-NIR imaging was performed in 10 newborns (11 surgeries) with first TEF operation or with persistent postoperative chylothorax after TEF operation. NIR imaging was performed 1h after an inter-toe injection of ICG. Thoracoscopic ligations against the NIR-detected leakage sites were performed with sutures.

RESULTS

The thoracic duct or lymphatic leakage was directly visualized in each patient. In 8 surgeries with first thoracoscopic TEF operation, one case had suspected minor chylous leakage without postoperative chylothorax. Another case with no chylous leakage at the first operation resulted in chylothorax at postoperative day 11. In three neonates with postoperative chylothorax, leakage points were detected near the ablation site of the azygos vein during the first operation. These points were properly ligated, and postoperative chylous leakage ceased with no adverse events.

CONCLUSIONS

Thoracoscopic ICG-NIR imaging encourages the repair of refractory chylothorax and seems reliable.

LEVEL OF EVIDENCE

IV.

Surgical chylothorax in neonates: management and outcomes

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.

Endolymphatic Interventions for the Treatment of Chylothorax and Chylous Ascites in Neonates: Technical and Clinical Success and Complications

BACKGROUND

The aim of this study was to report the technical and clinical success of performing minimally invasive endolymphatic embolization in neonates presenting with a chylothorax or chylous ascites.

METHODS

Three neonates, 2 males and 1 female, with a mean age of 28 days (range: 19-39 days) presented with a chylothorax or chylous ascites that was refractory to conservative management. All 3 patients (1 previously reported) underwent intranodal lymphangiography, followed by thoracic duct embolization, with 1 patient undergoing additional sclerosis of the retroperitoneal abdominal lymphatics.

RESULTS

Lymphangiography, thoracic duct embolization, and sclerosis of the retroperitoneal abdominal lymphatics were technically successful. The chylothorax resolved in both the patients. Persistent chylous ascites was noted after treatment which resolved after surgical placement of a vicryl mesh and fibrin sealant. One major complication occurred with nontarget embolization of glue into the lungs requiring embolectomy.

CONCLUSIONS

Thoracic duct and retroperitoneal abdominal lymphatic embolization can be performed in neonates. Resolution of chylothorax was seen in 2 patients (one previously reported) after embolization, whereas 1 patient with chylous ascites required surgical management after endolymphatic intervention.

Treatment of chylothorax developed after congenital heart disease surgery: a case report

Chylothorax is defined as the accumulation of lymphatic fluid or chyle in the pleural space. Chylothorax treatment is composed of conservative; pleural drainage, termination of enteral feeding, total parenteral nutrition and supplementation with medium- chain triglycerides and surgical therapies; ductus thoracicus ligation, pleuroperitoneal shunts or pleuredesis. Nowadays, for cases among which conservative therapies fail, treatment with octreotide has been reported to be beneficial with promising results. A neonate who developed chylothorax after surgery performed for congenital heart disease was treated successfully with octreotide.

Low Dose of Octreotide Can be Helpful in the Management of Congenital Chylothorax

Introduction:

A rare condition in newborns called congenital chylothorax (CC) occurs when lymphatic fluid accumulates within the pleural cavity. Here is a presentation of a birth traumatic case with bilateral pleural effusion successfully treated by octreotide.

Case Presentation:

A 3100-g-term male newborn delivered vaginally from a 33-year-old mother was admitted to the neonatal intensive care unit with respiratory distress signs. Early chest x-ray (CXR) showed bilateral pleural effusion. The thoracentesis pleural fluid had been drained with these characteristics: glucose: 1.9425 mmol/l, protein: 11 g/l, cholesterol: 1.295 mmol/l, and triglycerides: 3.39 mmol/l. Counts of red blood cells and white blood cells were 10,000 and 2500 per Cu/mm, respectively; so, congenital chylothorax was diagnosed and total parenteral nutrition (TPN) were initiated. Accumulation of plural fluid was approximately stopped after begging TPN for two weeks. Therefore, we started feeding with a medium chain triglyceride (MCT), but plural effusion was seen once again and we had to restart TPN. We decided to start octreotide subcutaneously (1 μg/kg/day). Finally, the CXR and ultrasound ’did not show any pleural effusion in both sides and the ultrasound done in the third month showed no pleural effusion either.

Conclusions:

Octreotide therapy as one of the conservative managements for CC can be considered before surgical methods. This treatment method also had some effects on the feeding initiation time and helped us to start feeding sooner. However, more studies like clinical trials are still necessary to investigate all aspects of octreotide treatment to determine the amount of its dose, initiation time, treatment duration, etc.

Pleurodesis with povidone-iodine for refractory chylothorax in newborns: Personal experience and literature review

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.

Octreotide for chylous effusions in congenital diaphragmatic hernia

BACKGROUND/PURPOSE

Chylothorax is a frequent complication in congenital diaphragmatic hernia (CDH) infants and is associated with significant morbidity. The optimal treatment strategy remains unclear. We hypothesize that octreotide decreases chylous effusions in infants with CDH.

METHODS

This is a retrospective study of all infants with CDH admitted to our institution from October 2006 to October 2011.

RESULTS

Eleven (12%) infants developed a chylothorax. Five infants were managed conservatively with thoracostomy and total parenteral nutrition. Six infants were started on octreotide therapy. None of the infants required surgical intervention to stop the effusion. There was no significant difference in survival to discharge, length of stay, or average daily chest tube output between groups. There appeared to be a temporally associated drop in chest tube output upon initiation of octreotide in two infants; however, the overall rate of decline in chest tube drainage was unchanged. In addition, there were infants in the conservative group who demonstrated a similar drop in daily chest tube output despite the absence of octreotide.

CONCLUSIONS

Our data suggest that the majority of chylous effusions in CDH infants resolve with conservative therapy alone.