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Dulmovits BM, Taha DK. Neonatal perspective on central lymphatic disorders. Semin Pediatr Surg 2024; 33:151424. [PMID: 38830311 DOI: 10.1016/j.sempedsurg.2024.151424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
Lymphatic disorders presenting in the first year of life are difficult to identify and manage given the broad range of underlying etiologies. Neonatal lymphatic disease arising from congenital or acquired conditions results in the abnormal accumulation of lymph fluid in the pleura (chylothorax), peritoneum (chylous ascites) and skin (edema/anasarca). There is also increasing recognition of lymphatic losses through the intestine resulting in protein-losing enteropathy (PLE). While the incidence of lymphatic disorders in neonates is unclear, advances in genetic testing and lymphatic imaging are improving our understanding of the underlying pathophysiology. Despite these advancements, medical management of neonatal lymphatic disorders remains challenging and variable among clinicians.
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Affiliation(s)
- Brian M Dulmovits
- Department of Pediatrics, Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Dalal K Taha
- Department of Pediatrics, Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
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2
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Deboever N, Feldman H, Eisenberg M, Antonoff MB, Mehran RJ, Rajaram R, Rice DC, Roth JA, Sepesi B, Swisher SG, Vaporciyan AA, Walsh GL, Hofstetter WL. Octreotide's role in the management of post-esophagectomy chylothorax. Dis Esophagus 2024; 37:doae011. [PMID: 38391198 DOI: 10.1093/dote/doae011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 11/29/2023] [Accepted: 12/19/2023] [Indexed: 02/24/2024]
Abstract
The use of octreotide in managing intrathoracic chyle leak following esophagectomy has gained popularity in the adult population. While the benefits of octreotide have been confirmed in the pediatric population, there remains limited evidence to support its use in the adults post-esophagectomy. Thus, we performed a single-institution cohort study to characterize its efficacy. The study was performed using a prospective, single-center database, from which clinicopathologic characteristics were extracted of patients who had post-esophagectomy chyle leaks. Kaplan-Meier and multivariable Cox regression analyses were performed to investigate the effect of octreotide use on chest tube duration (CTD), hospital length of stay (LOS), and overall survival (OS). In our cohort, 74 patients met inclusion criteria, among whom 27 (36.5%) received octreotide. Kaplan-Meier revealed no significant effect of octreotide on CTD (P = 0.890), LOS (P = 0.740), or OS (P = 0.570). Multivariable Cox regression analyses further corroborated that octreotide had no effect on CTD (HR = 0.62, 95% confidence interval [CI]: 0.32-1.20, P = 0.155), LOS (HR = 0.64, CI: 0.34-1.21, P = 0.168), or OS (1.08, CI: 0.53-2.19, P = 0.833). Octreotide use in adult patients with chyle leak following esophagectomy lacks evidence of association with meaningful clinical outcomes. Level 1 evidence is needed prior to further consideration in this population.
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Affiliation(s)
- Nathaniel Deboever
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hope Feldman
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael Eisenberg
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mara B Antonoff
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Reza J Mehran
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ravi Rajaram
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David C Rice
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jack A Roth
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Boris Sepesi
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Stephen G Swisher
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ara A Vaporciyan
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Garrett L Walsh
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Wayne L Hofstetter
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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LaFontaine R, Lyle ANJ, Upadhyay K. Respiratory Distress in a 3-Week-Old Late Preterm Male Neonate. Neoreviews 2024; 25:e220-e223. [PMID: 38556489 DOI: 10.1542/neo.25-3-e220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Affiliation(s)
- Rachel LaFontaine
- Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Allison N J Lyle
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Kirti Upadhyay
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA
- Neonatal Intensive Care Unit (NICU) at UW Medical Center-Montlake, Seattle Children's Hospital, University of Washington, Seattle, WA
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4
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LaFontaine R, Lyle ANJ, Upadhyay K. Respiratory Distress in a 3-Week-Old Late Preterm Male Neonate. Neoreviews 2024; 25:e220-e223. [PMID: 38556498 DOI: 10.1542/neo.25-4-e220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Affiliation(s)
- Rachel LaFontaine
- Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Allison N J Lyle
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Kirti Upadhyay
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA
- Neonatal Intensive Care Unit (NICU) at UW Medical Center-Montlake, Seattle Children's Hospital, University of Washington, Seattle, WA
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Toptan HH, Ozalkaya E, Karadag N, Topcuoglu S, Dincer E, Karatekin G. Neonatal Lymphatic Flow Disorder. Indian J Pediatr 2024; 91:248-253. [PMID: 37040015 DOI: 10.1007/s12098-023-04531-x] [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] [Received: 10/06/2022] [Accepted: 02/21/2023] [Indexed: 04/12/2023]
Abstract
OBJECTIVE To examine and discuss patients diagnosed with acquired and congenital chylothorax in the neonatal period in the light of the literature. METHODS The files of newborns followed-up in the neonatal intensive care unit (NICU) and diagnosed with congenital and acquired chylothorax were reviewed retrospectively. Patients with isolated chylothorax were classified as Group 1 and those with multiple lymphatic flow disorders were classified as Group 2. Antenatal and clinical features were recorded and compared between the groups. RESULTS Thirteen infants were diagnosed with chylothorax; 92.3% (n = 12) of the patients were congenital. The rate of antenatal diagnosis was 61.5% (n = 8). Eight patients (61.5%) were diagnosed with hydrops fetalis. Among the cases in Group 1 and Group 2, receiving ocreotide and the incidence of sepsis (p = 0.05) were partially significant. Seven of the patients (66.6%) responded to medium chain triglycerides (MCT), and complete resolution was seen in 6 (85.7%) of the responders. Complete resolution of chylothorax fluid was observed in 7 (77.7%) of nine patients who responded to ocreotide treatment. CONCLUSIONS In neonatal chylothorax, the postnatal period includes a multidisciplinary approach that requires drug therapy, dietary modifications, drainage of pleural fluid, and rarely, surgery.
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Affiliation(s)
- Handan Hakyemez Toptan
- Department of Neonatology, University of Health Sciences, Zeynep Kamil Maternity and Children's Disease Health Training and Research Center, Istanbul, Turkey.
| | - Elif Ozalkaya
- Department of Neonatology, University of Health Sciences, Zeynep Kamil Maternity and Children's Disease Health Training and Research Center, Istanbul, Turkey
| | - Nilgun Karadag
- Department of Neonatology, University of Health Sciences, Zeynep Kamil Maternity and Children's Disease Health Training and Research Center, Istanbul, Turkey
| | - Sevilay Topcuoglu
- Department of Neonatology, University of Health Sciences, Zeynep Kamil Maternity and Children's Disease Health Training and Research Center, Istanbul, Turkey
| | - Emre Dincer
- Department of Neonatology, University of Health Sciences, Zeynep Kamil Maternity and Children's Disease Health Training and Research Center, Istanbul, Turkey
| | - Guner Karatekin
- Department of Neonatology, University of Health Sciences, Zeynep Kamil Maternity and Children's Disease Health Training and Research Center, Istanbul, Turkey
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Holm-Weber T, Skov F, Mohanakumar S, Thorup L, Riis T, Christensen MB, Sonne DP, Jensen PB, Bødtkjer DB, Hjortdal VE. Octreotide improves human lymphatic fluid transport a translational trial. Eur J Cardiothorac Surg 2024; 65:ezad380. [PMID: 37951584 PMCID: PMC10832356 DOI: 10.1093/ejcts/ezad380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 10/17/2023] [Accepted: 11/08/2023] [Indexed: 11/14/2023] Open
Abstract
OBJECTIVES Chylothorax is a complex condition and many different pharmacological agents have been tried as treatment. Octreotide is used off-label to treat chylothorax, but the efficacy of octreotide remains unclear. A decrease in lymph production is suggested as the mechanism. In this cross-over study, we explore the direct effect of octreotide on human lymphatic drainage. METHODS Pre-clinical: the effect of octreotide on force generation was assessed during acute and prolonged drug incubation on human lymphatic vessels mounted in a myograph. Clinical: in a double-blinded, randomized, cross-over trial including 16 healthy adults, we administered either octreotide or saline as an intravenous infusion for 2.5 h. Near-infrared fluorescence imaging was used to examine spontaneous lymphatic contractions and lymph pressure in peripheral lymphatic vessels and plethysmography was performed to assess the capillary filtration rate, capillary filtration coefficient and isovolumetric pressures of the lower leg. RESULTS Pre-clinical: human thoracic duct (n = 12) contraction rate was concentration-dependently stimulated by octreotide with a maximum effect at 10 and 100 nmol/l in the myograph chamber. Clinical: spontaneous lymphatic contractions and lymph pressure evaluated by near-infrared fluorescence did not differ between octreotide or placebo (P = 0.36). Plethysmography revealed similar capillary filtration coefficients (P = 0.057), but almost a doubling of the isovolumetric pressures (P = 0.005) during octreotide infusion. CONCLUSIONS Octreotide stimulated lymphatic contractility in the pre-clinical setup but did not affect the spontaneous lymphatic contractions or lymph pressure in healthy individuals. Plethysmography revealed a doubling in the isovolumetric pressure. These results suggest that octreotide increases lymphatic drainage capacity in situations with high lymphatic afterload.
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Affiliation(s)
| | - Frederik Skov
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | | | - Lene Thorup
- Department of Thoracic Surgery, Rigshospitalet, Copenhagen, Denmark
| | - Troels Riis
- Department of Clinical Pharmacology, Copenhagen University Hospital—Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Mikkel Bring Christensen
- Department of Clinical Pharmacology, Copenhagen University Hospital—Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Copenhagen Center for Translational Research, Copenhagen University Hospital—Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - David Peick Sonne
- Department of Clinical Pharmacology, Copenhagen University Hospital—Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Per Bo Jensen
- Department of Biochemistry, Bispebjerg Hospital, Copenhagen, Denmark
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Marzotto KN, Choudhary T, Wright LA, Howell MP, Kimball TR, Pigula FA, Piggott KD. Nutritional markers accompanying acquired chylothorax in infants: a systematic review. Nutr Rev 2023; 81:1321-1328. [PMID: 36721321 DOI: 10.1093/nutrit/nuad005] [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: 02/02/2023] Open
Abstract
CONTEXT Chylothorax is a well-established acquired complication of thoracic surgery in infants. Current data suggest acquired chylothorax may affect infant growth and nutrition because of a loss of essential nutrients via chylous effusion. OBJECTIVE The 3 objectives for this study were: (1) identify nutritional markers affected by the development of acquired chylothorax in infants; (2) highlight the variability in methods used to assess nutritional status and growth in this patient population; and (3) highlight nutritional deficits that can serve as treatment targets during postoperative feeding protocols. DATA SOURCES A systematic literature search was conducted between May 31, 2021, and June 21, 2022, using the PubMed, Embase, CINAHL, and Web of Science databases. Search terms included, but were not limited to, "chylothorax," "infants," and "nutrition." DATA EXTRACTION Inclusion criteria required studies that measured quantitative markers of nutrition in ≥10 participants aged <1 year with acquired chylothorax. A total of 575 studies were screened and all but 4 were eliminated. Nutritional markers were categorized into 4 different groups: total serum protein level, triglyceride levels, growth velocity, and weight for length. DATA ANALYSIS The variation in methods, time points, interventional groups, and nutritional markers did not facilitate a meta-analysis. Risk of bias was assessed using the Cochrane Risk of Bias in Nonrandomized Studies assessment tool. CONCLUSION This review highlights the need for reliable quantitative markers of nutrition that will enable providers to assess the nutritional needs of infants with chylothorax. Future studies must focus on measuring markers of nutrition at regular intervals in larger study populations.
