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Winder MM, Schwartz S, Buckley JR, Fogg KL, Matiasek M, Lyman A, Tortorich A, Holmes K, Frank DU, Nasworthy M, Vichayavilas PE, Bertrandt RA, Kasmai C, Kuester JC, Raymond TT, Greiten LE, Reeder RW, Bailly DK. Optimal Fat-Modified Diet Duration for the Treatment of Postoperative Chylothorax in Children. Ann Thorac Surg 2024; 118:181-187. [PMID: 37308065 DOI: 10.1016/j.athoracsur.2023.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/12/2023] [Accepted: 05/16/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND Dietary modification is the mainstay of treatment for postoperative chylothorax in children. However, optimal fat-modified diet (FMD) duration to prevent recurrence is unknown. Our aim was to determine the association between FMD duration and chylothorax recurrence. METHODS Retrospective cohort study conducted across 6 pediatric cardiac intensive care units within the United States. Patients aged <18 years who developed chylothorax within 30 days after cardiac surgery between January 2020 and April 2022 were included. Patients with a Fontan palliation, who died, or were lost to follow-up or within 30 days of resuming a regular diet were excluded. FMD duration was defined as the first day of a FMD when chest tube output was <10 mL/kg/d without increasing until the resumption of a regular diet. Patients were classified into 3 groups (<3 weeks, 3-5 weeks, >5 weeks) based on FMD duration. RESULTS A total of 105 patients were included: <3 weeks (n = 61) 3-5 weeks (n = 18), and >5 weeks (n = 26). Demographic, surgical, and hospitalization characteristics were not different across groups. In the >5 weeks group, chest tube duration was longer compared with the <3 weeks and 3-5 weeks groups (median, 17.5 days [interquartile range, 9-31] vs 10 and 10.5 days; P = .04). There was no recurrence of chylothorax within 30 days once chylothorax was resolving regardless of FMD duration. CONCLUSIONS FMD duration was not associated with recurrence of chylothorax, suggesting that FMD duration can safely be shortened to at least <3 weeks from time of resolving chylothorax.
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Affiliation(s)
- Melissa M Winder
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, Utah.
| | - Stephanie Schwartz
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina
| | - Jason R Buckley
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Kristi L Fogg
- Medical University of South Carolina, Charleston, South Carolina
| | - Megan Matiasek
- Division of Cardiology, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Alissa Lyman
- Division of Pediatric Cardiology, Department of Pediatrics, Oregon Health and Science University, Portland, Oregon
| | - Alisa Tortorich
- Division of Pediatric Gastroenterology, Department of Pediatrics, Oregon Health and Science University, Portland, Oregon
| | - Kathy Holmes
- Division of Pediatric Cardiology, Department of Pediatrics, Oregon Health and Science University, Portland, Oregon
| | - Deborah U Frank
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Mandy Nasworthy
- Division of Pediatric Cardiology, Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | | | - Rebecca A Bertrandt
- Division of Pediatric Critical Care, Department of Pediatrics, Medical College of Wisconsin/Children's Wisconsin, Milwaukee, Wisconsin
| | - Cam Kasmai
- Division of Pediatric Critical Care, Department of Pediatrics, Medical College of Wisconsin/Children's Wisconsin, Milwaukee, Wisconsin
| | - Jill C Kuester
- Division of Pediatric Critical Care, Department of Pediatrics, Medical College of Wisconsin/Children's Wisconsin, Milwaukee, Wisconsin
| | - Tia T Raymond
- Department of Pediatrics, Cardiac Critical Care, Medical City Children's Hospital, Dallas, Texas
| | - Lawrence E Greiten
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Ron W Reeder
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - David K Bailly
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah, Salt Lake City, Utah
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Kumar A, Agarwal S, Joshi RK, Gupta A, Rudrappa SC, Aggarwal N, Joshi R. Chylothorax in Infants and Children After Congenital Heart Surgery: Approach and Review. World J Pediatr Congenit Heart Surg 2024:21501351241237952. [PMID: 38706207 DOI: 10.1177/21501351241237952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
Chylothorax in infants after surgery for congenital heart disease is associated with significant morbidity and mortality. Numerous management modalities applied alone or in various combinations have been utilized but definitive guidelines have not yet been established. We present two infants who developed refractory chylothorax after congenital heart surgery. We also reviewed evidence for the use of available treatment modalities. In our experience, the use of lymphangiography followed by pleurodesis by povidone-iodine was safe and our impression was that it may have played a decisive role in controlling the lymph leak.
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Affiliation(s)
- Anil Kumar
- Division of Pediatric Cardiac Intensive care, Department of Pediatric Cardiac Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | - Sristy Agarwal
- Division of Pediatric Cardiac Intensive care, Department of Pediatric Cardiac Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | - Reena Khantwal Joshi
- Division of Pediatric Cardiac Anesthesiology, Department of Pediatric Cardiac Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | - Arun Gupta
- Department of Interventional radiology, Sir Ganga Ram Hospital, New Delhi, India
| | - Siddhartha C Rudrappa
- Division of Pediatric Cardiac Surgery, Department of Pediatric Cardiac Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | - Neeraj Aggarwal
- Division of Pediatric Cardiology, Department of Pediatric Cardiac Sciences, Sir Ganga Ram Hospital, New Delhi, India
| | - Raja Joshi
- Division of Pediatric Cardiac Surgery, Department of Pediatric Cardiac Sciences, Sir Ganga Ram Hospital, New Delhi, India
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Rahmath MRK, Bhat AN, Lone RA, Kamal RY. Efficacy of nil per oral, total parenteral nutrition, milrinone and non-suction chest tube drainage-based management for chylothorax following pediatric cardiac surgery. Asian Cardiovasc Thorac Ann 2024; 32:186-193. [PMID: 38659299 DOI: 10.1177/02184923241249198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
OBJECTIVE A single centre experience with chylothorax in post cardiac surgical patients. METHODS Retrospective review. RESULTS Chylothorax developed in 55 out of 873 operated patients (6.3%). Median age of the chylothorax cohort was 95 days (range 1-995). Neonates constituted 36% and 49% were infants. Group-1(35 patients-treated during the years 2011-2015) included those who were managed with low fat diet initially with other standard measures including steroid, octreotide, pleurodesis, lymphangiogram or thoracic duct ligation whenever required.Group-2 (20 patients, treated between year 2016-2018) were managed with nil per oral, total parenteral nutrition, extended use of milrinone and no use of chest tube suction with other above standard measures when required.Group-1 and group-2 were comparable in terms of their age and weight (p > 0.05).We observed lower volume of chest drainage, shorter intubation time, length of intensive care stay and hospital stay in group-2 compared to group-1 though they were statistically not significant (p > 0.05). Occurrence of massive chylothorax (>20 ml/kg/day) in group-1 was significantly higher [18 patients (51%) in group-1 vs 4 patients in group-2 (20%) (Chi-square 5.25, p = 0.02)]. In hospital mortality in group-1 was higher compared to group-2 (5/35 = 14.5% vs 1/20 = 5%), however, it was statistically not significant [risk ratio 2.86; 95% CI 0.36, 22.77; p = 0.59)]. Acute kidney injury was observed in about 25% of patients who had chylothorax. A higher mortality was observed in patients with chylothorax who had acute kidney injury [5/14 (35%)] compared to those who did not have acute kidney injury [1/41 (2.4%)] (Chi-square 11.89, p = 0.001)]. SUMMARY In a heterogenous cohort of post-cardiac surgical patients who developed chylothorax, our suggested new regime (nil per oral, parenteral nutrition, extended use of milrinone and no suction applied to the chest drains) contributed to reduce the frequency of massive chylothorax occurrence significantly.
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Affiliation(s)
| | - Akhlaque N Bhat
- Pediatric Cardiac Surgery Division, CT Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Reyaz A Lone
- Pediatric Cardiac Surgery Division, CT Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Reema Y Kamal
- Pediatric Cardiology, Pediatrics, Hamad Medical Corporation, Doha, Qatar
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Zhang RG, Liu YM, Yao ZY, Fang JX, Li Y, Zheng ML, Sun X, Wen SS, Wang XM, Zhuang J, Luo DD, He SR. Risk Factors of Chylothorax After Congenital Heart Surgery in Infants: A Single-Centre Retrospective Study. Ther Clin Risk Manag 2024; 20:161-168. [PMID: 38476881 PMCID: PMC10929254 DOI: 10.2147/tcrm.s436991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 01/13/2024] [Indexed: 03/14/2024] Open
Abstract
Background Studies of chylothorax after congenital heart disease in infants are rare. Chylothorax has a higher incidence in infancy, but its risk factors are not well understood. Objective The purpose of this study is to investigate the risk factors of chylothorax after congenital heart surgery in infants. Methods This retrospective study included 176 infants who underwent congenital heart disease surgery at the Guangdong Cardiovascular Institute, China, between 2016 and 2020. According to the occurrence of chylothorax, the patients were divided into a control group (n = 88) and a case group (n = 88). Univariate and multivariate logistic regression were performed to analyse the incidence and influencing factors of chylothorax after congenital heart surgery in infants. Results Between 2016 and 2020, the annual incidence rate fluctuated between 1.55% and 3.17%, and the total incidence of chylothorax was 2.02%. Multivariate logistic regression analysis showed that postoperative albumin (p = 0.041; odds ratio [OR] = 0.095), preoperative mechanical ventilation (p = 0.001; OR = 1.053) and preterm birth (p = 0.002; OR = 5.783) were risk factors for postoperative chylothorax in infants with congenital heart disease. Conclusion The total incidence of chylothorax was 2.02% and the annual incidence rate fluctuated between 1.55% and 3.17% between 2016 and 2020. Premature infants, longer preoperative mechanical ventilation and lower albumin after congenital heart surgery may be risk factors for chylothorax. In addition, infants with chylothorax are inclined to be infected, need more respiratory support, use a chest drainage tube for longer and remain longer in hospital.
