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Rahmath MRK, Bhat AN, Lone RA, Kamal RY. Efficacy of nil per oral, total parenteral nutrition, milrinone and non-suction chest tube drainage-based management for chylothorax following pediatric cardiac surgery. Asian Cardiovasc Thorac Ann 2024; 32:186-193. [PMID: 38659299 DOI: 10.1177/02184923241249198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
OBJECTIVE A single centre experience with chylothorax in post cardiac surgical patients. METHODS Retrospective review. RESULTS Chylothorax developed in 55 out of 873 operated patients (6.3%). Median age of the chylothorax cohort was 95 days (range 1-995). Neonates constituted 36% and 49% were infants. Group-1(35 patients-treated during the years 2011-2015) included those who were managed with low fat diet initially with other standard measures including steroid, octreotide, pleurodesis, lymphangiogram or thoracic duct ligation whenever required.Group-2 (20 patients, treated between year 2016-2018) were managed with nil per oral, total parenteral nutrition, extended use of milrinone and no use of chest tube suction with other above standard measures when required.Group-1 and group-2 were comparable in terms of their age and weight (p > 0.05).We observed lower volume of chest drainage, shorter intubation time, length of intensive care stay and hospital stay in group-2 compared to group-1 though they were statistically not significant (p > 0.05). Occurrence of massive chylothorax (>20 ml/kg/day) in group-1 was significantly higher [18 patients (51%) in group-1 vs 4 patients in group-2 (20%) (Chi-square 5.25, p = 0.02)]. In hospital mortality in group-1 was higher compared to group-2 (5/35 = 14.5% vs 1/20 = 5%), however, it was statistically not significant [risk ratio 2.86; 95% CI 0.36, 22.77; p = 0.59)]. Acute kidney injury was observed in about 25% of patients who had chylothorax. A higher mortality was observed in patients with chylothorax who had acute kidney injury [5/14 (35%)] compared to those who did not have acute kidney injury [1/41 (2.4%)] (Chi-square 11.89, p = 0.001)]. SUMMARY In a heterogenous cohort of post-cardiac surgical patients who developed chylothorax, our suggested new regime (nil per oral, parenteral nutrition, extended use of milrinone and no suction applied to the chest drains) contributed to reduce the frequency of massive chylothorax occurrence significantly.
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Affiliation(s)
| | - Akhlaque N Bhat
- Pediatric Cardiac Surgery Division, CT Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Reyaz A Lone
- Pediatric Cardiac Surgery Division, CT Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Reema Y Kamal
- Pediatric Cardiology, Pediatrics, Hamad Medical Corporation, Doha, Qatar
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Bauer JK, Hocama N, Traub AC, Rutes G, Fachi MM, Moraes J, Lenzi A, Barreto HAG. Chylothorax After Heart Surgery in Children. Pediatr Cardiol 2023; 44:1847-1855. [PMID: 37561171 DOI: 10.1007/s00246-023-03250-6] [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: 05/15/2023] [Accepted: 07/24/2023] [Indexed: 08/11/2023]
Abstract
Chylothorax is a consequence of a thoracic duct injury that can occur during surgical procedures in patients with congenital heart disease. It is associated with high rates of morbimortality and increased use of clinical and hospital resources. The aim of this study was to evaluate the risk factors, distribution, manifestations, complications, and treatments for chylothorax in patients undergoing cardiac surgery in a tertiary pediatric hospital in southern Brazil. This is a retrospective, quantitative study, in which all medical records (n = 166) of patients with chylothorax after pediatric cardiac surgery between January 2014 and December of 2020 and a matched control group (n = 166) were analyzed. Over the study period, there was an increase in incidence of chylothorax from 4.5% in 2014 to 7.6% in 2020, a trend that has been reported in the literature. After multivariate analysis, the following were identified as risk factors for the diagnosis of chylothorax: genetic syndrome (OR 2.298); prolonged cardiopulmonary bypass time (greater than 120 min) (OR 2.410); fluid overload in the immediate postoperative period (OR 1.110); and SIRS (OR 2.527). Mortality was two times greater (p = 0.021) and there was a higher rate (34.4%) of infection (p < 0.001) in patients who developed chylothorax. In addition, a sensitivity analysis was performed comparing patients with low- and high-output chylothorax (> 20 mL/kg), which confirmed unfavorable outcomes for the latter group. Herein, we show that hemodynamic alterations were important factors for diagnosis. Understanding the risk factors, outcomes, and complications helps early identification and enables the reduction of morbidity and mortality.