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Affiliation(s)
- Kevin N Marzotto
- Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Tuhin Choudhary
- Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Laura A Wright
- Matas Library, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Meghan P Howell
- Department of Pediatrics, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Thomas R Kimball
- Department of Pediatrics, Louisiana State University Health, New Orleans, Louisiana, USA
| | - Frank A Pigula
- Department of Pediatrics, Louisiana State University Health, New Orleans, Louisiana, USA
| | - Kurt D Piggott
- Department of Surgery, Louisiana State University Health, New Orleans, Louisiana, USA
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Takada S, Shirota C, Uchida H, Amano H, Hinoki A, Sumida W, Makita S, Okamoto M, Takimoto A, Yasui A, Nakagawa Y, Kato D, Guo Y, Tainaka T. Management of Congenital and Postoperative Chylothorax: Use of Thoracoscopic Lymphatic Leak Ligations with Intraoperative ICG Lymphangiography. J Pediatr Surg 2023; 58:1754-1761. [PMID: 36609065 DOI: 10.1016/j.jpedsurg.2022.11.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 11/14/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Congenital chylothorax (CCT) and postoperative chylothorax (POCT) are rare and difficult to treat. We report our treatment strategy and outcomes for chylothorax, including thoracoscopic surgery with indocyanine-green (ICG) near-infrared fluorescence lymphangiography. METHODS A retrospective review of patients with CCT and POCT from 2014 to 2021 was performed. After definitive diagnosis, conservative treatments with octreotide, followed by intravenous steroids as needed, were performed. Patients who were refractory to conservative treatment were transferred to surgical treatment, consisting of thoracoscopic lymphatic leak ligations using ICG intraoperative lymphangiography. The effectiveness of conservative and surgical treatment was then examined. RESULTS We included 19 cases of CCT and 31 cases of POCT. The 31 POCT patients included 23 of 84 postoperative patients with congenital diaphragmatic hernia (CDH), 7 of 54 postoperative patients with esophageal atresia (EA), and 1 of 3 postoperative patients with lymphatic malformation. The efficacy of conservative treatment was 12/19 for CCT, 22/23 for CDH, and 4/7 for EA. Surgical intervention was performed in 10 patients, and the rate of resolution of chylothorax within 3 weeks after surgery was 90%. CONCLUSION Thoracoscopic lymphatic leak ligations with intraoperative ICG lymphangiography are feasible and useful in patients with chylothorax refractory to conservative treatment. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Shunya Takada
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Chiyoe Shirota
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroo Uchida
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Hizuru Amano
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Akinari Hinoki
- Department of Rare/Intractable Cancer Analysis Research, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Wataru Sumida
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Satoshi Makita
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masamune Okamoto
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Aitaro Takimoto
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Akihiro Yasui
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Youichi Nakagawa
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Daiki Kato
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yaohui Guo
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takahisa Tainaka
- Department of Pediatric Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Anger M, Hofmann J, Ruf B, Steinborn M, Reber D, Warncke K, Rieber N. Cough-induced chylothorax in a two-year-old boy - case report and review of the literature. BMC Pediatr 2023; 23:416. [PMID: 37612714 PMCID: PMC10464381 DOI: 10.1186/s12887-023-04221-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 07/31/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND Chylothorax is a very rare form of pleural effusion in children, especially after the neonatal period, and predominantly occurs secondary to cardiothoracic surgery. It can lead to significant respiratory distress, immunodeficiency, and malnutrition. Effective treatment strategies are therefore required to reduce morbidity. CASE PRESENTATION A previously healthy two-year old boy was admitted with history of heavy coughing followed by progressive dyspnea. The chest X-ray showed an extensive opacification of the right lung. Ultrasound studies revealed a large pleural effusion of the right hemithorax. Pleural fluid analysis delivered the unusual diagnosis of chylothorax, most likely induced by preceded excessive coughing. After an unsuccessful treatment attempt with a fat-free diet and continuous pleural drainage for two weeks, therapy with octreotide was initiated. This led to complete and permanent resolution of his pleural effusion within 15 days, without any side effects. CONCLUSIONS Severe cough may be a rare cause of chylothorax in young children. Octreotide seems to be an effective and safe treatment of spontaneous or traumatic chylothorax in children. There is, however, a lack of comprehensive studies for chylothorax in children and many issues concerning diagnostic strategies and treatment algorithms remain.
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Affiliation(s)
- Melanie Anger
- Department of Pediatrics, Kinderklinik München Schwabing, Munich Klinik and School of Medicine, Technical University of Munich, Kölner Platz 1, 80804, Munich, Germany
| | - Julian Hofmann
- Department of Pediatrics, Kinderklinik München Schwabing, Munich Klinik and School of Medicine, Technical University of Munich, Kölner Platz 1, 80804, Munich, Germany
| | - Bettina Ruf
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Marc Steinborn
- Department of Diagnostic and Interventional and Pediatric Radiology, Kinderklinik München Schwabing, Munich, Germany
| | - Daniela Reber
- Department of Pediatrics, Kinderklinik München Schwabing, Munich Klinik and School of Medicine, Technical University of Munich, Kölner Platz 1, 80804, Munich, Germany
| | - Katharina Warncke
- Department of Pediatrics, Kinderklinik München Schwabing, Munich Klinik and School of Medicine, Technical University of Munich, Kölner Platz 1, 80804, Munich, Germany
| | - Nikolaus Rieber
- Department of Pediatrics, Kinderklinik München Schwabing, Munich Klinik and School of Medicine, Technical University of Munich, Kölner Platz 1, 80804, Munich, Germany.
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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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11
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Hur S, Kim J, Ratnam L, Itkin M. Lymphatic Intervention, the Frontline of Modern Lymphatic Medicine: Part II. Classification and Treatment of the Lymphatic Disorders. Korean J Radiol 2023; 24:109-132. [PMID: 36725353 PMCID: PMC9892215 DOI: 10.3348/kjr.2022.0689] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 11/03/2022] [Accepted: 11/14/2022] [Indexed: 01/28/2023] Open
Abstract
Lymphatic disorders encompass a broad spectrum of diseases involving the lymphatic system, ranging from traumatic lymphatic leaks to lymphatic malformations. Lymphatic disorders can be categorized into traumatic and non-traumatic disorders according to their etiology. These two categories may be further divided into subgroups depending on the anatomical location of the lymphatic pathology and their association with clinical syndromes. Thoracic duct embolization was a milestone in the field of lymphatic intervention that encouraged the application of percutaneous embolization techniques to treat leaks and reflux disorders in the lymphatic system. Additional access routes for embolization, including retrograde thoracic duct and transhepatic lymphatic access, have also been developed. This article comprehensively reviews a variety of options for the treatment of lymphatic disorders, from conservative management to the most recent embolization techniques.
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Affiliation(s)
- Saebeom Hur
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jinoo Kim
- Department of Radiology, Ajou University Hospital, Suwon, Korea.
| | - Lakshmi Ratnam
- Department of Radiology, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Maxim Itkin
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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12
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Handal-Orefice R, Midura D, Wu JK, Parravicini E, Miller RS, Shawber CJ. Propranolol Therapy for Congenital Chylothorax. Pediatrics 2023; 151:190476. [PMID: 36651059 DOI: 10.1542/peds.2022-058555] [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] [Accepted: 11/14/2022] [Indexed: 01/19/2023] Open
Abstract
Congenital chylothorax is a rare and often severe anomaly without well-established medical therapies. Previously, propranolol use in patients with lymphatic malformations and secondary chylothorax was associated with improvement in clinical signs. We hypothesized that propranolol treatment would be beneficial for severe congenital chylothorax. We reviewed medical records of neonates born from 2015 to 2019 at our tertiary center with a prenatal diagnosis of congenital chylothorax for whom either prenatal or postnatal propranolol therapy was initiated. Inclusion was limited to fetuses diagnosed with severe congenital chylothorax without significant genetic, infectious, or cardiac anomalies, and who underwent prenatal interventions to mitigate consequences of the condition. Propranolol was administered orally to pregnant women at 20 mg 4 times daily and increased to a maximum dose of 40 mg 4 times daily, or to infants at 0.3 mg/kg/d and increased to 1 to 2 mg/kg/d. Primary outcomes were the time course of resolution of ultrasonographical, clinical, and/or radiologic signs of chylothorax after treatment with propranolol. Four neonates met the inclusion criteria. In 2 cases, prenatal initiation of propranolol led to resolution of the chylothoraxes before delivery (38 and 32 days after treatment) on a dose of 40 mg/day 4 times daily. Neonates had a normal postnatal course. Postnatal propranolol was initiated in 2 neonates with respiratory failure when chylothoraces were refractory to standard management. Stabilization and improvement of their pleural effusion was observed by imaging at 29 and 13 days after initiation of propranolol. There were no significant maternal or neonatal complications from prenatal or postnatal propranolol use. Propranolol may be efficacious in treating severe fetal congenital chylothorax.