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Affiliation(s)
- Rui-Gui Zhang
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510260, People’s Republic of China
- Department of Neonatal Pediatrics, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, People’s Republic of China
- Department of Pediatrics, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, People’s Republic of China
| | - Yu-Mei Liu
- Department of Neonatal Pediatrics, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, People’s Republic of China
- Department of Pediatrics, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, People’s Republic of China
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, People’s Republic of China
| | - Zhi-Ye Yao
- Department of Neonatal Pediatrics, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, People’s Republic of China
- Department of Pediatrics, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, People’s Republic of China
| | - Jing-Xuan Fang
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, People’s Republic of China
| | - Yuan Li
- Department of Neonatal Pediatrics, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, People’s Republic of China
- Department of Pediatrics, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, People’s Republic of China
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, People’s Republic of China
| | - Man-Li Zheng
- Department of Neonatal Pediatrics, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, People’s Republic of China
- Department of Pediatrics, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, People’s Republic of China
| | - Xin Sun
- Department of Neonatal Pediatrics, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, People’s Republic of China
- Department of Pediatrics, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, People’s Republic of China
| | - Shu-Sheng Wen
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, People’s Republic of China
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, People’s Republic of China
| | - Xi-Meng Wang
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, People’s Republic of China
- Global Health Research Center, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, People’s Republic of China
| | - Jian Zhuang
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, People’s Republic of China
| | - Dan-Dong Luo
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, People’s Republic of China
| | - Shao-Ru He
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510260, People’s Republic of China
- Department of Neonatal Pediatrics, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, People’s Republic of China
- Department of Pediatrics, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510080, People’s Republic of China
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Nakata T, Tachi M, Yasuda K, Nakashima S, Ikeda T, Minatoya K, Oda T. Pleurodesis using OK-432 for persistent pleural effusion after cardiac surgery in the neonatal period or early infancy. Asian Cardiovasc Thorac Ann 2024; 32:83-90. [PMID: 38073052 DOI: 10.1177/02184923231219606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
OBJECTIVE To evaluate the efficacy of pleurodesis using OK-432 after cardiac surgery in the neonatal period or early infancy. METHODS We retrospectively reviewed the data of 11 consecutive patients who underwent cardiac surgery in the neonatal period or early infancy and pleurodesis using OK-432 for persistent postoperative pleural effusion in two institutions. RESULTS The median age at surgery was 8 days (interquartile range [IR], 2-18) with a body weight of 2.84 kg (IR, 2.30-3.07). The maximum amount of pleural drainage before pleurodesis was 94.7 (IR, 60.2-107.7) ml/kg/day. Pleurodesis was initiated at postoperative day 20 (IR, 17-22) and performed in bilateral pleural spaces in seven patients and unilateral in four. The median numbers of injection were 4 (IR, 3-6) times per patient and 3 (IR, 2-3) times per pleural space. In 10 patients, pleural effusion was decreased effectively, and drainage tubes were removed without reaccumulation within 15 (IR, 12-28) days after initial pleurodesis. However, in one patient, with severe lymphedema, pleural effusion was uncontrollable, resulting in death due to sepsis. Adverse events were observed in nine patients; temporal deterioration of lung compliance and arterial blood gas occurred in two, insufficient drainage requiring new chest tube(s) in five, temporal atrial tachyarrhythmia in one, and lymphedema in four. CONCLUSIONS Pleurodesis using OK-432 is effective and reliable for persistent postoperative pleural effusion in neonates and early infants. Most of the complications, which derived from inflammatory reactions, were temporary and controllable. However, severe lymphedema is difficult to control.
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Affiliation(s)
- Tomohiro Nakata
- Departmet of Cardiovascular Surgery, Shimane University Faculty of Medicine, Matsue, Japan
| | - Maiko Tachi
- Departmet of Cardiovascular Surgery, Shimane University Faculty of Medicine, Matsue, Japan
| | - Kenji Yasuda
- Department of Pediatrics, Shimane University Faculty of Medicine, Matsue, Japan
| | - Shigeki Nakashima
- Department of Pediatrics, Shimane University Faculty of Medicine, Matsue, Japan
| | - Tadashi Ikeda
- Department of Cardiovascular Surgery, Kyoto University Faculty of Medicine, Kyoto, Japan
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Kyoto University Faculty of Medicine, Kyoto, Japan
| | - Teiji Oda
- Departmet of Cardiovascular Surgery, Shimane University Faculty of Medicine, Matsue, Japan
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Fogg KL, Trauth A, Horsley M, Vichayavilas P, Winder M, Bailly DK, Gordon EE. Nutritional management of postoperative chylothorax in children with CHD. Cardiol Young 2023; 33:1663-1671. [PMID: 36177859 DOI: 10.1017/s1047951122003109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Chylothorax after congenital cardiac surgery is associated with increased risk of malnutrition. Nutritional management following chylothorax diagnosis varies across sites and patient populations, and a standardised approach has not been disseminated. The aim of this review article is to provide contemporary recommendations related to nutritional management of chylothorax to minimise risk of malnutrition. METHODS The management guidelines were developed by consensus across four dietitians, one nurse practitioner, and two physicians with a cumulative 52 years of experience caring for children with CHD. A PubMed database search for relevant literature included the terms chylothorax, paediatric, postoperative, CHD, chylothorax management, growth failure, and malnutrition. RESULTS Fat-modified diets and nil per os therapies for all paediatric patients (<18 years of age) following cardiac surgery are highlighted in this review. Specific emphasis on strategies for treatment, duration of therapies, optimisation of nutrition including nutrition-focused lab monitoring, and supplementation strategies are provided. CONCLUSIONS Our deliverable is a clinically useful guide for the nutritional management of chylothorax following paediatric cardiac surgery.
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Affiliation(s)
- Kristi L Fogg
- Department of Pediatrics, Division of Pediatric Cardiology, Medical University of South Carolina, Charleston, SC, USA
| | - Amiee Trauth
- Division of Nutrition Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Megan Horsley
- Division of Nutrition Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Melissa Winder
- Department of Pediatrics, Division of Pediatric Cardiology, University of Utah, Salt Lake City, UT, USA
| | - David K Bailly
- Department of Pediatrics, Division of Pediatric Critical Care, University of Utah, Salt Lake City, UT, USA
| | - Erin E Gordon
- Department of Pediatrics, Division of Pediatric Critical Care, University of Texas Southwestern, Dallas, TX, USA
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Moza R, Winder M, Adamson GT, Ou Z, Presson AP, Vijayarajah S, Goldstein SA, Bailly DK. Prediction Model with External Validation for Early Detection of Postoperative Pediatric Chylothorax. Pediatr Cardiol 2023:10.1007/s00246-022-03034-4. [PMID: 36754886 DOI: 10.1007/s00246-022-03034-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 10/14/2022] [Indexed: 02/10/2023]
Abstract
Earlier diagnosis of chylothorax following pediatric cardiac surgery is associated with decreased duration of chylothorax. Pleural fluid testing is used to diagnosis chylothorax which may delay detection in patients who are not enterally fed at time of chylothorax onset. Our aim was to develop and externally validate a prediction model to detect chylothorax earlier than pleural fluid testing in pediatric patients following cardiac surgery. A multivariable logistic regression model was developed to detect chylothorax using a stepwise approach. The model was developed using data from patients < 18 years following cardiac surgery from Primary Children's Hospital, a tertiary-care academic center, between 2017 and 2020. External validation used a contemporary cohort (n = 171) from Lucille Packard Children's Hospital. A total of 763 encounters (735 patients) were analyzed, of which 72 had chylothorax. The final variables selected were chest tube output (CTO) the day after sternal closure (dichotomized at 15.6 mL/kg/day, and as a continuous variable) and delayed sternal closure. The highest odds of chylothorax were associated with CTO on post-sternal closure day 1 > 15.6 mL/kg/day (odds ratio 11.3, 95% CI 6,3, 21.3). The c-statistic for the internal and external validation datasets using the dichotomized CTO variable were 0.78 (95% CI 0.73, 0.82) and 0.84 (95% CI, 0.78, 0.9) and performance improved when using CTO as a continuous variable (OR 0.84, CI: 95% CI 0.80, 0.87). Using the models described, chylothorax after pediatric cardiac surgery may be detected earlier and without reliance on enteral feeds.
