Neonatal chylothorax: a report and discussion of nine consecutive cases

Superior vena cava syndrome causing chylothoraces in a preterm neonate: a case report and literature review

A preterm neonate developed catheter-related central venous and dural sinus thrombosis. Superior vena cava (SVC) obstruction caused significant bilateral chylothoraces and SVC thrombotic obstruction led to generalized anasarca and multiple organ failure. Six weeks after the diagnosis of SVC and sagittal sinus occlusion and chylothoraces, the infant expired. We report a rare case of a chylothoraces secondary to SVC obstruction, and superior sagittal sinus thrombosis in a preterm neonate, and review the literature.

Treatment with OK-432 for persistent congenital chylothorax in newborn infants resistant to octreotide

Chylothorax is a relatively uncommon condition defined as an abnormal collection of lymphatic fluid within the pleural space. We are reporting the use of OK-432 for treatment of prolonged idiopathic congenital chylothorax in 2 newborn infants who failed to respond to conservative medical therapy, including octreotide injection.

Octreotide therapy for chylothorax in infants and children: A brief review

OBJECTIVES

We review physiology and pharmacology relating to the use of octreotide for chylothorax in infants and children. We review the published experience of octreotide dosing in this context.

DATA SOURCE

Systematic review of the literature, including PubMed (English-only journals), citations from relevant articles, major textbooks, and personal files.

CONCLUSIONS

Octreotide has been used as a successful therapeutic adjunct in a small number of neonatal cases and a larger number of pediatric cases. No consensus has been reached as to the optimal route of administration, dose, duration of therapy, or strategy for discontinuation of therapy. We suggest using higher doses (80-100 microg/kg/day) and initiating therapy early rather than using a low initial dose with upward titration. Duration of therapy required to elicit a significant response may vary between patients.

Congenital chylothorax associated with isolated congenital hypoplastic superior caval vein: a case report

Congenital absence, or hypoplasia, of the superior vena cava (SVC) with situs solitus is quite uncommon. Most cases have been found incidentally and concomitant with left persistent SVC or other cardiac disorders. Congenital chylothorax may be associated with cardiac anomalies, various syndromes, thoracic ductal or venous thrombosis, birth trauma or local compression of the thoracic duct, but it is rarely caused directly by congenital SVC anomalies.

CONCLUSION

We report a rare case of congenital chylothorax associated with isolated congenital hypoplastic SVC and underdeveloped collateral circulation.

Successful use of somatostatin in a case of neonatal chylothorax

A 2-week-old infant status postrepair of gastroschisis had spontaneous bilateral chylothoraces necessitating thoracostomy drainage. Voluminous chylous drainage persisted despite cessation of enteral feedings. On administration of the somatostatin analogue octreotide, pleural drainage diminished markedly and ceased entirely within 4 days. These results, along with reported successes in treatment of chylothorax after thoracic surgery, support the prospective investigation of somatostatin use in problematic chylothorax.

Superior vena cava syndrome following neonatal cardiac surgery

OBJECTIVE: To review the incidence, diagnosis, and management of superior vena cava syndrome (SVCS) after surgery for congenital heart disease. DESIGN: Retrospective clinical review. All patients were computer registered. Our database includes daily follow-up. SETTING: Pediatric cardiac surgery intensive care unit in a university hospital. PATIENTS: A total of 1853 consecutive pediatric cardiac operations performed in 285 neonates and 1568 older children from 1993 to 1999 are reviewed. MEASUREMENTS AND MAIN RESULTS: The diagnosis of SVCS was suspected clinically: Color changes and swelling of the upper part of the body, confirmed by echo-Doppler, showed no or minimal flow in the superior vena cava at the beginning and collateral flow later on. Nine patients developed SVCS (0.5%). All the study patients were neonates. The prevalence of SVCS in our neonatal patients was 3.15% (nine of 285), with no SVCS in older children. Accompanying complications included chylothorax (five), hydrocephalous (four)-three of whom required ventriculoperitoneal shunt during follow-up. Thrombolytic therapy was used in five patients, and thrombectomy was used in one patient. The ventilation period ranged from 4 to 46 days (mean 20.1 days), and the length of hospital stay ranged from 37 to 120 days (mean 61.3 days). No mortality was observed during follow-up. CONCLUSIONS: SVCS is an uncommon, severe complication following neonatal cardiac surgery. It may cause chylothorax, hydrocephalus, and severe respiratory complications leading to high morbidity. Early diagnosis and thrombolytic therapy may prevent the progression of this syndrome to its subsequent sequels.