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Affiliation(s)
| | - Devin Midura
- Surgery.,Contributed equally as co-first authors
| | | | - Elvira Parravicini
- Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York-Presbyterian Morgan Stanley Children's Hospital, New York, New York
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13
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Pérez-Pérez A, Vigil-Vázquez S, Gutiérrez-Vélez A, Solís-García G, López-Blázquez M, Zunzunegui Martínez JL, Medrano López C, Gil-Jaurena JM, de Agustín-Asensio JC, Sánchez-Luna M. Chylothorax in newborns after cardiac surgery: a rare complication? Eur J Pediatr 2023; 182:1569-1578. [PMID: 36646910 DOI: 10.1007/s00431-023-04808-5] [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] [Received: 11/27/2022] [Revised: 01/02/2023] [Accepted: 01/04/2023] [Indexed: 01/18/2023]
Abstract
UNLABELLED The aim of this study was to analyze patients diagnosed with chylothorax after congenital heart disease surgery among a cohort of neonatal patients, comparing the evolution, complications, and prognosis after surgery of patients who were and were not diagnosed with chylothorax, and to analyze possible risk factors that may predict the appearance of chylothorax in this population. Retrospective and observational study included all neonates (less than 30 days since birth) who underwent congenital heart disease surgery in a level III neonatal intensive care department. We included infants born between January 2014 and December 2019. We excluded those infants who were born before 34 weeks of gestational age or whose birth weight was less than 1800 g. We also excluded catheter lab procedures and patent ductus arteriosus closure surgeries. Included patients were divided into two groups depending on whether they were diagnosed with chylothorax or not after surgery, and both groups were compared in terms of perinatal-obstetrical information, surgical data, and NICU course after surgery. We included 149 neonates with congenital heart disease surgery. Thirty-one patients (20.8%) developed chylothorax, and in ten patients (32.3%), it was considered large volume chylothorax. Regarding the evolution of these patients, 22 infants responded to general dietetic measures, a catheter procedure was performed in 9, and 5 of them finally required pleurodesis. Cardiopulmonary bypass, median sternotomy, and delayed sternal closure were the surgical variables associated with higher risks of chylothorax. Patients with chylothorax had a longer duration of inotropic support and mechanical ventilation and took longer to reach full enteral feeds. As complications, they had higher rates of cholestasis, catheter-related sepsis, and venous thrombosis. Although there were no differences in neonatal mortality, patients with chylothorax had a higher rate of mortality after the neonatal period. In a multiple linear regression model, thrombosis and cardiopulmonary bypass multiplied by 10.0 and 5.1, respectively, the risk of chylothorax and have an umbilical vein catheter decreases risk. CONCLUSION We have found a high incidence of chylothorax after neonatal cardiac surgery, which prolongs the average stay and causes significant morbidity and mortality. We suggested that chylothorax could be an underestimated complication of congenital heart disease surgery during the neonatal period. WHAT IS KNOWN • Acquired chylothorax in the neonatal period usually appears as a complication of congenital heart disease surgery, being the incidence quite variable among the different patient series (2.5-16.8%). The appearance of chylothorax as a complication of a cardiac surgery increases both mortality and morbidity in these patients, which makes it a quality improvement target in the postsurgical management of this population. WHAT IS NEW •Most of the published studies include pediatric patients of all ages, from newborns to teenagers, and there is a lack of studies focusing on neonatal populations. The main strength of our study is that it reports, to the best of our knowledge, one of the largest series of neonatal patients receiving surgery for congenital heart disease in the first 30 days after birth. We have found a high incidence of chylothorax after cardiac surgery during the neonatal period compared to other studies. We suggested that chylothorax could be an underestimated complication of congenital heart disease surgery during this period of life.
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Affiliation(s)
- Alba Pérez-Pérez
- Neonatology Department, Hospital General Universitario Gregorio Marañón, O'Donnell 48, Madrid, 28009, Spain.
| | - Sara Vigil-Vázquez
- Neonatology Department, Hospital General Universitario Gregorio Marañón, O'Donnell 48, Madrid, 28009, Spain
| | - Ana Gutiérrez-Vélez
- Neonatology Department, Hospital General Universitario Gregorio Marañón, O'Donnell 48, Madrid, 28009, Spain
| | | | - María López-Blázquez
- Cardiology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | | | - Juan Miguel Gil-Jaurena
- Pediatric Cardiac Surgery Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Manuel Sánchez-Luna
- Neonatology Department, Hospital General Universitario Gregorio Marañón, O'Donnell 48, Madrid, 28009, Spain
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14
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Mills KI, Kim JH, Fogg K, Goldshtrom N, Graham EM, Kataria-Hale J, Osborne SW, Figueroa M. Nutritional Considerations for the Neonate With Congenital Heart Disease. Pediatrics 2022; 150:189883. [PMID: 36317972 DOI: 10.1542/peds.2022-056415g] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 02/25/2023] Open
Abstract
The importance of nutrition in managing critically ill infants with congenital heart disease (CHD) is foundational to optimizing short- and long-term health outcomes. Growth failure and malnutrition are common in infants with CHD. The etiology of growth failure in this population is often multifactorial and may be related to altered metabolic demands, compromised blood flow to the intestine leading to nutrient malabsorption, cellular hypoxia, inadequate energy intake, and poor oral-motor skills. A dearth of high-quality studies and gaps in previously published guidelines have led to wide variability in nutrition practices that are locally driven. This review provides recommendations from the nutrition subgroup of the Neonatal Cardiac Care Collaborative for best evidence-based practices in the provision of nutritional support in infants with CHD. The review of evidence and recommendations focused on 6 predefined areas of clinical care for a target population of infants <6 months with CHD admitted to the ICU or inpatient ward. These areas include energy needs, nutrient requirements, enteral nutrition, feeding practice, parenteral nutrition, and outcomes. Future progress will be directed at quality improvement efforts to optimize perioperative nutrition management with an increasing emphasis on individualized care based on nutritional status, cardiorespiratory physiology, state of illness, and other vulnerabilities.
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Affiliation(s)
- Kimberly I Mills
- Division of Cardiovascular Critical Care, Department of Cardiology, Harvard Medical School and Boston Children's Hospital, Boston, Massachusetts.,Contributed equally as co-first authors
| | - Jae H Kim
- Division of Neonatology, Perinatal Institute, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, College of Medicine, Cincinnati, Ohio.,Contributed equally as co-first authors
| | - Kristi Fogg
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Nimrod Goldshtrom
- Division of Neonatology, Department of Pediatrics, Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, New York
| | - Eric M Graham
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Jasmeet Kataria-Hale
- Division of Neonatology, Department of Pediatrics, Mission Children's Hospital, Asheville, North Carolina
| | - Scott W Osborne
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Mayte Figueroa
- Division of Cardiology and Critical Care, Department of Pediatrics, St Louis Children's Hospital, Washington University School of Medicine, St Louis, Missouri
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15
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Wang B, Feng Y, Guo Y, Kan Q, Zou Y, Wu Y, Zheng M, Cheng R. Clinical features and outcomes of congenital chylothorax: a single tertiary medical center experience in China. J Cardiothorac Surg 2022; 17:276. [PMID: 36303149 PMCID: PMC9615329 DOI: 10.1186/s13019-022-02009-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 09/24/2022] [Indexed: 11/14/2022] Open
Abstract
Objective Congenital chylothorax (CC) is an uncommon congenital disease. The objective of this study was to analyze the clinical features, treatment, and outcome of infants with CC in a Chinese tertiary medical center. Methods CC was defined as a non-traumatic pleural effusion with ≥ 80% lymphocytes detected before birth or within 28 days after birth. Clinical data were collected in CC infants discharged from June 2017 to March 2021. Results A total of 24 CC infants were discharged during the study period, accounting for 67% of congenital pleural effusions. The median gestational age at birth was 36+4 weeks (range 29+5–41 weeks) and the birth weight was 3025 g (range 1850–4250 g). Twenty-one infants were diagnosed antenatally. The median gestational age at the time of diagnosis was 30+3 weeks (range 24–36+6 weeks). Nine infants presented with hydrops fetalis; 18 were bilateral. Prenatal interventions were performed in 13 fetuses. Nine infants (38%) had birth asphyxia. Compared with the infants without hydrops fetalis, the infants with CC and hydrops fetalis had lower Apgar scores at 1 and 5 min (P < 0.05) and a lower gestational age at birth (P < 0.05). Postnatally, 17 infants required continuous pleural drainage for 10 days (range 2–30 days). Analysis of the pleural effusion showed a higher cell count, lymphocyte fraction, and protein content after enteral feeding (P < 0.05). Fifteen infants required mechanical ventilation; 9 did not require any respiratory support. Ten infants received a delayed feeding strategy and 17 received a medium-chain triglyceride (MCT) formula. Only 1 infant received octreotide therapy. Twenty-one infants survived and 3 died. The main cause of death was pulmonary dysplasia. The duration of hospital stay in survivors was 21.5 days (range 10–43) days. For infants with CC and hydrops fetalis, prenatal therapy shortened the duration of pleural drainage and the length of hospital stay (P < 0.05). Conclusion CC is the most common cause of congenital pleural effusions. The poor prognosis is mainly associated with prematurity, hydrops fetalis, and pulmonary dysplasia. Prenatal intervention may improve the outcome of infants with hydrops fetalis.
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Affiliation(s)
- Beibei Wang
- Department of Neonatology, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, Jiangsu, China
| | - Yun Feng
- Department of Neonatology, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, Jiangsu, China
| | - Yan Guo
- Department of Neonatology, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, Jiangsu, China
| | - Qing Kan
- Department of Neonatology, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, Jiangsu, China
| | - Yunsu Zou
- Department of Neonatology, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, Jiangsu, China
| | - Yue Wu
- Department of Neonatology, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, Jiangsu, China
| | - Mingming Zheng
- Department of Obstetrics and Gynecology, The Affiliated Drum and Tower Hospital of Medical School of Nanjing University, Nanjing, China
| | - Rui Cheng
- Department of Neonatology, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, Jiangsu, China.
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16
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Nakano TA, Rankin AW, Annam A, Kulungowski AM, McCallen LM, Hill LR, Chatfield KC. Trametinib for Refractory Chylous Effusions and Systemic Complications in Children with Noonan Syndrome. J Pediatr 2022; 248:81-88.e1. [PMID: 35605646 DOI: 10.1016/j.jpeds.2022.05.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 05/10/2022] [Accepted: 05/17/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To evaluate the effect of the RAS-MAPK pathway inhibitor trametinib on medically refractory chylous effusions in 3 hospitalized patients with Noonan syndrome. STUDY DESIGN Pharmacologic MEK1/2 inhibition has been used to treat conditions associated with Noonan syndrome, given that activation of RAS-MAPK pathway variants leads to downstream MEK activation. We describe our experience with 3 patients with Noonan syndrome (owing to variants in 3 distinct genes) and refractory chylous effusions treated successfully with MEK inhibition. A monitoring protocol was established to standardize medication dosing and monitoring of outcome measures. RESULTS Subjects demonstrated improvement in lymphatic leak with additional findings of improved growth and normalization of cardiac and hematologic measurements. Trametinib was administered safely, with only moderate skin irritation in 1 subject. CONCLUSIONS Improvements in a variety of quantifiable measurements highlight the potential utility of MEK1/2 inhibition in patients with Noonan syndrome and life-threatening lymphatic disease. Larger, prospective studies are needed to confirm efficacy and assess long-term safety.