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Affiliation(s)
- Rohin Moza
- Division of Pediatric Critical Care, University of Utah/Primary Children's Hospital, 295 Chipeta Way, Salt Lake City, UT, 84108, USA.
| | - Melissa Winder
- Division of Pediatric Critical Care, University of Utah/Primary Children's Hospital, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Gregory T Adamson
- Department of Pediatric Cardiology, Stanford University/Lucile Packard Children's Hospital, 725 Welch Road, Palo Alto, CA, 94304, USA
| | - Zhining Ou
- Division of Epidemiology, Department of Internal Medicine, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84132, USA
| | - Angela P Presson
- Division of Epidemiology, Department of Internal Medicine, University of Utah, 295 Chipeta Way, Salt Lake City, UT, 84132, USA
| | - Senthuran Vijayarajah
- Section of Pediatric Critical Care, University of Oklahoma Health Sciences Center, 1200 Everett Dr, Oklahoma City, OK, 73104, USA
| | - Stephanie A Goldstein
- Division of Pediatric Critical Care, University of Utah/Primary Children's Hospital, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - David K Bailly
- Division of Pediatric Critical Care, University of Utah/Primary Children's Hospital, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
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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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9
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Ramirez-Suarez KI, Tierradentro-García LO, Biko DM, Otero HJ, White AM, Dori Y, Smith CL, Vatsky S, Rapp JB. Lymphatic anomalies in congenital heart disease. Pediatr Radiol 2022; 52:1862-1876. [PMID: 35840695 DOI: 10.1007/s00247-022-05449-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 05/16/2022] [Accepted: 06/30/2022] [Indexed: 10/17/2022]
Abstract
Congenital heart disease can lead to various lymphatic complications including traumatic leaks, lymphatic overproduction, conduction abnormalities or lymphedema. Advancements in the imaging of central lymphatics and guided interventions have improved outcomes in these children. Dynamic contrast-enhanced magnetic resonance (MR) lymphangiography allows for the assessment of abnormal lymphatic drainage. This technique is preferred for evaluating lymphatic conditions such as plastic bronchitis, chylothorax, chyloptysis, chylopericardium, protein-losing enteropathy and chylous ascites, among other lymphatic disorders. In this review, we discuss lymphatic abnormalities encountered on MRI in children with congenital heart disease. We also briefly review treatment options.
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Affiliation(s)
- Karen I Ramirez-Suarez
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | | | - David M Biko
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Hansel J Otero
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ammie M White
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Yoav Dori
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Christopher L Smith
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Seth Vatsky
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jordan B Rapp
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA. .,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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10
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Development of consensus recommendations for the management of post-operative chylothorax in paediatric CHD. Cardiol Young 2022; 32:1202-1209. [PMID: 35792060 DOI: 10.1017/s1047951122001871] [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: 11/06/2022]
Abstract
OBJECTIVE A standardised multi-site approach to manage paediatric post-operative chylothorax does not exist and leads to unnecessary practice variation. The Chylothorax Work Group utilised the Pediatric Critical Care Consortium infrastructure to address this gap. METHODS Over 60 multi-disciplinary providers representing 22 centres convened virtually as a quality initiative to develop an algorithm to manage paediatric post-operative chylothorax. Agreement was objectively quantified for each recommendation in the algorithm by utilising an anonymous survey. "Consensus" was defined as ≥ 80% of responses as "agree" or "strongly agree" to a recommendation. In order to determine if the algorithm recommendations would be correctly interpreted in the clinical environment, we developed ex vivo simulations and surveyed patients who developed the algorithm and patients who did not. RESULTS The algorithm is intended for all children (<18 years of age) within 30 days of cardiac surgery. It contains rationale for 11 central chylothorax management recommendations; diagnostic criteria and evaluation, trial of fat-modified diet, stratification by volume of daily output, timing of first-line medical therapy for "low" and "high" volume patients, and timing and duration of fat-modified diet. All recommendations achieved "consensus" (agreement >80%) by the workgroup (range 81-100%). Ex vivo simulations demonstrated good understanding by developers (range 94-100%) and non-developers (73%-100%). CONCLUSIONS The quality improvement effort represents the first multi-site algorithm for the management of paediatric post-operative chylothorax. The algorithm includes transparent and objective measures of agreement and understanding. Agreement to the algorithm recommendations was >80%, and overall understanding was 94%.
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Cini C. Characterising chylothorax in the paediatric population with Congenital Heart Disease. PROGRESS IN PEDIATRIC CARDIOLOGY 2022. [DOI: 10.1016/j.ppedcard.2022.101548] [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: 11/25/2022]
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12
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Samanidis G, Kourelis G, Bounta S, Kanakis M. Postoperative Chylothorax in Neonates and Infants after Congenital Heart Disease Surgery-Current Aspects in Diagnosis and Treatment. Nutrients 2022; 14:nu14091803. [PMID: 35565771 PMCID: PMC9104302 DOI: 10.3390/nu14091803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 04/22/2022] [Accepted: 04/24/2022] [Indexed: 11/28/2022] Open
Abstract
Postoperative chylothorax is a rare complication following cardiac surgery for congenital heart disease (CHD) in the pediatric population, including neonates and infants. Multiple mechanisms are involved in the development of postoperative chylous effusions, mainly the traumatic injury of lymphatic vessels, systemic venous obstruction and dysfunction of the right ventricle. In this review, we focus on the existing evidence regarding the definition and diagnosis of postoperative chylothorax in children with CHD, as well as current therapeutic approaches, both nutritional and interventional, for the management of these patients. As part of nutritional management, we specifically comment on the use of defatted human milk and its effect on both chylothorax resolution and patient growth. A consensus with regard to several key aspects of this potentially significant complication is warranted given its impact on the cost, morbidity and mortality of children with CHD.
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Affiliation(s)
- Georgios Samanidis
- Department of Adult Cardiac Surgery, Onassis Cardiac Surgery Center, 17674 Athens, Greece
- Department of Pediatric and Adult Congenital Heart Surgery, Onassis Cardiac Surgery Center, 17674 Athens, Greece;
- Correspondence:
| | - Georgios Kourelis
- Pediatric Cardiac and Adult Congenital Heart Disease Intensive Care Unit, Onassis Cardiac Surgery Center, 17674 Athens, Greece; (G.K.); (S.B.)
| | - Stavroula Bounta
- Pediatric Cardiac and Adult Congenital Heart Disease Intensive Care Unit, Onassis Cardiac Surgery Center, 17674 Athens, Greece; (G.K.); (S.B.)
| | - Meletios Kanakis
- Department of Pediatric and Adult Congenital Heart Surgery, Onassis Cardiac Surgery Center, 17674 Athens, Greece;
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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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Winder MM, Vijayarajah S, Reeder RW, Glenn ET, Moza R, Eckhauser AW, Bailly DK. Successfully Reducing Fat-modified Diet Duration for Treating Postoperative Chylothorax in Children. Ann Thorac Surg 2021; 114:2363-2371. [PMID: 34801476 DOI: 10.1016/j.athoracsur.2021.10.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 10/06/2021] [Accepted: 10/11/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Medical management, primarily a fat-modified diet (FMD), is the mainstay of treatment for the majority of patients with chylothorax. Duration of FMD is traditionally reported as 6 weeks, but no studies demonstrate the shortest effective duration that prevents recurrence of chylothorax. Our aim was to decrease FMD duration to 2 weeks in children with postoperative chylothorax without a significant increase in recurrence. METHODS Our single-center study included pediatric (<18 years of age) patients that developed chylothorax within 30 days of cardiac surgery. Patients with cavopulmonary anastomoses were excluded. The pre-intervention cohort was 19 patients diagnosed between 2/2014-6/2015, and the post-intervention cohort was 98 patients from 7/2015-12/2019. FMD duration was decreased from 6 weeks to 4 weeks in May 2016, and to 2 weeks in June 2018. Recurrence was defined as a return of a chylous effusion requiring chest tube placement or hospital readmission within 30 days of resuming a regular diet. RESULTS The median duration of FMD decreased from 42 days (interquartile range: 30,43) in the pre-intervention cohort to 26 days (interquartile range: 14,29) post-intervention, with no recurrence of chylothorax in any group. Compliance to the FMD duration instruction in the 6-week, 4-week, and 2-week groups was 100%, 84% and 67% respectively. Compared to the first 6 months, compliance to the 2-week FMD instruction during the final 12 months increased from 40% (6/15) to 79% (26/33). CONCLUSIONS At our center, FMD duration decreased from 6 weeks to 2 weeks without any recurrence of chylothorax.