Etiology and management of pediatric chylothorax

OBJECTIVES

To determine the incidence and etiology of chylothorax and to assess our therapeutic management approach.

STUDY DESIGN

We reviewed 51 patients diagnosed with chylothorax over a 12-year period. Cause, interval between operation and diagnosis, duration of chylothorax, and total volume loss per weight were recorded.

RESULTS

Chylothorax was diagnosed in 46 children after cardiothoracic surgery, giving an incidence of 2.5% (46/1842); in 1 child chylothorax occurred after chest trauma, and in 4 the chylothorax was congenital or a manifestation of lymph angiomatosis. Three etiologic groups were identified: group 1, direct injury to the thoracic duct (33/51 = 65%); group 2, thrombosis and/or high venous pressure in the superior vena cava (14/51 = 27%); and group 3, congenital (4/51 = 8%). Conservative treatment was the only treatment in 80% of the patients. Surgical procedures consisted of 4 ligations of the thoracic duct, placement of 7 pleurodesis shunts, and placement of 2 pleuroperitoneal shunts. Patients in groups 2 and 3 were at higher risk for failure of conservative treatment (P <. 005). Longer duration of chylothorax and higher volume of drainage were present in group 2 compared with group 1 (P <.01).

CONCLUSION

Conservative treatment was successful in 80% of the patients with our management approach. Prevention, early recognition, and treatment of potential complications, such as superior vena cava thrombosis or obstruction, may further improve success of conservative treatment. Congenital chylothorax seems different and may require a specific approach.

Congenital chylothorax in a patient with 21 trisomy syndrome

A female infant with 21 trisomy syndrome associated with congenital chylothorax was reported. She was born at a gestational age of 34 weeks by Cesarean section because of fetal hydrothorax and hydrops fetus, confirmed by ultrasonography at 32 weeks. Emergent resuscitation and immediate thoracentesis were performed soon after birth. After beginning breast feeding, the serous pleural fluid became opalescent and a diagnosis of congenital chylothorax was made. Feeding was changed to medium-chain triglyceride (MCT) feeding and the production of pleural effusion disappeared after thoracentesis was performed several times. Accumulating evidence suggested that MCT feeding and intermittent thoracentesis under echo guide were effective. Some reports on patients, including this one, suggest that there may be more patients with 21 trisomy associated with congenital hydrothorax. Therefore, congenital hydrothorax might be listed as a complication of 21 trisomy.

Successful management of a chylothorax in infancy using a pleurectomy

The management of chylothorax is described in three infants. Because none of them had had a direct injury to the thoracic duct, it was suspected that the chylothoraces had a significant chance of recurrence after simple ligation of the duct. To avoid recurrence, formal stripping of the parietal pleura was performed using a technique not previously reported in the literature. The operation was simple to perform and resulted in resolution of the chylothorax in all infants. The three cases and details of the surgical procedure are described.

Chylothorax in the neonatal period

Chylothorax is defined as an effusion of lymph in the pleural cavity. In the neonate both congenital and traumatic (iatrogenic) forms exist. Birth asphyxia and respiratory insufficiency are major symptoms of congenital chylothorax, requiring resuscitation and artificial ventilation. Antenatal diagnosis by ultrasound allows early therapeutic intervention such as ventilatory support and drainage of chylous fluid immediately after birth. Traumatic chylothorax is mainly seen after intrathoracic surgery. Treatment primarily consists of continuous or intermittent drainage of chyle with replacement of fluid-, electrolyte-, and protein losses and parenteral nutrition. Introduction of oral feeding is considered only after a substantial period without chyle production in the pleural cavity and consists of a medium-chain triglyceride containing formula. In a minority of cases surgical intervention is necessary.

Chylothorax secondary to obstruction of the superior vena cava: a complication of the LeVeen shunt

A case of thrombosis of the superior vena cava was complicated by bilateral chylothoraces and a widened mediastinum. Removal of a clotted LeVeen shunt led to prompt resolution of the obstruction and chylothoraces.