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Affiliation(s)
- Taizo A Nakano
- Vascular Anomalies Center, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO; Center for Cancer and Blood Disorders, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO
| | - Alexander W Rankin
- Center for Cancer and Blood Disorders, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO
| | - Aparna Annam
- Vascular Anomalies Center, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO; Department of Pediatric Radiology, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO
| | - Ann M Kulungowski
- Vascular Anomalies Center, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO; Department of Pediatric Surgery, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO
| | - Leslie M McCallen
- Vascular Anomalies Center, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO; Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO
| | - Lauren R Hill
- Vascular Anomalies Center, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO
| | - Kathryn C Chatfield
- Vascular Anomalies Center, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO; Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, CO.
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17
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Nakano TA, Dori Y, Gumer L, Liptzin DR, Hill LRS, Kulungowski AM. How we approach pediatric congenital chylous effusions and ascites. Pediatr Blood Cancer 2022; 69 Suppl 3:e29246. [PMID: 36070215 DOI: 10.1002/pbc.29246] [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: 04/23/2021] [Revised: 06/19/2021] [Accepted: 06/27/2021] [Indexed: 11/10/2022]
Abstract
Congenital lymphatic leak may develop in patients with maldeveloped lymphatics and result in life-threatening fluid and electrolyte imbalance, protein deficiency, and immunodeficiency. Rapid diagnosis and therapy are necessary to prevent these complications; however, the field lacks clinical trials to support standardized diagnostic treatment guidelines. We present our current multidisciplinary approach to the diagnosis and management of congenital lymphatic leak including chylous pleural effusions and ascites. Depending on the rate of lymphatic leak, therapy can range from observation with nutritional modifications to surgical and interventional procedures aimed to reduce lymphatic drainage. Modalities to image central and peripheral lymphatics have advanced considerably. Genetic variants and subsequent targets that drive lymphatic maldevelopment have expanded the repertoire of possible pharmacotherapeutic options.
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Affiliation(s)
- Taizo A Nakano
- Vascular Anomalies Center, Children's Hospital Colorado, Aurora, Colorado, USA.,Center for Cancer and Blood Disorders, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Yoav Dori
- Division of Cariology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Lindsey Gumer
- Division of Pediatric Gastroenterology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Deborah R Liptzin
- Breathing Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Lauren R S Hill
- Vascular Anomalies Center, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Ann M Kulungowski
- Vascular Anomalies Center, Children's Hospital Colorado, Aurora, Colorado, USA.,Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado, USA
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18
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Tang X, Chen Z, Shen X, Xie T, Wang X, Liu T, Ma X. Refractory thrombocytopenia could be a rare initial presentation of Noonan syndrome in newborn infants: a case report and literature review. BMC Pediatr 2022; 22:142. [PMID: 35300644 PMCID: PMC8928670 DOI: 10.1186/s12887-021-02909-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 09/22/2021] [Indexed: 01/01/2023] Open
Abstract
Background Noonan syndrome (NS) is a relatively rare inherited disease. Typical clinical presentation is important for the diagnosis of NS. But the initial presentation of NS could be significant variant individually which results in the difficult of working diagnosis. Here we report a rare neonatal case of NS who presented with refractory thrombocytopenia as the initial manifestation. Case presentation This was a preterm infant with refractory thrombocytopenia of unknown origin transferred from obstetric hospital at 6 weeks of age. During hospitalization, typical phenotypes of NS in addition to thrombocytopenia were observed, such as typical facial characteristics, short stature, atrial septal defect, cryptochidism, coagulation defect and chylothorax. Genetic testing showed a pathogenic variant at exon 2 of the PTPN11 gene with c.124A > G (p.T42A). Respiratory distress was deteriorated with progressive chylothorax. Chest tube was inserted for continuous draining. Chemical pleurodesis with erythromycin was tried twice, but barely effective. Finally, parents decided to withdraw medical care and the patient died. Conclusions Thrombocytopenia could be the first symptom of Noonan syndrome. After ruling out other common causes of thrombocytopenia, NS should be considered as the working diagnosis.
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Affiliation(s)
- Xiujun Tang
- Children's Hospital, Zhejiang University School of Medicine, No.3333 Binsheng Road, Binjiang District, Hangzhou, 310052, China.,National Clinical Research Center for Child Health, National Children's Regional Medical Center, No.3333 Binsheng Road, Binjiang District, Hangzhou, 310052, China
| | - Zheng Chen
- Children's Hospital, Zhejiang University School of Medicine, No.3333 Binsheng Road, Binjiang District, Hangzhou, 310052, China.,National Clinical Research Center for Child Health, National Children's Regional Medical Center, No.3333 Binsheng Road, Binjiang District, Hangzhou, 310052, China
| | - Xiaoxia Shen
- Children's Hospital, Zhejiang University School of Medicine, No.3333 Binsheng Road, Binjiang District, Hangzhou, 310052, China.,National Clinical Research Center for Child Health, National Children's Regional Medical Center, No.3333 Binsheng Road, Binjiang District, Hangzhou, 310052, China
| | - Tian Xie
- Children's Hospital, Zhejiang University School of Medicine, No.3333 Binsheng Road, Binjiang District, Hangzhou, 310052, China.,National Clinical Research Center for Child Health, National Children's Regional Medical Center, No.3333 Binsheng Road, Binjiang District, Hangzhou, 310052, China
| | - Xiaohong Wang
- Children's Hospital, Zhejiang University School of Medicine, No.3333 Binsheng Road, Binjiang District, Hangzhou, 310052, China.,National Clinical Research Center for Child Health, National Children's Regional Medical Center, No.3333 Binsheng Road, Binjiang District, Hangzhou, 310052, China
| | - Taixiang Liu
- Children's Hospital, Zhejiang University School of Medicine, No.3333 Binsheng Road, Binjiang District, Hangzhou, 310052, China.,National Clinical Research Center for Child Health, National Children's Regional Medical Center, No.3333 Binsheng Road, Binjiang District, Hangzhou, 310052, China
| | - Xiaolu Ma
- Children's Hospital, Zhejiang University School of Medicine, No.3333 Binsheng Road, Binjiang District, Hangzhou, 310052, China. .,National Clinical Research Center for Child Health, National Children's Regional Medical Center, No.3333 Binsheng Road, Binjiang District, Hangzhou, 310052, China.
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19
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Kinota N, Kodama H, Moriyama T, Taniguchi J, Maruyama M, Ogasawara A, Kako Y, Kobayashi K, Takaki H, Shibata A, Minagawa K, Takeshima Y, Yamakado K. Lymphangiography as a Treatment for Refractory Congenital Chylothorax Due to RASopathies: A Report of Two Cases. INTERVENTIONAL RADIOLOGY 2022; 7:17-20. [PMID: 35911871 PMCID: PMC9327383 DOI: 10.22575/interventionalradiology.2021-0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 06/28/2021] [Indexed: 12/02/2022]
Abstract
In this study, we report two cases in which intranodal lymphangiography helped improve congenital chylothorax due to RASopathies. We performed lymphangiography after conservative treatments failed to improve chylothorax in an 8-year-old girl with cardiofaciocutaneous syndrome and a 2-month-old boy with Noonan syndrome. Inguinal lymph nodes were punctured with 25-gauge needles under ultrasonographic guidance, and 4 and 1 mL of iodized oil were injected, respectively, showing a backflow of iodized oil into the lungs. Chylothorax had improved in both patients after nodal lymphangiography. However, the second child experienced worsening of disease-associated extremity edema and died of sepsis 4 months later.
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Affiliation(s)
- Naoya Kinota
- Department of Radiology, Hyogo College of Medicine
| | | | | | | | | | | | | | | | | | - Akio Shibata
- Department of Pediatrics, Hyogo College of Medicine
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20
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Mas E, Borrelli O, Broekaert I, de-Carpi JM, Dolinsek J, Miele E, Pienar C, Koninckx CR, Thomassen RA, Thomson M, Tzivinikos C, Benninga MA. Drugs in Focus: Octreotide Use in Children With Gastrointestinal Disorders. J Pediatr Gastroenterol Nutr 2022; 74:1-6. [PMID: 34508049 DOI: 10.1097/mpg.0000000000003294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
ABSTRACT Octreotide, a somatostatin analogue, has been used for more than 20 years in children with gastrointestinal bleeding, chylothorax or chylous ascites, intestinal lymphangiectasia, pancreatitis, intestinal dysmotility, and severe diarrhoea; however, until now, there is a lack of randomised clinical trials evaluating the efficacy of this compound in childhood. Hence, we aimed to review the literature in order to determine the evidence of its use and safety in children, using PubMed from 2000 to 2021 with the search terms "octreotide" and "children" and "bleeding or chylous ascites or chylothorax or acute pancreatitis or lymphangiectasia or diarrhoea or intestinal dysmotility".
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Affiliation(s)
- Emmanuel Mas
- Unité de Gastroentérologie, Hépatologie, Nutrition, Diabétologie et Maladies Héréditaires du Métabolisme, Hôpital des Enfants, CHU de Toulouse; IRSD, Université de Toulouse, INSERM, INRAE, ENVT, UPS, Toulouse, France
| | - Osvaldo Borrelli
- Department of Paediatric Gastroenterology, Neurogastroenterology and Motility Unit, Great Ormond Street Hospital, London, UK
| | - Ilse Broekaert
- Department of Paediatrics, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - J Martin de-Carpi
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Jernej Dolinsek
- Department of Paediatrics, University Medical Centre Maribor, Maribor, Slovenia
| | - Erasmo Miele
- Department of Translational Medical Science, Section of Paediatrics, University of Naples "Federico II", Naples Italy
| | - Corina Pienar
- Department of Paediatrics, 2 Paediatric Clinic, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | - C Ribes Koninckx
- Paediatric Gastroenterology, La Fe University Hospital, Valencia, Spain
| | - Ruth-Anne Thomassen
- Department of Paediatric Medicine, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Mike Thomson
- Centre for Paediatric Gastroenterology, Sheffield Children's Hospital NHS Foundation Trust, Sheffield, UK
| | - Christo Tzivinikos
- Department of Paediatric Gastroenterology, Al Jalila Children's Specialty Hospital, Dubai, UAE
| | - Marc A Benninga
- Department of Paediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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21
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Takahashi Y, Kinoshita Y, Kobayashi T, Arai Y, Ohyama T, Yokota N, Saito K, Sugai Y, Takano S. Management of refractory chylothorax in the neonatal intensive care unit: A 22-year experience. Pediatr Int 2022; 64:e15043. [PMID: 34706149 DOI: 10.1111/ped.15043] [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: 06/02/2021] [Revised: 10/01/2021] [Accepted: 10/25/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The aim was to assess the therapeutic strategy of patients with chylothorax in a neonatal intensive care unit. METHODS Twenty-eight infants with chylothorax were included in this study. Their clinical characteristics and outcomes were reviewed retrospectively. RESULTS The male-to-female ratio was 1:1. The mean gestational age and birthweight were 35.1 ± 3.5 weeks and 2,692 ± 791 g, respectively. Eighteen patients were diagnosed with congenital chylothorax; chylothorax occurred postoperatively in 10 patients. Chromosomal anomalies were diagnosed in 8 patients. Six patients received surgical therapy, such as pleurodesis, thoracic duct ligation, or lymphaticovenous anastomosis. Two patients required surgery due to resistance to pleurodesis. In surgically managed patients, the daily maximum amount of pleural effusion (mL)/bodyweight (kg) ratio was significantly larger than in non-surgically managed patients: 229.0 ± 180.5 versus 59.7 ± 49.2 mL/kg. In the receiver operating characteristic analysis of the daily maximum amount of pleural effusion/bodyweight ratio, the area under the curve was 0.889 when the cut-off value was 101 mL/kg, and the sensitivity was 0.8333 and the specificity was 0.8095 (P = 0.0059). CONCLUSIONS Pleurodesis using OK432 could become a surgical first-line therapy for chylothorax even for neonates. It was important to initiate pleurodesis for refractory chylothorax at an earlier stage. A daily chylous effusion/bodyweight ratio of >101 mL/kg was a good predictor and seemed to be a useful parameter for prompt surgical intervention.