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Affiliation(s)
- Melissa M Winder
- Department of Pediatrics, Division of Cardiology, University of Utah, Salt Lake City, UT; Pediatric Critical Care Services, Primary Children's Hospital, Salt Lake City, UT.
| | - Senthuran Vijayarajah
- Department of Pediatrics, Division of Pediatric Critical Care, University of Oklahoma, Oklahoma City, OK
| | - Ron W Reeder
- Department of Pediatrics, Division of Pediatric Critical Care, University of Utah, Salt Lake City, UT
| | - Emilee T Glenn
- Department of Cardiothoracic Surgery, Primary Children's Hospital, Salt Lake City, UT
| | - Rohin Moza
- Department of Pediatrics, Division of Pediatric Critical Care, University of Utah, Salt Lake City, UT
| | - Aaron W Eckhauser
- Department of Surgery, Division of Pediatric Cardiothoracic Surgery, University of Utah, Salt Lake City, UT
| | - David K Bailly
- Department of Pediatrics, Division of Pediatric Critical Care, University of Utah, Salt Lake City, UT
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Deogaonkar G, Sinha MD, Jones M, Calder F, Karunanithy N, Qureshi SA. Percutaneous Venous Reconstruction for Central Thrombosis-Associated Chylothorax: A Safe and Efficacious Option. JACC Case Rep 2021; 3:1569-1575. [PMID: 34729502 PMCID: PMC8543144 DOI: 10.1016/j.jaccas.2021.06.002] [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: 03/05/2021] [Revised: 05/25/2021] [Accepted: 06/01/2021] [Indexed: 11/30/2022]
Abstract
Central thrombosis–associated chylothorax is underrecognized in children and frequently refractory to conservative management. Central venous catheterizations are the predominate cause. We present 3 cases highlighting endovascular techniques used to treat persistent chylous effusions. (Level of Difficulty: Advanced.)
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Key Words
- CT, computed tomography
- CTaC, central thrombosis–associated chylothorax
- CVT, central vein thrombosis
- IVC, inferior vena cava
- MCT, medium-chain triglyceride
- MPA, main pulmonary artery
- MRI, magnetic resonance imaging
- RPA, right pulmonary artery
- SVC, superior vena cava
- TPN, total parenteral nutrition
- central line
- central vein obstruction
- chylothorax
- chylous effusion
- endovenous reconstruction
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Affiliation(s)
- Ganesh Deogaonkar
- Department of Interventional Radiology, Evelina London Children's Hospital, London, United Kingdom
| | - Manish D Sinha
- Department of Nephrology, Evelina London Children's Hospital, London, United Kingdom
| | - Matthew Jones
- Department of Pediatric Cardiology, Evelina London Children's Hospital, London, United Kingdom
| | - Francis Calder
- Department of Renal Transplantation, Evelina London Children's Hospital. London, United Kingdom
| | - Narayan Karunanithy
- Department of Interventional Radiology, Evelina London Children's Hospital, London, United Kingdom.,School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Shakeel A Qureshi
- Department of Pediatric Cardiology, Evelina London Children's Hospital, London, United Kingdom
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16
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Lymphatic Endothelial Cell Defects in Congenital Cardiac Patients With Postoperative Chylothorax. ACTA ACUST UNITED AC 2021; 2. [PMID: 34590077 PMCID: PMC8478352 DOI: 10.1097/jova.0000000000000016] [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] [Indexed: 11/26/2022]
Abstract
Objectives Chylothorax following cardiac surgery for congenital cardiac anomalies is a complication associated with severe morbidities and mortality. We hypothesize that there are intrinsic defects in the lymphatics of congenital cardiac patients. Methods Postsurgical chylothorax lymphatic endothelial cells (pcLECs) (n = 10) were isolated from the chylous fluid from congenital cardiac defect patients, and characterized by fluorescent-activated cell sorting, immunofluorescent staining, and quantitative RT-PCR. Results were compared to normal human dermal lymphatic endothelial cells (HdLECs). pcLECs (n = 3) and HdLECs were xenografted into immunocompromised mice. Implants and postoperative chylothorax patient's pulmonary tissues were characterized by immunostaining for lymphatic endothelial proteins. Results pcLECs expressed endothelial markers VECADHERIN, CD31, VEGFR2, lymphatic endothelial markers PROX1, podoplanin, VEGFR3, and progenitor endothelial markers CD90 and CD146. However, pcLECs had key differences relative to HdLECs, including altered expression and mislocalization of junctional proteins (VECADHERIN and CD31), and essential endothelial proteins, VEGFR2, VEGFR3, and PROX1. When xenografted in mice, pcLECs formed dilated lymphatic channels with poor cell-cell association. Similar to congenital lymphatic anomalies, the pulmonary lymphatics were dilated in a patient who developed postoperative chylothorax after cardiac surgery. Conclusions Recent studies have shown that some postoperative chylothoraces in congenital cardiac anomalies are associated with anatomical lymphatic defects. We found that pcLECs have defects in expression and localization of proteins necessary to maintain lymphatic specification and function. This pcLEC phenotype is similar to that observed in lymphatic endothelial cells from congenital lymphatic anomalies. Co-existence of lymphatic anomalies should be considered as a feature of congenital cardiac anomalies.
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17
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Corda R, Chrisomalis-Dring S, Crook S, Shawber CJ, Wu JK, Chai PJ. Propranolol treatment for chylothorax after congenital cardiac surgery. J Thorac Cardiovasc Surg 2021; 163:1630-1641.e2. [PMID: 34583843 DOI: 10.1016/j.jtcvs.2021.09.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 08/09/2021] [Accepted: 09/01/2021] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Postoperative chylothorax causes significant morbidities in pediatric patients with cardiac disease. New treatment approaches based on evolving understanding of underlying lymphatic dysfunction are being developed. We hypothesized that propranolol reduces morbidities and duration of chest tube requirement in high-output chylous effusion. METHODS The postoperative courses of 50 pediatric patients with cardiac disease and high-output chylous effusion (control, n = 25; propranolol-treated, n = 25) were reviewed, including morbidities, length of hospitalization, and duration of chest tube requirement. Statistical analysis was performed using Welch's t test, Kruskal-Wallis tests for continuous variables, and chi-square and Fisher exact tests for categorical variables. Univariable logistic regression was used to determine predictors of response. RESULTS Propranolol response was defined as 80% or more drainage reduction in 9 days or less. Treated patients were grouped into responders (<9 days) and nonresponders (>10 days). Neither initial amount of drainage (P = .12) nor day of propranolol initiation (P = .17) correlated with response. When compared with controls and nonresponders, responders had significantly fewer days with chest tube requirement (P < .01), infection (P < .0002), and thrombus (P = .005), and shorter hospitalization (P < .05). All patients had low serum albumin, although nonresponders had significantly decreased serum albumin when compared with responders and control patients (P < .002), and were more likely to receive albumin replacement (P < .01). Malnutrition was prevalent in all patient groups. CONCLUSIONS Responders to propranolol had significantly less morbidity and duration of chest tube requirement when compared with control patients and nonresponders. Nonresponders did not have worse outcomes than control patients. We conclude that propranolol may be an effective treatment of patients with refractory chylothorax.
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Affiliation(s)
- Rozelle Corda
- Division of Cardiothoracic Surgery, Department of Surgery, New York Presbyterian/Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY.
| | - Sophia Chrisomalis-Dring
- Division of Pediatric Cardiology, Department of Pediatrics, New York Presbyterian/Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY
| | - Sarah Crook
- Division of Pediatric Cardiology, Department of Pediatrics, New York Presbyterian/Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY
| | - Carrie J Shawber
- Division of Reproductive Science, Department of Ob/Gyn and Department of Surgery, Vagelos College of Physicians & Surgeons, Columbia University Irving Medical Center, New York, NY
| | - June K Wu
- Division of Plastic Surgery, Department of Surgery, Vagelos College of Physicians & Surgeons, Columbia University Irving Medical Center, New York, NY
| | - Paul J Chai
- Division of Cardiothoracic Surgery, Department of Surgery, New York Presbyterian/Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY; Now with Division of Cardiothoracic Surgery, Department of Surgery, Children's Healthcare of Atlanta and Emory University, Atlanta, Ga
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18
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Höck M, Höller A, Hammerl M, Wechselberger K, Krösslhuber J, Kiechl-Kohlendorfer U, Scholl-Bürgi S, Karall D. Dietary treatment of congenital chylothorax with skimmed breast milk. Ital J Pediatr 2021; 47:175. [PMID: 34446079 PMCID: PMC8390271 DOI: 10.1186/s13052-021-01125-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 07/09/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Congenital chylothorax (CC) is a rare but potentially life-threatening condition in newborns. It is defined as an accumulation of chyle in the pleural cavity. The few publications regarding medical management and therapeutic dietary intervention motivated us to share our experience. METHODS Neonates diagnosed with congenital chylothorax and treated at Innsbruck Medical University Hospital between 2013 and 2020 (n = 6, gestational age: 36 3/7, 32 5/7, 36 4/7, 35 0/7, 35 4/7, 37 3/7 weeks) were eligible for this report. The cornerstones of treatment for chylothorax conventionally consist of chest tube drainage (CTD), respiratory support, dietary restriction of long-chain triglycerides (LCT) or total parenteral nutrition (TPN). In further course the introduction of a medium-chain triglyceride (MCT)-based formula followed by an overlapping switch to a formula with low LCT and high MCT, containing the essential long-chain fatty acids (LCFA), is attempted. In three patients we used fat-modified (skimmed) breast milk to provide a high protein and low fat diet and to avoid the discontinuation of breast milk. RESULTS The outcome of an early introduction of LCFA in the form of skimmed breast milk after resolution of chylothorax diverse. One patient had a favourable outcome, meaning no recurrence of pleural effusion, adequate weight gain and a content mother, while another patient had a relapse of pleural effusion after the administration of skimmed milk and was therefore transitioned back to Basic F® . The CC of patient 5 was difficult due to Noonan syndrome. Two weeks after the introduction of skimmed breast milk the mother wanted to stop to express breast milk, so nutrition was changed to Basic F®. CONCLUSION The first-line therapy of chylothorax is a combination of respiratory stabilization and dietary modification. The use of skimmed breast milk is advisable in CC and feasible by means of a simple milk defatting procedure. It offers benefits to mothers who wish to resume breast feeding after resolution of chylothorax and has proven positive effects, above all in preterm infants as optimal nutrition with protective components superior to formula feeding. However, the nutritional analysis of the skimmed milk and the correlation to a re-accumulation of pleural fluid remains a question to be answered.