Pleuroperitoneal shunts in the management of persistent chylothorax

Between June 1981 and June 1988, we placed pleuroperitoneal shunts in 16 patients for the management of refractory chylothorax on the Pediatric Surgical Service, University of Virginia. The cause of the chylothorax was caval thrombosis from central venous catheters in 5 patients, idiopathic in 3, and mediastinal lymphangioma in 2, and in 6, it developed after a cardiac procedure. Chylothorax in each patient was unresponsive to thoracentesis, tube thoracostomy, and dietary manipulations. A Denver double-valved shunt system is currently employed and is implanted using general anesthesia. Manual pumping is required postoperatively for several months. Twelve (75%) of the 16 patients had excellent results with complete elimination of the chylothorax and resolution of symptoms. In 10 of these 12, the shunt has been removed. Four had an unsatisfactory result: 3 had inferior vena cava hypertension, and 3 were low-birth-weight premature infants. Four patients seen early in this series required revision of the position of the pleural catheter, with successful drainage in each instance. Pleuroperitoneal shunting is a safe, simple, and effective treatment of chylothorax in infants and children. In view of our success in treating chylothorax with these shunts, we recommend early shunting before the development of nutritional or immunological depletion.

Primary fetal hydrothorax: natural history and management

Primary fetal hydrothorax presents a wide spectrum of severity ranging from small, harmless effusions, to life-threatening thoracic compression. To define natural history and management, we reviewed 32 cases seen at two large perinatal centers from 1980 to 1987. Spontaneous resolution of the effusions was seen in three fetuses, all of whom survived. Three fetuses were electively terminated. The overall mortality was 53%. In the 24 untreated fetuses, sex and the presence of polyhydramnios did not influence mortality, but hydrops, gestational age less than 35 weeks at delivery, and bilateral effusions were associated with a poor prognosis. Five fetuses underwent in utero decompression. In four, thoracentesis was performed, with rapid reaccumulation of the effusion. All four died from pulmonary insufficiency. In the fifth fetus, a thoracoamniotic shunt permanently decompressed the effusion, with resolution of the hydrops, and delivery of a normal viable infant. We conclude that (1) primary fetal hydrothorax may resolve or progress to hydrops, necessitating close follow-up with ultrasound; (2) pulmonary hypoplasia as a result of undrained large pleural effusions may result in neonatal mortality; (3) the gestational age at both diagnosis and delivery, the development of hydrops, and bilaterality of effusions are important prognostic predictors; and (4) the fetus with large effusions and hydrops has a poor prognosis, and thoracic decompression with a thoracoamniotic shunt may prove life saving.

Primary lymphatic dysplasia in children: chylothorax, chylous ascites, and generalized lymphatic dysplasia

Primary lymphatic "dysplasia", a congenital maldevelopment, interferes with function of the lymphatic system and causes effusion of chyle or lymph into the limbs and pleural or peritoneal cavity. Between 1955 and 1982, 38 Mayo Clinic patients were found to have a chylous effusion or dysplasia of the lymphatic system. In 22, the condition was secondary to surgery or other medical problems and in 16 it was primary. These cases were separated into three categories: chylothorax, chylous ascites, and generalized lymphatic dysplasia. Conservative therapy, such as a restricted fat diet or total parenteral nutrition with repeated thoracentesis or paracentesis, was effective in the children with isolated abnormalities of the lymphatic system (75% resolution rate, no deaths). All five children with documented generalized dysplasia reported in the literature had died; of the three reported here, one has died and two have become progressively worse.

Pleuroperitoneal shunts in the management of neonatal chylothorax

Pleuroperitoneal shunts have been placed in five ventilator-dependent newborns with persistent chylothorax. The etiology of the chylothorax appeared to be secondary to superior vena caval obstruction in three patients and was idiopathic in the remaining two. Despite traditional therapies these infants were on a progressively deteriorating clinical course. Hakim-Cordis low-pressure ventricular-peritoneal shunt catheter systems were used in each infant. Ultrasonography was used to follow the regression of pleural effusions and to determine the need for shunt compression. Shunt patency was confirmed with radionuclide studies. Four of five infants had a complete resolution of their chylothorax and pulmonary insufficiency. Three of these infants were extubated within 28 days following the placement of the shunt. Nutritional and metabolic stability was rapidly achieved. The shunts were removed several weeks later without recurrence of the chylothorax. A fifth infant failed to improve after the placement of the pleuroperitoneal shunt and died of progressive pulmonary insufficiency. The placement of pleuroperitoneal shunts in infants with refractory chylothorax is safe, technically easy to perform, and is associated with few complications.