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Affiliation(s)
- Yoshiaki Takahashi
- Department of Pediatric Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata City, Japan
| | - Yoshiaki Kinoshita
- Department of Pediatric Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata City, Japan
| | - Takashi Kobayashi
- Department of Pediatric Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata City, Japan
| | - Yuhki Arai
- Department of Pediatric Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata City, Japan
| | - Toshiyuki Ohyama
- Department of Pediatric Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata City, Japan
| | - Naoki Yokota
- Department of Pediatric Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata City, Japan
| | - Koichi Saito
- Department of Pediatric Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata City, Japan
| | - Yu Sugai
- Department of Pediatric Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata City, Japan
| | - Shoichi Takano
- Department of Pediatric Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata City, Japan
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22
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Perri A, Tana M, Sbordone A, Patti ML, Sattin G, Vento G. "Open Questions" and Role of Lung Ultrasound in the Management of Congenital Chylothorax. Respiration 2021; 101:16-17. [PMID: 34814155 DOI: 10.1159/000520313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 10/08/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
- Alessandro Perri
- Dipartimento Universitario Scienze della Vita e Sanità Pubblica, Unità Operativa Complessa di Neonatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Milena Tana
- Dipartimento Universitario Scienze della Vita e Sanità Pubblica, Unità Operativa Complessa di Neonatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Annamaria Sbordone
- Dipartimento Universitario Scienze della Vita e Sanità Pubblica, Unità Operativa Complessa di Neonatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Maria Letizia Patti
- Dipartimento Universitario Scienze della Vita e Sanità Pubblica, Unità Operativa Complessa di Neonatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giulia Sattin
- Dipartimento Universitario Scienze della Vita e Sanità Pubblica, Unità Operativa Complessa di Neonatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giovanni Vento
- Dipartimento Universitario Scienze della Vita e Sanità Pubblica, Unità Operativa Complessa di Neonatologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
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Power R, Smyth P, Donlon NE, Nugent T, Donohoe CL, Reynolds JV. Management of chyle leaks following esophageal resection: a systematic review. Dis Esophagus 2021; 34:doab012. [PMID: 33723611 PMCID: PMC8597908 DOI: 10.1093/dote/doab012] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 01/28/2021] [Accepted: 02/01/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Chyle leakage is an uncommon but potentially life-threatening complication following esophageal resections. The optimal management strategy is not clear, with a limited evidence base. METHODS Searches were conducted up to 31 December 2020 on MEDLINE, Embase, and Web of Science for randomized trials or retrospective studies that evaluated the management of chyle leakage following esophageal resection. Two authors independently screened studies, extracted data, and assessed for bias. The protocol was prospectively registered on PROSPERO (CRD: 42021224895) and reported in accordance with preferred reporting items for systematic reviews and meta-analyses guidelines. RESULTS A total of 530 citations were reviewed. Twenty-five studies, totaling 1016 patients met the inclusion criteria, including two low-quality clinical trials and 23 retrospective case series. Heterogeneity of study design and outcomes prevented meta-analysis. The overall incidence of chyle leak/fistula was 3.2%. Eighteen studies describe management of chyle leaks conservatively, 17 by surgical ligation of the thoracic duct, 5 by pleurodesis, and 6 described percutaneous lymphangiography with thoracic duct embolization or disruption. CONCLUSIONS The evidence base for optimal management of chyle leakage postesophagectomy is lacking, which may be related to its low incidence. There is a paucity of high-quality prospective studies directly comparing treatment modalities, but there is some low-certainty evidence that percutaneous approaches have reduced morbidity but lower efficacy compared with surgery. Further high-quality, prospective studies that compare interventions at different levels of severity are needed to determine the optimal approach to treatment.
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Affiliation(s)
- Robert Power
- National Oesophageal and Gastric Centre, St James's Hospital, Dublin, Ireland
| | - Philip Smyth
- National Oesophageal and Gastric Centre, St James's Hospital, Dublin, Ireland
| | - Noel E Donlon
- National Oesophageal and Gastric Centre, St James's Hospital, Dublin, Ireland
| | - Timothy Nugent
- National Oesophageal and Gastric Centre, St James's Hospital, Dublin, Ireland
| | - Claire L Donohoe
- National Oesophageal and Gastric Centre, St James's Hospital, Dublin, Ireland
| | - John V Reynolds
- National Oesophageal and Gastric Centre, St James's Hospital, Dublin, Ireland
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24
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Jackson S, Jnah AJ. Chylothorax: A Stepwise Approach to Diagnosis and Treatment. Neonatal Netw 2021; 40:386-392. [PMID: 34845089 DOI: 10.1891/11-t-705] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2021] [Indexed: 11/25/2022]
Abstract
Chylothorax, a lymphatic flow disorder characterized by an abnormal circulation of lymph fluid into the pleural cavity, is the most common cause of pleural effusions during the neonatal period. This condition affects 1/15,000 neonates every year. Affected neonates often manifest with respiratory distress, electrolyte imbalances, sepsis, and even immunodeficiencies. Mortality risk is highest among neonates undergoing cardiac surgery as well as those with associated hydrops fetalis. Conservative treatment options include bowel rest with administration of parenteral nutrition, followed with medium-chain triglyceride enteral feedings, and octreotide therapy. Severe or persistent cases require surgical intervention. This can involve a unilateral or bilateral pleurectomy and thoracic duct ligation, with or without pleurodesis. Early identification and successful treatment of this condition is contingent upon awareness of the most current evidence and a timely cross-disciplinary approach to care.
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25
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Khan MS, Casson C, Bergman G, Mokdad A, Josephs S, Qureshi FG. Radiological management of traumatic lymphatic injuries in children. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2021. [DOI: 10.1016/j.epsc.2021.102062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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26
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Hydrophilic Interaction Liquid Chromatography Coupled with Fluorescence Detection (HILIC-FL) for the Quantitation of Octreotide in Injection Forms. ANALYTICA 2021. [DOI: 10.3390/analytica2040012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Octreotide is a synthetic cyclic octapeptide analogue of somatostatin-14. It is mainly administered for the treatment of acromegaly, severe diarrhea, and neuroendocrine neoplasias. In this work, a hydrophilic interaction liquid chromatography (HILIC) method with fluorescence (FL) detection was developed and validated for the quantitation of octreotide in solutions for injection. Chromatographic separation was performed on an XBridge®-HILIC analytical column under isocratic elution with a short chromatographic run time of less than 10 min. The mobile phase consisted of ammonium bicarbonate 8.6 mM (pH 8.1)/acetonitrile 35/65 (v/v). The high sensitivity and selectivity of the fluorescence detection, with the excitation wavelength (λexcitation) set at 280 nm and the emission wavelength set at (λemission) 330 nm, enabled a simple sample preparation procedure that included only dilution steps. The calibration curve showed good linearity with a correlation coefficient greater than 0.998. The method was successfully applied to the analysis of commercially available octreotide injection forms.
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27
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Rocha G, Arnet V, Soares P, Gomes AC, Costa S, Guerra P, Casanova J, Azevedo I. Chylothorax in the neonate-A stepwise approach algorithm. Pediatr Pulmonol 2021; 56:3093-3105. [PMID: 34324269 DOI: 10.1002/ppul.25601] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 07/21/2021] [Accepted: 07/24/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Chylothorax in neonates results from leakage of lymph from thoracic lymphatic ducts and is mainly congenital or posttraumatic. The clinical course of the effusion is heterogeneous, and consensus on treatment, timing, and modalities of measures has not yet been established. This review aims to present, along with levels of evidence and recommendation grades, all current therapeutic possibilities for the treatment of chylothorax in neonates. METHODS An extensive search of publications between 1970 and 2020 was performed in the PubMed, Cochrane Database of Systematic Reviews, and UpToDate databases. A stepwise approach algorithm was proposed for both congenital and traumatic conditions to guide the clinician in a rational and systematic way for approaching the treatment of neonates with chylothorax. DISCUSSION AND CONCLUSION The treatment strategy for neonatal chylothorax generally involves supportive care and includes drainage and procedures to reduce chyle flow. A stepwise approach starting with the least invasive method is advocated. Progression in the invasiveness of treatment options is determined by the response to previous treatments. A practical stepwise approach algorithm is proposed for both, congenital and traumatic chylothoraces.