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Affiliation(s)
- Michaela Höck
- Department of Paediatrics II, Neonatology, Medical University of Innsbruck, Innsbruck, Austria
| | - Alexander Höller
- Service for Nutrition and Dietetics, Medical University of Innsbruck, Innsbruck, Austria
| | - Marlene Hammerl
- Department of Paediatrics II, Neonatology, Medical University of Innsbruck, Innsbruck, Austria
| | - Karina Wechselberger
- Department of Paediatrics II, Neonatology, Medical University of Innsbruck, Innsbruck, Austria
| | - Jakob Krösslhuber
- Department of Paediatrics I, Intensive Care Unit, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Sabine Scholl-Bürgi
- Department of Paediatrics I, Inherited Metabolic Disorders, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Daniela Karall
- Department of Paediatrics I, Inherited Metabolic Disorders, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
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Silva ACSSD, Stipp MAC, Paes GO, Knupp VMDAO, Góes FGB, Sá Neto JAD. Tools for managing childcare in the postoperative period of cardiac surgery: an integrative review. Rev Bras Enferm 2021; 74:e20200073. [PMID: 33909809 DOI: 10.1590/0034-7167-2020-0073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 12/21/2020] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To analyze the scientific literature on the application of management tools in the postoperative period of pediatric cardiac surgery. METHODS integrative review including studies published between 2004 and 2018 in the following databases: LILACS, BDENF, coleciona SUS, MEDLINE/PUBMED, CINAHL and SCOPUS, via Portal de Periódicos da Capes, Scientific Electronic Library Online (SciELO) and Academic Google research. RESULTS Twelve articles that met the inclusion criteria were analyzed. The studies demonstrated that strategies such as extracorporeal membrane oxygenation, renal replacement therapy and the risk scores for Risk Adjustment for Congenital Heart Surgery 1 and Aristotle Basic Score favored the stratification the demand for care and predicted the risk for mortality. FINAL CONSIDERATIONS The applicability of risk scores and emerging strategies for the management of childcare in the postoperative period of cardiac surgery was described by the evaluation of possibilities of performance and/or efficiency of the treatments developed.
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Pediatric pulmonary lymphatic flow Disorders: Diagnosis and management. Paediatr Respir Rev 2020; 36:2-7. [PMID: 31884062 DOI: 10.1016/j.prrv.2019.11.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 11/22/2019] [Indexed: 11/20/2022]
Abstract
Pulmonary lymphatic flow disorders involve the abnormal lymphatic flow via lymphatic channels to the lungs and pleural space. Plastic bronchitis and chylothorax are the main complications of this abnormal lymphatic perfusion, which has been termed pulmonary lymphatic perfusion syndrome (PLPS). Following lymphatic access, dynamic contrast MR lymphangiography is the imaging modality of choice to diagnose these disorders. Management includes medical therapy, percutaneous interventions under fluoroscopy, and surgical interventions.
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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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Abstract
Visceral vascular anomalies are common in patients with vascular malformations in other parts of the body and can include lymphatic, venous, and arteriovenous malformations. Depending on the organ or organs involved they may present differently and pose different treatment challenges. Defining the malformation and understanding its extent is paramount in devising management regimens. Medical, interventional, and surgical therapies are often required in combination to treat these complex lesions. There are new and promising advances in the development of therapeutic agents targeting the PI3K/AKT/mTOR pathway. Due to the complex nature of these lesions a coordinated, multi-disciplinary approach is necessary to manage and mitigate symptoms and complications of this diverse group of vascular malformations.
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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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Taksande A, Injeti G, Joshi M, Meshram R. Chylothorax in a young child after a palliative cardiac surgery. INTERNATIONAL JOURNAL OF ACADEMIC MEDICINE 2020. [DOI: 10.4103/ijam.ijam_90_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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25
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Neumann L, Springer T, Nieschke K, Kostelka M, Dähnert I. ChyloBEST: Chylothorax in Infants and Nutrition with Low-Fat Breast Milk. Pediatr Cardiol 2020; 41:108-113. [PMID: 31729543 DOI: 10.1007/s00246-019-02230-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Accepted: 10/17/2019] [Indexed: 11/27/2022]
Abstract
Chylothorax occurs in 2.8-5% of infants after cardiac surgery and can increase morbidity and mortality. First-line conservative treatment consists of a chest tube drainage and a fat-free and medium-chain triglyceride (MCT)-enriched diet. This typically leads to a discontinuity of breast milk feeding due to high content of long-chain triglycerides within the breast milk. Modified breast milk with low fat content (LFBM) could provide numerous benefits like immunological properties of breast milk even for patients with chylothorax. This study was conducted at Herzzentrum Leipzig comparing clinical and growth outcomes between infants with chylothorax after surgery for congenital heart disease treated with LFBM (n = 13) versus MCT-Formula (n = 10). LFBM was prepared by centrifugation of native breast milk added with MCT-oil and fortifier. There were no differences in volume and duration of chest tube drainage between LFBM and MCT-formula treatment groups. Furthermore, no statistically significant differences with regard to weight and length gains could be observed between both feeding groups. LFBM is an efficient and unharmful treatment for chylothorax following cardiac surgery in young children.
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Affiliation(s)
- Lisa Neumann
- Klinik für Kinderkardiologie, Herzzentrum Leipzig, Strümpellstraße 39, 04289, Leipzig, Germany.
| | - Tina Springer
- Klinik für Kinderkardiologie, Herzzentrum Leipzig, Strümpellstraße 39, 04289, Leipzig, Germany
| | - Kathleen Nieschke
- Klinik für Kinderkardiologie, Herzzentrum Leipzig, Strümpellstraße 39, 04289, Leipzig, Germany
| | - Martin Kostelka
- Klinik für Herzchirurgie, Herzzentrum Leipzig, Stümpellstraße 39, 04289, Leipzig, Germany
| | - Ingo Dähnert
- Klinik für Kinderkardiologie, Herzzentrum Leipzig, Strümpellstraße 39, 04289, Leipzig, Germany
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Abstract
INTRODUCTION Although chylothorax is an uncommon complication following paediatric cardiothoracic surgery, it has significant associated morbidities and increased in-hospital mortality, as well as results in higher costs. A lack of prospective evidence or consensus guidelines for management of chylothorax further hinders optimal management. The aim of this survey was to characterise variations in practice in the management of chylothorax and to identify areas for future research. MATERIALS AND METHODS A descriptive, observational survey investigating conservative management practices of chylothorax was distributed internationally to health-care professionals in paediatric intensive care and cardiology units. The survey investigated five domains: the first providing general information about health-care professionals and four domains focusing on clinical practice including diet composition and duration. RESULTS In total, sixty-four health-care professionals completed the survey, representing 38 organisations from 16 countries. The respondents were dietitians (80%), physicians (19%), and nurses (1%). In Australia and New Zealand, management was most commonly directed by physicians' preference (67%) as compared to unit protocols in Europe (67%), United States of America (67%), and Other regions (55%). Dietitians in Australia/New Zealand, United Kingdom, and Ireland followed the most restrictive diet therapy recommending <5 g long chain triglyceride fat per day (p < 0.00001). The duration of diet therapy significantly varied between regions: Australia/New Zealand: 4 weeks (36%) and 6 weeks (43%); Europe: 4 weeks (25%) and 6 weeks (57%); and North America: 4 weeks (18%) and 6 weeks (75%) (p < 0.00001). CONCLUSIONS This survey highlights international variations in practice in the management of chylothorax, particularly with respect to treatment duration and dietary fat restriction. Future research should include a multi-centre randomised controlled trial to inform evidence-based practice and reduce morbidity, particularly poor growth.
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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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Shin SH, Song JH, Kim MJ, Hur S, Kim WS, Suh DI. Clinical characteristics of nontraumatic chylothorax in pediatric patients. ALLERGY ASTHMA & RESPIRATORY DISEASE 2019. [DOI: 10.4168/aard.2019.7.4.206] [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]
Affiliation(s)
- So Hyun Shin
- Department of Pediatrics, Seoul National University Hospital, Seoul, Korea
| | - Jun Hyuk Song
- Department of Pediatrics, Myongji Hospital, Hanyang University College of Medicine, Goyang, Korea
| | - Min Jung Kim
- Department of Pediatrics, Seoul National University Hospital, Seoul, Korea
| | - Saebeom Hur
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
| | - Woo Sun Kim
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
| | - Dong In Suh
- Department of Pediatrics, Seoul National University Hospital, Seoul, Korea
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29
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Nutrition Management: Parenteral and Enteral Nutrition and Oral Intake. CONGENIT HEART DIS 2019. [DOI: 10.1007/978-3-319-78423-6_7] [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: 10/27/2022]
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Lymphovenous Anastomosis for the Treatment of Chylothorax in Infants: A Novel Microsurgical Approach to a Devastating Problem. Plast Reconstr Surg 2018; 141:1502-1507. [PMID: 29794709 DOI: 10.1097/prs.0000000000004424] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
With the expanding horizon of microsurgical techniques, novel treatment strategies for lymphatic abnormalities are increasingly reported. Described in this article is the first reported use of lymphovenous anastomosis surgery to manage recalcitrant chylothoraces in infants. Chylothorax is an increasingly common postoperative complication after pediatric cardiac surgery, with a reported incidence of up to 9.2 percent in infants. Although conservative nutritional therapy has a reported 70 percent success rate in this patient population, failed conservative management leading to persistent chylothorax is associated with a significant risk of multisystem complications and mortality. Once conservative medical strategies are deemed unsuccessful, surgical or radiologic interventions, such as percutaneous thoracic duct embolization or ligation, are often attempted. However, these procedures lack high-level evidence in the infant population and remain a challenge, given the small size of the lymphatic vessels. As such, we report our experience with performing lymphovenous anastomoses in two infants who had developed refractory chylothoraces secondary to thoracic duct injury following cardiac surgery for congenital cardiac anomalies. In addition, this article reviews the relevant pathophysiology of chylothoraces, current treatment algorithm following failed conservative management, and potential role of the microsurgeon in the multidisciplinary management of this life-threatening problem. As part of the evolving microsurgery frontier, physiologic operations, such as lymphovenous anastomosis, may have a considerable role in the management of refractory pediatric chylothoraces. In our experience, lymphovenous anastomosis can restore normal lymphatic circulation within 1 to 2 weeks, liberate patients from mechanical ventilation, and enable expeditious return to enteral feeding. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, V.
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Predictive Factors for Central Line-Associated Bloodstream Infections in Pediatric Cardiac Surgery Patients With Chylothorax. Pediatr Crit Care Med 2018; 19:810-815. [PMID: 29923938 DOI: 10.1097/pcc.0000000000001634] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVES To assess the prevalence of central line-associated bloodstream infections in pediatric patients with and without chylothorax after cardiac surgery and identify risk factors that predict those patients at highest risk for developing a central line-associated bloodstream infection. DESIGN Retrospective single-center cohort study. SETTING A PICU located within a tertiary-care academic pediatric hospital. PATIENTS All pediatric patients admitted to the PICU after cardiac surgery between 2008 and 2014. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We identified 1,191 pediatric cardiac surgery patients in the study time frame, of which 66 (5.5%) had chylothorax. Patients with chylothorax were more likely to have a central line-associated bloodstream infection (23% vs 3.8%; p < 0.001). Patients with both chylothorax and central line-associated bloodstream infection had longer durations of central venous catheter, higher Risk Adjustment Congenital Heart Surgery score, longer PICU stay, and higher mortality compared with patients with chylothorax who did not have a central line-associated bloodstream infection. Multivariable analysis identified higher Risk Adjustment Congenital Heart Surgery score, longer duration of central venous catheter, and higher chest tube output at 24 hours after initiating treatment for chylothorax to be predictive of increased central line-associated bloodstream infection risk in patients with chylothorax. CONCLUSIONS The prevalence of central line-associated bloodstream infection is higher in pediatric patients with chylothorax after heart surgery. In patients with chylothorax, complexity of surgery, central venous catheter duration, and chest tube output are associated with increased risk for developing a central line-associated bloodstream infection. Using this knowledge will allow us to identify patients at increased risk for central line-associated bloodstream infections and to focus extra prevention efforts on them.
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32
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Justice L, Buckley JR, Floh A, Horsley M, Alten J, Anand V, Schwartz SM. Nutrition Considerations in the Pediatric Cardiac Intensive Care Unit Patient. World J Pediatr Congenit Heart Surg 2018; 9:333-343. [PMID: 29692230 DOI: 10.1177/2150135118765881] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Adequate caloric intake plays a vital role in the course of illness and the recovery of critically ill patients. Nutritional status and nutrient delivery during critical illness have been linked to clinical outcomes such as mortality, incidence of infection, and length of stay. However, feeding practices with critically ill pediatric patients after cardiac surgery are variable. The Pediatric Cardiac Intensive Care Society sought to provide an expert review on provision of nutrition to pediatric cardiac intensive care patients, including caloric requirements, practical considerations for providing nutrition, safety of enteral nutrition in controversial populations, feeding considerations with chylothorax, and the benefits of feeding beyond nutrition. This article addresses these areas of concern and controversy.
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Affiliation(s)
- Lindsey Justice
- 1 The Heart Institute, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | | | - Alejandro Floh
- 3 The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | - Megan Horsley
- 1 The Heart Institute, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Jeffrey Alten
- 1 The Heart Institute, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Vijay Anand
- 4 Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.,5 Pediatric Cardiac Intensive Care Unit, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Steven M Schwartz
- 3 The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
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Abstract
OBJECTIVE Our primary goal was to decrease time to resolution of postoperative chylothorax as demonstrated by total days of chest tube utilisation through development and implementation of a management protocol. METHODS A chylothorax management protocol was implemented as a quality improvement project at a tertiary-care paediatric hospital in July, 2015. Retrospective analysis was completed on patients aged 0-17 years diagnosed with chylothorax within 30 days of cardiac surgery in a pre-protocol cohort (February, 2014 to June, 2015, n=20) and a post-protocol cohort (July, 2015 to March, 2016, n=22).Measurements and resultsPatient characteristics were similar before and after protocol implementation. Duration of mechanical ventilation and cardiac ICU and hospital lengths of stay were unchanged between cohorts. Following protocol implementation, total duration of chest tube utilisation decreased from 12 to 7 days (p=0.047) with a decrease in maximum days of chest tube utilisation from 44 to 13 days. Duration of medium-chain triglyceride feeds decreased from 42 days to 31 days (p=0.01). In total, three patients in the post-protocol cohort underwent additional surgical procedures to treat chylothorax with subsequent resolution of chylothorax within 24 hours. There were no chest tube re-insertions or re-admissions related to chylothorax in either the pre- or post-protocol cohorts. Protocol compliance was 81%. CONCLUSIONS Adoption of a chylothorax management protocol is feasible, and in our small cohort of patients implementation led to a significant decrease in the duration of chest tube utilisation, while eliminating practice variability among providers.
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34
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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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Christofe NM, Pessotti CFX, Paiva L, Jatene IB. Incidence and Treatment of Chylothorax in Children Undergoing Corrective Surgery for Congenital Heart Diseases. Braz J Cardiovasc Surg 2018; 32:390-393. [PMID: 29211219 PMCID: PMC5701103 DOI: 10.21470/1678-9741-2017-0011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Accepted: 07/04/2017] [Indexed: 11/23/2022] Open
Abstract
Introduction Chylothorax is a lymphatic extravasation into pleural cavity and its
incidence is 0.25%-5.3% in children undergoing cardiac surgery. Objective To evaluate the incidence of chylothorax in pediatrics patients operated,
linking it in each surgical intervention. Evaluate treatment types and
efficiency. Methods Retrospective study using medical records of children undergoing cardiac
surgery in the Hospital do Coração between 2004 and 2014. For
statistical analysis, qualitative variables by absolute frequency and
relative frequency; quantitative variables, by median of 25 and 75
percentiles, as they did not present normal distribution (Shapiro-Wilk,
P<0.05). The Chi-square test was used for the
association between type of treatment and result. The adopted confidence
level was 95%. Results Incidence of chylothorax was 2.1% (0.9% in intracardiac surgery, 1.7%
correction of patent ductus arteriosus and aortic coarctation, 8.3% Glenn's
surgery, 11.8% total cavopulmonary surgery and 3% in others). Among
treatments, fasting associated with total parenteral nutrition (TPN)
resolved 51% of the cases. Hypoglossal diet had failed treatment and
surgical referral in 22% of the cases. Fasting with TPN associated with
octreotide had success in the treatment of chylothorax in a period exceeding
15 days in 78% of cases, and 3.7% were referred for surgery. Conclusion According to the results, incidence of chylothorax was 2.18%. Treatment with
fasting and TPN leads to resolutions in 86.5%, and the association with
octreotide was successful in 85.1% of cases, showing an efficient option,
while the treatment with hypoglossal diet had therapeutic failure in 22% of
the cases in which it was used.