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Affiliation(s)
- Gustavo Rocha
- Department of Neonatology, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Vanessa Arnet
- Department of Neonatology, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Paulo Soares
- Department of Neonatology, Centro Hospitalar Universitário de São João, Porto, Portugal.,Department of Gynecology-Obstetrics and Pediatrics, Faculty of Medicine, Universidade do Porto, Porto, Portugal
| | - Ana Cristina Gomes
- Department of Neonatology, Centro Hospitalar Universitário de São João, Porto, Portugal.,Department of Gynecology-Obstetrics and Pediatrics, Faculty of Medicine, Universidade do Porto, Porto, Portugal
| | - Sandra Costa
- Department of Neonatology, Centro Hospitalar Universitário de São João, Porto, Portugal.,Department of Gynecology-Obstetrics and Pediatrics, Faculty of Medicine, Universidade do Porto, Porto, Portugal
| | - Paula Guerra
- Department of Gynecology-Obstetrics and Pediatrics, Faculty of Medicine, Universidade do Porto, Porto, Portugal.,Department of Pediatrics, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Jorge Casanova
- Department of Cardiothoracic Surgery, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Inês Azevedo
- Department of Gynecology-Obstetrics and Pediatrics, Faculty of Medicine, Universidade do Porto, Porto, Portugal.,Department of Pediatrics, Centro Hospitalar Universitário de São João, Porto, Portugal.,EPIUnit, Public Health Institution, University of Porto, Porto, Portugal
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28
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An unusual complication of tumor surgery: chylous leakage. Surg Today 2021; 52:330-336. [PMID: 34223990 DOI: 10.1007/s00595-021-02334-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 05/24/2021] [Indexed: 10/25/2022]
Abstract
PURPOSE This study was designed to evaluate the effectiveness of conservative treatment for chylous leak after tumor surgery and to propose a management algorithm. METHODS The data of patients with postoperative chylous leak after tumor surgery in our institution between 2010 and 2019 were retrospectively reviewed. In this study, 469 laparotomies, 89 thoracotomies, and 57 cervical excisions were performed for tumor surgery in our institution. RESULTS Twelve patients with a median age of 4 (IQR, 3-8) years had postoperative chylous leak. All patients received total parenteral nutrition for a median of 13 days. Five patients had intravenous somatostatin for a median of 14 days (IQR, 9-16) to decrease chyle production. Eventually, chylous leak ceased in all patients with conservative treatment and surgical drains were removed after no leak was observed with enteral feeding. CONCLUSIONS The incidence of chylous leak in childhood tumor surgery is approximately 2%. Extended tumor resection and lymph node dissection lead to the injury of the delicate structures that drain chyle. Conservative treatment with total parenteral nutrition and somatostatin seems to be effective. In particular, somatostatin may be used in resistant cases. Conservative treatment can take up to 1 month. The algorithm consists of how to manage postoperative chylous leak in childhood.
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Alhasoon MA. The use of high dose octreotide in management of neonatal chylothorax: Review. J Neonatal Perinatal Med 2021; 14:457-461. [PMID: 33843702 DOI: 10.3233/npm-200644] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Being a rare condition, the incidence of chylothorax among neonates is low, but the mortality rate is high. In a dire effort to reduce the risk of death, octreotide treatment is used to effectively treat acquired and congenital chylothorax. Octreotide is proven to effectively treat chylothorax in pre-term and full-term neonates. However, previous studies have not consistently demonstrated the optimal dose of octreotide or the best mode of administration. The objectives of this work were to review previous literature to determine the outcomes of administering high doses of octreotide compared to lower dose regimens in neonates with chylothorax and to determine best practices. METHODS A literature search was performed using electronic databases using the key words neonates, chylothorax, and octreotide. RESULTS Octreotide has been administrated in doses ranging from 0.5μg/kg/h to > 20μg/kg/h. Both low- and high-doses of octreotide are effective in resolving chylothorax with little to no side effects. When side effects were reported, neonates experienced side effects that are less significant in nature and scope. CONCLUSIONS We recommend that the dose of octreotide in neonatal chylothorax can be titrated safely to a maximum of 20μg/kg/h without significant side effects.
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Affiliation(s)
- M A Alhasoon
- Department of Pediatrics, Unaizah College of Medicine and Medical Sciences, Qassim University, Kingdom of Saudi Arabia
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30
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Midodrine, an Oral Alpha-1 Adrenoreceptor Agonist, Successfully Treated Refractory Congenital Chylous Pleural Effusion and Ascites in a Neonate. Chest 2021; 159:e189-e191. [PMID: 34022016 DOI: 10.1016/j.chest.2020.10.071] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 10/19/2020] [Accepted: 10/21/2020] [Indexed: 11/21/2022] Open
Abstract
A trisomy 21 neonate presented with congenital chylous pleural effusion and ascites that was refractory to conventional pharmacotherapy. Midodrine, an oral alpha-1-adrenoreceptor agonist, achieved remission of chylous effusion without any adverse effects. To the best of our knowledge, this is the first neonatal case of successful management of congenital chylous pleural effusion and ascites with midodrine.
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31
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Hur S, Jun H, Jeong YS. Novel interventional radiological management for lymphatic leakages after gynecologic surgery: lymphangiography and embolization. Gland Surg 2021; 10:1260-1267. [PMID: 33842273 DOI: 10.21037/gs-2019-ursoc-10] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Post-operative lymphatic leakage is a common complication of a radical gynecologic surgery involving aggressive lymph node dissection. Its manifestation varies from asymptomatic lymphoceles to life-threatening chylous ascites. In the past, nuclear medicine lymphoscintigraphy was the sole imaging modality for the confirmation of the leakage, of which application is limited due to its poor spatial resolution. While a conservative treatment with percutaneous drainage was the mainstream treatment method, surgical exploration was the last resort for the recalcitrant leakages. Recently, there have been a series of innovations in the field of interventional radiology, including intranodal Lipiodol® lymphangiography, dynamic magnetic resonance (MR) lymphangiography, lymphatic embolization, and mesenteric lymph node lymphangiography. Intranodal Lipiodol® lymphangiography provides very reliable and secure access to the lymphatic system, while requiring only fundamental skills and equipment available to all interventional radiologists. Besides, Lipiodol® is being received a spotlight for its potential therapeutic effects on refractory lymphatic leakage. Dynamic MR lymphangiography plays a vital role in the diagnosis and management of non-traumatic lymphatic diseases, as well as in the post-operative lymphatic leakage with its superior contrast, spatial and temporal resolution. Lymphatic embolization is a technique of using N-BCA glue, a liquid embolic agent, for lymphatic leakages. It can be further described as lymphopseudoaneurysm (LPA) embolization or lymph node embolization, according to which structure is being embolized. Lymphatic embolization opened a new realm of possibilities in the field of interventional lymphology, resulting in the development of treatment approaches for chylous ascites and lymphoceles. Mesenteric lymph node lymphangiography offers the opacification of the upstream mesenteric chylous lymphatic system and can detect lymphatic leakage from the intestinal trunk or the more proximal parts of the mesenteric lymphatic system. With the advent of these latest interventional radiological techniques, more comprehensive approaches to the management of recalcitrant post-operative lymphatic leakages have been enabled.
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Affiliation(s)
- Saebeom Hur
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
| | - Hoyong Jun
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
| | - Yoon Soo Jeong
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
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32
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Gallipoli A, MacLean G, Walia JS, Sehgal A. Congenital Chylothorax and Hydrops Fetalis: A Novel Neonatal Presentation of RASA1 Mutation. Pediatrics 2021; 147:peds.2020-011601. [PMID: 33608416 DOI: 10.1542/peds.2020-011601] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/01/2020] [Indexed: 11/24/2022] Open
Abstract
Mutations in the RASA1 gene are known to cause arteriovenous malformations (AVMs), with evidence of associated lymphatic malformations. We report for the first time, to the best of our knowledge, an infant with RASA1 mutation presenting with hydrops fetalis and chylothorax, but without an associated AVM. Previously, researchers studying rodents have found chylothorax associated with RASA1 mutations, and, in previous case reports, researchers have reported on infants with RASA1 mutations born with hydrops fetalis and AVMs. In this report, we describe the case of a "late preterm" female infant born with nonimmune hydrops fetalis and congenital chylothorax who was detected to have a RASA1 deletion on genetic workup. Although classically described phenotypes of RASA1 mutations present with venous malformations, no such malformations were found in this infant on extensive imaging. This combination is a novel and nonclassic presentation of RASA1 mutation. In cases of congenital chylothorax, especially with nonimmune hydrops fetalis, RASA1 mutations should be considered as part of the differential diagnosis and genetic testing should be included as part of a complete workup to allow for screening for associated vascular anomalies.
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Affiliation(s)
- Alessia Gallipoli
- Department of Pediatrics, Queen's University, Kingston, Ontario, Canada
| | - Gillian MacLean
- Department of Pediatrics, Queen's University, Kingston, Ontario, Canada
| | - Jagdeep S Walia
- Department of Pediatrics, Queen's University, Kingston, Ontario, Canada
| | - Anupam Sehgal
- Department of Pediatrics, Queen's University, Kingston, Ontario, Canada
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33
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Tai HL, Mok TYD, Chao AS, Chu SM, Lien R. Staged Management of Congenital Chylothorax With Hydrops Fetalis: An Insight Into EXIT Related Procedures. Front Pediatr 2021; 9:633051. [PMID: 33681104 PMCID: PMC7925828 DOI: 10.3389/fped.2021.633051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 01/19/2021] [Indexed: 11/21/2022] Open
Abstract
Background: Idiopathic congenital chylothorax is a rare but serious disease. Advancement in perinatal care and the renovated treatment modalities have brought about significant improvement in patient outcome. Objective: To describe the clinical course of severe forms of idiopathic congenital chylothorax, focusing on the development of recent treatment modalities and their impacts. Design: A retrospective cohort by review of medical records in the NICU of a perinatal referral center in Taiwan. Study period was from January 2006 to June 2017. Neonates with the diagnosis of idiopathic congenital chylothorax with non-immune hydrops fetalis were enrolled. Clinical relevant including demographic data, perinatal interventions, post-natal course, and treatment outcome were described and analyzed. Results: Twenty-eight neonatal patients were included. The median gestational age at birth was 34 (range 27-36) weeks and median birth weight was 2,369 (range 1,430-3,608) g. Prenatal intervention was performed in 39.3% of the patients. Besides, 11 out of the 28 neonates developed tension pneumothorax in the first 24 h and 4 (36.4%) of them died. Sepsis was documented in two patients (7.1%). Overall survival rate was 71.4%. There were five patients enrolled during the last 2 years of the study period. EXIT with intubation was performed in two and octreotide was given to four of these most recent neonates, and all of them survived. Conclusion: Recent advances in the management of these neonates, specifically EXIT with intubation and use of octreotide. Both of them improved patient survival in our cohort, but the evidence of impact has yet to be validated.