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Affiliation(s)
| | | | - Laércio Paiva
- Faculdade de Medicina do ABC, Santo André, SP, Brazil
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Lo Rito M, Al-Radi OO, Saedi A, Kotani Y, Ben Sivarajan V, Russell JL, Caldarone CA, Van Arsdell GS, Honjo O. Chylothorax and pleural effusion in contemporary extracardiac fenestrated fontan completion. J Thorac Cardiovasc Surg 2017; 155:2069-2077. [PMID: 29249497 DOI: 10.1016/j.jtcvs.2017.11.046] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 10/27/2017] [Accepted: 11/11/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND We hypothesized that chylothorax could be a sign of intolerance to the Fontan physiology, and thus patients who develop chylothorax or pleural effusion have worse medium-term to long-term survival. METHODS A total of 324 patients who underwent the Fontan operation between 2000 and 2013 were included. Chylothorax was defined as ≥5 mL/kg/day of chylomicron-positive chest drainage fluid no earlier than postoperative day 5 or drainage with >80% lymphocytes. Outcomes were compared between the chylothorax and non-chylothorax groups by the Kaplan-Meier method and log-rank test. Independent predictors of chylothorax and number of days of any chest drainage were analyzed with multivariable logistic regression and multivariable generalized negative binomial regression for count data, respectively. RESULTS Chylothorax occurred in 78 patients (24%). Compared with the non-chylothorax group, the chylothorax group had a longer duration of chest tube requirement (median, 18 days vs 9 days; P < .000) and a longer length of hospital stay (median, 19 days vs 10 days; P < .000). Eight patients (10.3%) required thoracic duct ligation. The chylothorax group had lower freedom from death (P = .013) and from composite adverse events (P = .021). No predictor was found for chylothorax. Pulmonary atresia (P = .031) and pre-Fontan pulmonary artery pressure (P = .01) were predictive of prolonged pleural effusion (>14 days). CONCLUSIONS Occurrence of chylothorax following the Fontan operation can be a marker of poorer medium-term clinical outcomes. It is difficult to predict occurrence of chylothorax owing to its multifactorial nature and involvement of lymphatic compensatory capacity that is unmasked only after the Fontan operation.
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Affiliation(s)
- Mauro Lo Rito
- Department of Cardiac Surgery, IRCCS Policlinico San Donato, Milan, Italy
| | - Osman O Al-Radi
- Department of Surgery, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Arezou Saedi
- Division of Cardiovascular Surgery, Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Yasuhiro Kotani
- Department of Cardiovascular Surgery, Okayama University, Okayama, Japan
| | - V Ben Sivarajan
- Pediatric Cardiac Intensive Care, Department of Pediatrics, Stollery Children's Hospital, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Jennifer L Russell
- Division of Cardiology, Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Christopher A Caldarone
- Division of Cardiovascular Surgery, Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Glen S Van Arsdell
- Division of Cardiovascular Surgery, Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Osami Honjo
- Division of Cardiovascular Surgery, Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
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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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El Mhabrech H, Zrig A, Besbes H, Ksia A, Ben Ameur K, Hajjeji A, Hafsa C. An unusual cause of neonatal respiratory distress: neurenteric cyst. J OBSTET GYNAECOL 2017; 37:528-530. [PMID: 28317455 DOI: 10.1080/01443615.2017.1281898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Houda El Mhabrech
- a Department of Radiology B , Fattouma Bourguiba Hospital, University of Monastir , Monastir , Tunisia
| | - Ahmed Zrig
- b Department of Radiology A , Fattouma Bourguiba Hospital, University of Monastir , Monastir , Tunisia
| | - Habib Besbes
- a Department of Radiology B , Fattouma Bourguiba Hospital, University of Monastir , Monastir , Tunisia
| | - Amine Ksia
- c Department of Pediatric Surgery , Fattouma Bourguiba Hospital, University of Monastir , Monastir , Tunisia
| | - Karim Ben Ameur
- d Departments of Neonatology, Maternal and Fetal Unit , Fattouma Bourguiba Hospital, University of Monastir , Monastir , Tunisia
| | - Aouatef Hajjeji
- e Departments Obstetrics and Gynecology, Maternal and Fetal Unit , Fattouma Bourguiba Hospital, University of Monastir , Monastir , Tunisia
| | - Chiraz Hafsa
- a Department of Radiology B , Fattouma Bourguiba Hospital, University of Monastir , Monastir , Tunisia
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Treatment of chylothorax developed after congenital heart disease surgery: a case report. North Clin Istanb 2017; 2:227-230. [PMID: 28058372 PMCID: PMC5175111 DOI: 10.14744/nci.2015.58569] [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: 09/08/2015] [Accepted: 11/02/2015] [Indexed: 11/20/2022] Open
Abstract
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.
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Bilateral spontaneous chylothorax after severe vomiting in children. REVISTA PAULISTA DE PEDIATRIA (ENGLISH EDITION) 2016. [PMID: 27178371 PMCID: PMC5176075 DOI: 10.1016/j.rppede.2016.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Objective: To report the case of a child with bilateral chylothorax due to infrequent etiology: thoracic duct injury after severe vomiting. Case description: Girl, 7 years old, with chronic facial swelling started after hyperemesis. During examination, she also presented with bilateral pleural effusion, with chylous fluid obtained during thoracentesis. After extensive clinical, laboratory, and radiological investigation of the chylothorax etiology, it was found to be secondary to thoracic duct injury by the increased intrathoracic pressure caused by the initial manifestation of vomiting, supported by lymphoscintigraphy findings. Comments: Except for the neonatal period, chylothorax is an infrequent finding of pleural effusion in children. There are various causes, including trauma, malignancy, infection, and inflammatory diseases; however, the etiology described in this study is poorly reported in the literature.
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Rodrigues ALL, Romaneli MTDN, Ramos CD, Fraga ADMA, Pereira RM, Appenzeller S, Marini R, Tresoldi AT. Bilateral spontaneous chylothorax after severe vomiting in children. REVISTA PAULISTA DE PEDIATRIA 2016; 34:518-521. [PMID: 27178371 DOI: 10.1016/j.rpped.2016.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 02/28/2016] [Accepted: 03/24/2016] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To report the case of a child with bilateral chylothorax due to infrequent etiology: thoracic duct injury after severe vomiting. CASE DESCRIPTION Girl, 7 years old, with chronic facial swelling started after hyperemesis. During examination, she also presented with bilateral pleural effusion, with chylous fluid obtained during thoracentesis. After extensive clinical, laboratory, and radiological investigation of the chylothorax etiology, it was found to be secondary to thoracic duct injury by the increased intrathoracic pressure caused by the initial manifestation of vomiting, supported by lymphoscintigraphy findings. COMMENTS Except for the neonatal period, chylothorax is an infrequent finding of pleural effusion in children. There are various causes, including trauma, malignancy, infection, and inflammatory diseases; however, the etiology described in this study is poorly reported in the literature.
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Affiliation(s)
| | | | - Celso Dario Ramos
- Faculdade de Ciências Médicas da Universidade Estadual de Campinas (Unicamp), Campinas, SP, Brasil
| | | | - Ricardo Mendes Pereira
- Faculdade de Ciências Médicas da Universidade Estadual de Campinas (Unicamp), Campinas, SP, Brasil
| | - Simone Appenzeller
- Faculdade de Ciências Médicas da Universidade Estadual de Campinas (Unicamp), Campinas, SP, Brasil
| | - Roberto Marini
- Faculdade de Ciências Médicas da Universidade Estadual de Campinas (Unicamp), Campinas, SP, Brasil
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Wong JJM, Cheifetz IM, Ong C, Nakao M, Lee JH. Nutrition Support for Children Undergoing Congenital Heart Surgeries: A Narrative Review. World J Pediatr Congenit Heart Surg 2016; 6:443-54. [PMID: 26180163 DOI: 10.1177/2150135115576929] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Energy imbalance in infants and children with congenital heart disease (CHD) is common and influenced by age, underlying cardiac diagnoses, and presence or absence of congestive heart failure. During the surgical hospitalization period, these children are prone to nutritional deterioration due to stress of surgery, anesthetic/perfusion techniques, and postoperative care. Poor nutrition is associated with increased perioperative morbidity and mortality. This review aims to examine various aspects of nutrition in critically ill children with CHD, including (1) energy expenditure, (2) perioperative factors that contribute to energy metabolism, (3) bedside practices that are potentially able to optimize nutrient delivery, and (4) medium- to long-term impact of energy balance on clinical outcomes. We propose a nutrition algorithm to optimize nutrition of these children in the perioperative period where improvements in nutrition status will likely impact surgical outcomes.
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Affiliation(s)
- Judith J M Wong
- Department of Pediatric Medicine, KK Women's and Children's Hospital, Singapore
| | - Ira M Cheifetz
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - Chengsi Ong
- Department of Nutrition and Dietetics, KK Women's and Children's Hospital, Singapore
| | - Masakazu Nakao
- Department of Paediatric Cardiothoracic Surgery, KK Women's and Children's Hospital, Singapore
| | - Jan Hau Lee
- Department of Pediatric Subspecialties, Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore Office of Clinical Sciences, Duke-NUS Graduate School of Medicine, Singapore
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Pillay TG, Singh B. A review of traumatic chylothorax. Injury 2016; 47:545-50. [PMID: 26776461 DOI: 10.1016/j.injury.2015.12.015] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 12/03/2015] [Accepted: 12/13/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Traumatic chylothorax is an extremely rare complication following thoracic trauma or surgery. The aetiology of traumatic chylothorax is dominated by iatrogenic causes, with a reported incidence of 0.5% to 3% following oesophageal surgery. The mortality from a chylothorax post oesophagectomy can be as high as 50%. Iatrogenic causes in total account for approximately 80% of traumatic causes. Non-iatrogenic traumatic chylothoraces are exceedingly uncommon. The complication rate in blunt thoracic trauma is said to be 0.2% to 3%, whilst in penetrating trauma, the incidence is 0.9% to 1.3%. If recognised late or managed poorly, this condition has devastating complications, including nutritional depletion, physiological derangements and immunological depression. This review revisits the anatomy of the thoracic duct, the physiology of chyle production and associated dynamics as well as the current management strategies available for traumatic chylothorax. METHODS A review of selected English literature from 1980 to 2015 was undertaken. Databases used included Pubmed, Cochrane and Science Direct. Publications of both traumatic and postoperative chylothorax were reviewed. The appropriate literature was analysed by comparing and contrasting content with particular emphasis on management issues. Keywords and phrases were used to achieve a streamlined and focused review of the topic. CONCLUSION Chylothorax remains a rare complication of thoracic surgery and thoracic trauma. The potential complications can result in serious morbidity and can even be fatal. Understanding the pathophysiology of a chyle leak underpins the principles of management. The overall success of conservative management ranges from 20% to 80%. The timing of surgical intervention remains debatable. Benefits of early surgical intervention are clearly documented, resulting in a gradual shift toward early operative treatment with reports suggesting thoracic duct ligation yielding a 90% success rate. Technological advances such as thoracic duct embolisation, with a potential success rate of 90%, and thoracoscopic interventions are attractive alternatives to orthodox open surgery.
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Affiliation(s)
- T G Pillay
- Department of Surgery, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa.
| | - B Singh
- Department of Surgery, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
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Thatcher AL, Yu J, Kuo KW. High-volume bilateral chylothorax presenting with hypoxemia and shock in a pediatric patient following tracheostomy revision: a case report. J Med Case Rep 2015; 9:235. [PMID: 26493840 PMCID: PMC4618843 DOI: 10.1186/s13256-015-0721-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 10/02/2015] [Indexed: 01/30/2023] Open
Abstract
INTRODUCTION Chylothorax is a rare complication of surgical neck dissection. This is the first reported pediatric case of bilateral chylothorax following cervical surgery and the first to occur after tracheoplasty. Chylothorax can lead to significant complications, including hypoxemia and shock, and requires timely treatment. This case report discusses the clinical presentation, diagnosis, and treatment of our patient and reviews possible pathophysiologic mechanisms to explain the development of postoperative bilateral chylous effusions. CASE PRESENTATION An 18-month-old white baby girl with a complex past medical history including choanal atresia, atrioventricular septal defect, failure to thrive, developmental delay, and tracheostomy dependence developed significant hypoxemia and shock following a routine tracehostomy revision. She was subsequently found to have developed massive bilateral chylothorax, requiring escalation of mechanical ventilation, thoracostomy tube drainage, vasoactive support, and eventual surgical ligation of her thoracic duct. CONCLUSIONS Massive bilateral chylothorax is a rare but potentially life-threatening complication following tracheoplasty. Clinicians caring for this patient population postoperatively should be aware of this potential complication and its management.
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Affiliation(s)
- Aaron L Thatcher
- Department of Otolaryngology, University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, 48109, USA.
| | - Jane Yu
- Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, 48109, USA.
| | - Kevin W Kuo
- Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, 1500 E Medical Center Drive, Ann Arbor, MI, 48109, USA.
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Altun G, Pulathan Z, Kutanis D, Hemsinli D, Erturk E, Civelek A. Conservative management of chylothorax after coronary artery bypass grafting. Tex Heart Inst J 2015; 42:148-51. [PMID: 25873827 DOI: 10.14503/thij-13-3532] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Chylothorax is a rare sequela to cardiac surgery, associated with high rates of morbidity and mortality. There are various medical and surgical options for its management. We describe 2 cases of chylothorax that developed after coronary artery bypass grafting and were managed successfully with medical therapy alone. Conservative treatment such as we describe aims to reduce chyle flow, to drain the pleural cavity in an effective manner, and to prevent chronic sequelae. Optimal conservative treatment, consisting of nothing by mouth and the administration of a pleurodetic agent, should be started immediately upon diagnosis. In most cases, it reduces the need for reoperation and long-term hospitalization. Prospective randomized controlled trials are nonetheless needed to confirm these assumptions.
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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
The etiologies of pediatric lung injury requiring surgical intervention can be infectious, traumatic, congenital, or iatrogenic. Childhood pneumonia is a significant global health problem affecting 150 million children worldwide. Sequelae of pulmonary infections potentially requiring surgery include bronchiectasis, lung abscess, pneumatocele, and empyema. Trauma, congenital conditions such as cystic fibrosis and iatrogenic injuries can result in pneumothoraces, chylothoraces, or bronchopleural fistulae. Recurrence rates for spontaneous pneumothorax treated non-operatively in pediatric patients approach 50-60%. Chylothoraces in newborns may occur spontaneously or due to birth trauma, whereas in older children the etiology is almost always iatrogenic. This article examines the surgical management for the complications of lung injury in pediatric patients. In addition, we review the available pediatric evidence for early tracheostomy as well as treatment strategies for the negative ramifications of tracheostomy.
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Affiliation(s)
| | - Chad Hamner
- Cook Children׳s Medical Center, Fort Worth, Texas.
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Yang J, Codreanu I, Zhuang H. Minimal lymphatic leakage in an infant with chylothorax detected by lymphoscintigraphy SPECT/CT. Pediatrics 2014; 134:e606-10. [PMID: 25070312 DOI: 10.1542/peds.2013-2689] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
A 7-month-old girl with history of persistent left chylous pleural effusion was referred for lymphoscintigraphy. A previous chest computed tomography (CT) scan demonstrated a small to moderate-sized left pleural effusion but could not identify the lymphatic leakage site. Lymphoscintigraphy using filtered (99m)Tc sulfur colloid showed minimal focal activity in the lower chest. A correlative single-photon emission computed tomography (SPECT)/CT localized this activity to distal paraesophageal region, being highly suggestive of the site of lymphatic leakage. Subsequent lymphangiography confirmed these findings, revealing an abnormal lymphatic branch at the level of T10 and T11 vertebrae with retrocrural extravasation toward the left hemithorax. Thoracic duct embolization was accomplished at and proximal to the site of chyle leak using a platinum coil and n-Butyl cyanoacrylate glue. The patient was followed up for >24 months and demonstrated no recurrence of pleural effusion. No ascites or other complications related to the procedure were noted. The case demonstrates that (99m)Tc sulfur colloid lymphoscintigraphy SPECT/CT can be a useful modality for detecting the chyle leakage site in children with chylothorax even when the amount of leakage is minimal.
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Affiliation(s)
- Jigang Yang
- Department of Nuclear Medicine, Beijing Friendship Hospital of Capital Medical University, Beijing, China;Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Ion Codreanu
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; andDepartment of Radiology, Medpark International Hospital, State University of Medicine and Pharmacy Nicolae Testemitanu, Chisinau, Moldova
| | - Hongming Zhuang
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
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Abstract
AIM To describe the incidence, patient profile, management strategies and outcome for infants and children who developed a chylothorax in the UK. METHODS A prospective study of infants and children ≥24 weeks' gestation - ≤16 years, who developed a chylothorax in the UK and were reported through the British Paediatric Surveillance Unit (BPSU). Clinicians completed a questionnaire on the presentation, diagnosis, management and outcome of these children. Three further data sources were accessed to confirm these data. RESULTS The incidence in children in the UK was 0.0014% (1.4 per 100,000) and 3.2% (3200 per 100,000) for those developing a chylothorax following a cardiac surgical procedure. The incidence was highest in infants ≤12 months at 16 per 100,000 (0.016%). A total of 219 questionnaires were returned with 172 cases meeting the eligibility criteria. Development of a chylothorax was most commonly associated with cardiac surgical procedure (65.1%) and was most frequently confirmed by laboratory verification of triglyceride content of the pleural fluid ≥1.1 mmol/L (66%). Although a variety of management strategies were employed, treatment with an intercostal pleural catheter (86.5%) and a medium chain triglyceride (MCT) diet (89%) was most commonly reported. The majority of the children had a prolonged hospital stay with a reported mortality of 12.2%. CONCLUSIONS Development of a chylothorax in infants and children in the UK was not common. The primary association was with a cardiac surgical procedure. The child's hospital stay was lengthy and therefore the impact on the child, family and hospital resources were significant. Common management strategies existed but national guidance is required to optimise practice. This study allows for better information relating to this serious complication to be given to patients and families and provides the basis for future research and practice development.
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Affiliation(s)
- Caroline Haines
- Bristol Royal Hospital for Children, Bristol, UK University of Southampton, Southampton, UK
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