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Affiliation(s)
- Hung-Lin Tai
- Department of Pediatrics, Saint Paul's Hospital, Taoyuan City, Taiwan.,Division of Neonatalogy, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Tze Yee Diane Mok
- Division of Neonatalogy, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan City, Taiwan.,New Taipei Municipal TuCheng Hospital (Built and Operated by Chang Gung Medical Foundation), New Taipei City, Taiwan
| | - An-Shine Chao
- Department of Obstetrics and Gynecology, Chang Gung Medical Center, Taoyuan City, Taiwan.,School of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Shih-Ming Chu
- Division of Neonatalogy, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan City, Taiwan.,School of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Reyin Lien
- Division of Neonatalogy, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan City, Taiwan.,School of Medicine, Chang Gung University, Taoyuan City, Taiwan
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34
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Neville JJ, Chacon CS, Jordan S, Roberton B, Semple T, Padley S, Clarke SA. Use of lymphangiography in neonates prior to thoracic duct ligation. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2021. [DOI: 10.1016/j.epsc.2020.101699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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35
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Octreotide Infusion for the Treatment of Congenital Chylothorax. Case Rep Pediatr 2020; 2020:8890860. [PMID: 33224547 PMCID: PMC7673913 DOI: 10.1155/2020/8890860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/27/2020] [Accepted: 10/30/2020] [Indexed: 11/17/2022] Open
Abstract
Congenital chylothorax is an uncommon cause of pleural effusion in the pediatric age group, and it should be kept in consideration when evaluating a neonate with pleural effusion, as it is the commonest cause of pleural effusion in this age group (Tutor, 2014). No commonly accepted guidelines have been published so far regarding the management of congenital chylothorax in the neonate, but trials of octreotide have appeared to be promising (Bellini et al., 2018). We present a neonate with congenital chylothorax successfully treated with octreotide infusion.
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36
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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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37
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Long WG, Cai B, Deng JM, Liu Y, Wang WJ, Luo J. Chemical pleurodesis and somatostatin in treating spontaneous chylothorax in pediatric patients: a retrospective analysis and review of the literature. Transl Pediatr 2020; 9:551-560. [PMID: 32953553 PMCID: PMC7475317 DOI: 10.21037/tp-20-199] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Chylothorax is a rare disease, defined as an abnormal accumulation of chylous lymphatic effusion in thoracic cavity, with a high mortality rate in pediatric patients. At present, there are few studies on the treatment of pediatric chylothorax, and conservative treatments like somatostatin (SST) and pleurodesis are performed empirically. SST has been used for treating pediatric chylothorax over 20 years, and povidone-iodine chemical pleurodesis (PICP) is adopted in recent years with a high cure rate, but both the effect are still uncertain. The safety and efficacy of SST and PICP in treating pediatric chylothorax was compared in this study. METHODS From January 2009 to May 2020, 27 pediatric chylothorax patients who accepted life support, SST and PICP treatment were retrospectively reviewed in this study. Their medical history, clinical manifestations, pleural effusion examinations, treatment methods, effects, and complications were screened. PICP and SST was performed in 19 and 8 children, respectively. Each patient was followed up after discharge from the hospital. RESULTS After admission, chest X-ray and ultrasound diagnosed pleural effusion in 27 patients (18 males and 9 females), including 13 and 6 cases on the left and right side, and 8 cases on both sides. In the pleural effusion, the mean leukocyte count was (9,826±9,482)×106/L, the mean lymphocyte ratio was (84.82±6.58)%, the mean triglyceride content was 7.11±6.63 mmol/L. In PICP and SST group, the mean length of stay was 38.42±19.42 and 35.13±12.72 d (P=0.664), the mean time of thoracic drainage was 24.58±16.34 and 19.63±8.88 d (P=0.440), the mean time of parenteral nutrition was 27.16±18.29 and 25.25±13.52 d (P=0.793), respectively. PICP was performed for 3.16±2.27 times, and SST was used for 14.75±9.08 d with the dosage of 0.5 to 10 µg/kg/hour. After the treatment, all patients in PICP group had mild chest pain and low-grade fever, and 12 cases were observed with transient decrease of oxygen saturation. Eight patients in SST group had nausea and vomit, and 1 child had diarrhea simultaneously. Both were cured by symptomatic treatment, thoracic drainage and discontinuing using SST. Three children were diagnosed with refractory chylothorax and cured by PICP after SST. Pleural effusion in 27 patients was finally absorbed. All of them achieved a clinical cure successfully, and there was no recurrence during discharge follow-up. CONCLUSIONS PICP has a high success rate and few adverse reactions in treating spontaneous chylothorax in pediatric patients, expected to be a new treatment option for pediatric chylothorax after SST.
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Affiliation(s)
- Wei-Guang Long
- Department of Chest Wall Surgery, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Bin Cai
- Department of Chest Wall Surgery, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Jian-Ming Deng
- Department of Chest Wall Surgery, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Yang Liu
- Department of Chest Wall Surgery, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Wen-Jie Wang
- Department of Chest Wall Surgery, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Juan Luo
- Department of Chest Wall Surgery, Guangdong Second Provincial General Hospital, Guangzhou, China
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38
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Congenital Chylothorax with Lymphatic Malformation and Successful Antenatal and Postnatal Management. Indian Pediatr 2020. [DOI: 10.1007/s13312-020-1827-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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39
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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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Reisen B, Kovach SJ, Levin LS, Pinto E, Nadolski GJ, Itkin M, Dori Y, Laje P. Thoracic duct-to-vein anastomosis for the management of thoracic duct outflow obstruction in newborns and infants: a CASE series. J Pediatr Surg 2020; 55:234-239. [PMID: 31708212 DOI: 10.1016/j.jpedsurg.2019.10.029] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Accepted: 10/26/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Thoracic duct (TD) outflow obstruction causes high morbidity and mortality in newborns. It can be congenital/idiopathic or acquired (secondary to central venous thrombosis or injury during cardiothoracic surgery). Re-routing the TD to the venous system by microsurgical techniques to restore lymphatic flow is a potential surgical solution. We present a series of newborns and infants who underwent thoracic duct-to-vein anastomosis (TDVA) to restore TD outflow. MATERIALS AND METHODS A retrospective review of all TDVA September 2015-March 2019 was performed. All patients underwent extensive pre-operative imaging evaluation by dynamic MRI and fluoroscopic lymphangiography. The TDVAs were done under high-power microscopy. RESULTS Eight patients underwent TDVA. Age at surgery was 1 to 9 months. Four patients had a history of cardiac surgery (one with complete thrombosis of the central venous system), one patient had a history of ECMO and thrombosis of the SVC, and three patients had a history of fetal hydrothorax and non-immune hydrops. Six patients had a successful TDVA with restoration of the lymphatic flow through the TD and clinical improvement. Two patients had a technically adequate TDVA but without improvement of the flow due to persistently high central venous pressure. Five patients remain alive, two patients died from complications of the lymphatic disorder, and one patient died from an unrelated cause. CONCLUSIONS Patients with congenital or acquired TD outlet obstruction for whom no improvement is achieved by non-surgical interventions may benefit from TDVA. A thorough understanding of the anatomy and physiology of each patient is critical for the success of the operation. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Breanne Reisen
- Division of General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Stephen J Kovach
- Division of Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - L Scott Levin
- Division of Plastic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Erin Pinto
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Gregory J Nadolski
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Maxim Itkin
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Yoav Dori
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Pablo Laje
- Division of General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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A rare case of congenital chylothorax in a Palestinian neonate. Respir Med Case Rep 2019; 28:100937. [PMID: 31667073 PMCID: PMC6812307 DOI: 10.1016/j.rmcr.2019.100937] [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: 06/01/2019] [Revised: 09/15/2019] [Accepted: 09/22/2019] [Indexed: 11/24/2022] Open
Abstract
Congenital chylothorax (CCT) is a rare condition which is characterized by an accumulation of lymphatic fluid in the pleural space and exposes the newborn to respiratory distress and losing of proteins, coagulation factors and immunoglobulins. These cases are liable to have sepsis and high mortality rate. We report a case of a female fetus in Gaza delivered at 36 weeks gestational age diagnosed with CCT. The antenatal ultrasonography showed right sided significant pleural effusion and at birth; she had severe respiratory distress. The baby was intubated at birth and right-sided chest tube drain inserted to drain the pleural fluid which was chylus. The case responded partially to intravenous (IV) octreotide and sildenafil. Chylus stopped completely after 2 days of treatment with octreotide and medium chains triglyceride (MCT) oil-based formula feeding. Conclusion: A female newborn diagnosed with right-sided pleural effusion by antenatal scan was confirmed to have congenital chylothorax postnataly. The infant responded to IV octreotide and MCT based formula feeding.
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Wu C, Wang Y, Pan Z, Wu Y, Wang Q, Li Y, An Y, Li H, Wang G, Dai J. Analysis of the etiology and treatment of chylothorax in 119 pediatric patients in a single clinical center. J Pediatr Surg 2019; 54:1293-1297. [PMID: 29884553 DOI: 10.1016/j.jpedsurg.2018.05.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 05/11/2018] [Accepted: 05/12/2018] [Indexed: 01/30/2023]
Abstract
PURPOSE To summarize the etiology and treatment of 119 patients with chylothorax in our hospital. METHODS A total of 119 patients with chylothorax, divided into a neonate group, an infant group, and an older-than-1-year group, were included in our study and analyzed from January 2000 to July 2017 in the Children's Hospital of Chongqing Medical University. RESULTS A total of 90 males and 29 females were included in our study. In the neonate group, 21 chylothorax cases were due to idiopathic factors, constituting 72.4% of the cases; 8 were related to cardiothoracic surgery, constituting 27.6%. In the infant group, 15 chylothorax cases were due to cardiothoracic surgery, constituting 55.6% of the cases; 11 were related to idiopathic factors, constituting 40.7%; and 1 was related to lymphoma, constituting 3.8%. In the older-than-1-year group, 33 chylothorax cases were due to idiopathic factors, constituting 52.4% of the cases; 25 were cardiothoracic surgery, constituting 39.7%; 2 were related to another internal medicine disease, constituting 3.2%; 2 were due to injury, constituting 3.2%; and 1 was related to lymphoma, constituting 1.6%. All the patients sequentially underwent thoracic drainage therapy, followed by fasting, thoracic injection of an adhesion-promoting agent, and thoracic duct ligation surgery. Among the neonates, 23 patients (79%) with fasting therapy improved, and 5 patients with fasting + intrapleural injection improved (17%). In the infant group, fasting promoted recovery in 14 patients, accounting for 51%, and fasting + thoracic injection improved the conditions of 10 patients, accounting for 37%. In the older-than-1-year group, fasting was effective in 35 patients, accounting for 55%; fasting + thoracic injection was effective in 22 patients, accounting for 34%; and fasting + thoracic injection + thoracic duct ligation surgery enabled the recovery of 2 patients, accounting for 3.2%. CONCLUSION In our center, the main causes of chylothorax in the neonates group are idiopathic factors but may also include a history of unspecified birth trauma; the proportions of idiopathic factors in the infant and older-than-1-year groups are also higher, but the iatrogenic factors are significantly increased in the latter 2 groups. All the patients underwent thoracic drainage therapy, and fasting promoted the recovery of most children. When fasting was ineffective, subsequent thoracic injections were effective. If the above two methods failed, surgery was a method of choice, but it was not always effective. LEVEL OF EVIDENCE Level IV. TYPE OF STUDY Retrospective study.
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Affiliation(s)
- Chun Wu
- Department of Cardio-Thoracic Surgery, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Yi Wang
- Pediatric intensive care unit, Children's Hospital, Chongqing Medical University, Chongqing, China.
| | - Zhengxia Pan
- Department of Cardio-Thoracic Surgery, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Yuhao Wu
- Department of Cardio-Thoracic Surgery, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Quan Wang
- Department of Cardio-Thoracic Surgery, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Yonggang Li
- Department of Cardio-Thoracic Surgery, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Yong An
- Department of Cardio-Thoracic Surgery, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Hongbo Li
- Department of Cardio-Thoracic Surgery, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Gang Wang
- Department of Cardio-Thoracic Surgery, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Jiangtao Dai
- Department of Cardio-Thoracic Surgery, Children's Hospital of Chongqing Medical University, Chongqing, China; Ministry of Education Key Laboratory of Child Development and Disorders, China international Science and Technology Cooperation base of child development and critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China.
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Zhang C, Zhang H, Wu W, Liu D, Yang D, Zhang M, Lu C. Prophylactic octreotide does not reduce the incidence of postoperative chylothorax following lobectomy: Results from a retrospective study. Medicine (Baltimore) 2019; 98:e16599. [PMID: 31335742 PMCID: PMC6708833 DOI: 10.1097/md.0000000000016599] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Chylothorax after lobectomy is common, lacking reliable preventive measures. Octreotide is widely used for treatment of chyle leakage, but its role in preventing chylothorax has not been estimated. The aim of this study was to evaluate whether prophylactic octreotide could reduce the incidence of postoperative chylothorax.Patients who underwent lobectomy for lung cancer from January 2016 to September 2018 were retrospectively reviewed. The cases in prophylactic group received octreotide 1 day before the surgery until removal of chest tubes, while those in the control group did not use it unless the diagnosis of chylothorax.A total of 379 patients were enrolled, with 190 patients in control and 189 cases in prophylactic group. Octreotide was well tolerated in patients who received this agent. No 30-day mortality was indicated. Seven cases in control (3.7%, 7/190) and 3 cases in prophylactic group (1.6%, 3/189) with chylothorax were observed (P = .337). The patients in prophylactic group showed shorter duration of chest drainage ([3.6 ± 1.6] days vs [4.1 ± 2.0] days, P = .006) and reduced drainage volume ([441.8 ± 271.1] mL vs [638.7 ± 463.3] mL, P < .001). In addition, they showed similar stations and numbers of dissected lymph nodes, surgery-related complications, and postoperative hospital stay. Besides, 11 (5.8%, 11/190) patients in control and 6 (3.2%, 6/189) cases in the prophylactic group were readmitted for pleural effusion needing reinsertion of chest tubes (P = .321). Moreover, multivariable logistic analysis showed that induction therapy (odds ratio [OR] =12.03; 95% confidence interval [CI] 3.15-46.03, P < .001) was a risk factor, while high-volume experience of the surgeon (OR = 0.23; 95% CI 0.06-0.97, P = .045) was a preventive factor of surgery-related chylothorax. Additionally, prophylactic octreotide (OR = 0.18; 95% CI 0.11-0.28, P < .001) and perioperative low-fat diet (OR = 0.46; 95% CI 0.29-0.73, P = .001) were negatively associated with the drainage volume of pleural effusion. Furthermore, high-volume experience of the surgeon (OR = 6.03; 95% CI 1.30-27.85, P = .021) and induction therapy (OR = 8.87; 95% CI 2.97-26.48, P < .001) were risk factors of unplanned readmission.Prophylactic octreotide does not reduce the incidence of postoperative chylothorax or unplanned readmission following anatomic lobectomy. The routine application of octreotide should not be recommended. High-quality trials are required to validate these findings.
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Affiliation(s)
- Chu Zhang
- Department of Thoracic Surgery, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing
| | - Hui Zhang
- Department of Thoracic Surgery, Xuzhou Central Hospital Affiliated to Southeast University, Xuzhou, China
| | - Wenbin Wu
- Department of Thoracic Surgery, Xuzhou Central Hospital Affiliated to Southeast University, Xuzhou, China
| | - Dong Liu
- Department of Thoracic Surgery, Xuzhou Central Hospital Affiliated to Southeast University, Xuzhou, China
| | - Dunpeng Yang
- Department of Thoracic Surgery, Xuzhou Central Hospital Affiliated to Southeast University, Xuzhou, China
| | - Miao Zhang
- Department of Thoracic Surgery, Xuzhou Central Hospital Affiliated to Southeast University, Xuzhou, China
| | - Cuntao Lu
- Department of Thoracic Surgery, Xuzhou Central Hospital Affiliated to Southeast University, Xuzhou, China
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Refractory Chylothorax: Where Do We Go Now? CURRENT PULMONOLOGY REPORTS 2019. [DOI: 10.1007/s13665-019-0226-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Neonatal Chylothoraces: A 10-Year Experience in a Tertiary Neonatal Referral Centre. Case Rep Pediatr 2019; 2019:3903598. [PMID: 31001445 PMCID: PMC6436362 DOI: 10.1155/2019/3903598] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 02/27/2019] [Indexed: 01/31/2023] Open
Abstract
Background Neonatal chylothorax is a rare condition, but has a high mortality. Study Objectives To analyse the outcomes of a series of neonates with chylothorax and review the literature to determine best practice. Design A case series review and a literature review using electronic databases including the key words neonates and chylothorax. Results Six cases of neonatal chylothorax were identified during a ten-year period, two had congenital chylothoraces and four iatrogenic chylothoraces after thoracic surgery or chest instrumentation. The neonates were ventilated for a median of 30 (range 13–125) days with a median maximum daily pleural fluid output of 218 (range 86–310) ml/kg/day. All the neonates were given medium-chain triglyceride (MCT) feeds which stabilised pleural fluid output in four and reduced it in another. Octreotide was used in three neonates, but the dosage used had no significant effect on pleural output. Two neonates required surgical intervention. The literature review demonstrated MCT feeds can reduce or stabilise pleural fluid output, but highlighted variable use of octreotide and inconsistent dosing regimens and outcomes. No consensus regarding indications for surgical intervention was identified. Summary and Conclusion Neonatal chylothorax is uncommon, but affected neonates require high healthcare utilisation.
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Abstract
Background and Objective Octreotide is a somatostatin analogue and has been used off-label for a variety of conditions. There are no specific guidelines for the use of octreotide in neonates and its safety and efficacy have not been systematically evaluated. The objective of this study is to present our experience of using octreotide therapy in neonates. Methods This is a retrospective study of neonates who received octreotide therapy during their hospital stay over a 15 years period (2003–2017) in a tertiary neonatal centre. The demographic details and indications of octreotide therapy including time of initiation, route, dose, duration and adverse effects of therapy were noted. The clinical course following octreotide administration was also analysed. Results Eleven neonates received octreotide therapy during the study period, of which nine had chylothorax and two had chylous ascites. Resolution of the chylous effusion with octreotide therapy was achieved in 4 out of 11 (36.3%) of the cases. The median duration of octreotide therapy in cases with successful resolution was 17.5 days. With the exception of minor side effects such as hyperglycaemia, none of the patients had any significant side effects that required discontinuation of therapy. Conclusion Octreotide was used safely as an adjunctive therapy for the treatment of chylothorax and chylous ascites in neonates. However, larger prospective controlled trials are required to establish the optimal dose, time of initiation, duration and efficacy of octreotide therapy in neonates.
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Affiliation(s)
- Syed Ahmed Zaki
- Monash Newborn, Monash Children's Hospital, Clayton, VIC, Australia
| | | | - Atul Malhotra
- Monash Newborn, Monash Children's Hospital, & Department of Paediatrics, Monash University, 246 Clayton Road, Clayton, VIC, Australia.
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Tacoronte Pérez S, Cerón Navarro J, Pastor Colom A, Morcillo Aixelá A. Chylothorax due to Venous Thrombosis in a Double-Lung Transplant Patient. Arch Bronconeumol 2018; 55:381-382. [PMID: 30541670 DOI: 10.1016/j.arbres.2018.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 11/06/2018] [Accepted: 11/08/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Sergio Tacoronte Pérez
- Servicio de Cirugía Torácica, Hospital Universitario y Politécnico La Fe, Valencia, España.
| | - Jose Cerón Navarro
- Servicio de Cirugía Torácica, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - Amparo Pastor Colom
- Servicio de Cirugía Torácica, Hospital Universitario y Politécnico La Fe, Valencia, España
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Sahoo T, Mangla MK, Sethi A, Thukral A. Successful treatment of congenital chylothorax with skimmed milk and long course octreotide. BMJ Case Rep 2018; 11:bcr-2018-226347. [PMID: 30567162 PMCID: PMC6301530 DOI: 10.1136/bcr-2018-226347] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2018] [Indexed: 11/03/2022] Open
Abstract
Congenital chylothorax (CC) is a rare entity in neonatal period requiring multimodal management strategies. Despite optimum treatment, some cases remain refractory posing significant challenge to the treating physician. We here describe a 33-week preterm neonate presenting with refractory congenital chylothorax who needed treatment with combination of skimmed milk, high dose and prolonged duration octreotide for resolution. This case highlighted that octreotide has a good safety profile in newborn infants with congenital chylothorax and locally available skimmed milk fortified with medium chain triglyceride (MCT) oil is a cheap and safe alternative.
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Affiliation(s)
- Tanushree Sahoo
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, New Delhi, India
| | - Mukul Kumar Mangla
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, New Delhi, India
| | - Amanpreet Sethi
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, New Delhi, India
| | - Anu Thukral
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, New Delhi, India
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Bellini C, De Angelis LC, Bellini T. Octreotide treatment for neonatal chylothorax. World J Pediatr 2018; 14:623. [PMID: 30218414 DOI: 10.1007/s12519-018-0184-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 08/30/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Carlo Bellini
- Neonatal Intensive Care Unit, Neonatal Emergency Transport Service, Department of Intensive Care, IRCCS Gaslini, Largo G. Gaslini 5, 16147, Genoa, Italy.
| | - Laura Costanza De Angelis
- Neonatal Intensive Care Unit, Neonatal Emergency Transport Service, Department of Intensive Care, IRCCS Gaslini, Largo G. Gaslini 5, 16147, Genoa, Italy
| | - Tommaso Bellini
- Neonatal Intensive Care Unit, Neonatal Emergency Transport Service, Department of Intensive Care, IRCCS Gaslini, Largo G. Gaslini 5, 16147, Genoa, Italy
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50
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Shen K. Reply to "Causes and manifestation of chylothorax in children". Pediatr Investig 2018; 2:204. [PMID: 32851264 PMCID: PMC7331320 DOI: 10.1002/ped4.12058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Kunling Shen
- Department of Respiratory MedicineBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
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