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Affiliation(s)
- Juliane Kuster Bauer
- Pequeno Príncipe Hospital, Desembargador Motta st., 80.250-060, Curitiba, PR, 1070, Brasil
| | - Nathalia Hocama
- Pequeno Príncipe Hospital, Desembargador Motta st., 80.250-060, Curitiba, PR, 1070, Brasil
| | - Anna Clara Traub
- Pequeno Príncipe Hospital, Desembargador Motta st., 80.250-060, Curitiba, PR, 1070, Brasil
| | - Gabriel Rutes
- Pequeno Príncipe Hospital, Desembargador Motta st., 80.250-060, Curitiba, PR, 1070, Brasil
| | - Mariana Millan Fachi
- Pequeno Príncipe Hospital, Desembargador Motta st., 80.250-060, Curitiba, PR, 1070, Brasil
| | - Janaina Moraes
- Pequeno Príncipe Hospital, Desembargador Motta st., 80.250-060, Curitiba, PR, 1070, Brasil
| | - Andrea Lenzi
- Pequeno Príncipe Hospital, Desembargador Motta st., 80.250-060, Curitiba, PR, 1070, Brasil
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Saad D, Makarem A, Fakhri G, Al Amin F, Bitar F, El Rassi I, Arabi M. The use of steroids in treating chylothorax following cardiac surgery in children: a unique perspective. Cardiol Young 2022; 32:1-6. [PMID: 35361290 DOI: 10.1017/s1047951122000750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Chylothorax is the accumulation of chyle fluid in the pleural space. The incidence of chylothorax is quite common post-cardiac surgeries in pediatrics especially in Fontan procedures. Although several treatment lines are known for the management of chylothorax, steroids were scarcely reported as a treatment option. We present a unique case of a 4-year-old child who underwent Fontan procedure and suffered a long-term consequence of chylothorax. The chylothorax only fully resolved after introducing corticosteroids as part of her management. METHODS A literature review about management of chylothorax post-cardiac surgery in children using Ovid Medline (19462021), PubMed, and google scholar was performed. CONCLUSION Conservative management without additional surgical intervention is adequate in most patients. Additionally, somatostatin can be used with variable success rate. However, a few cases mentioned using steroids in such cases. More research and reporting on the use of steroids in the treatment of chylothorax post-cardiac surgeries in children is needed to prove its effectivity. In this article, we describe a case of chylothorax post-Fontan procedure that supports the use of steroids.
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Affiliation(s)
- Dima Saad
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Adham Makarem
- Faculty of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ghina Fakhri
- Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Farah Al Amin
- Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Fadi Bitar
- Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Issam El Rassi
- Department of Cardiothoracic Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mariam Arabi
- Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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Cochrane CN, Collin N, Langton Hewer SC. A breathless teenager. Breathe (Sheff) 2021; 17:210027. [PMID: 34295426 PMCID: PMC8291959 DOI: 10.1183/20734735.0027-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 04/15/2021] [Indexed: 11/24/2022] Open
Abstract
A 14-year-old girl presented to hospital with breathlessness and fatigue. On admission she was hypoxaemic with oxygen saturations of 90%, tachycardic with a heart rate of 120 beats·min−1 and tachypnoeic with a respiratory rate of 40–50 breaths·min−1. In children with persistent chylothoraces of unknown origin, intranodal lymphangiography can be used to help identify the source of a leak. This may enable embolisation with glue and coils to enable resolution of the chylothoraces.https://bit.ly/3gskhgJ
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Affiliation(s)
| | - Neil Collin
- Dept of Radiology, Southmead Hospital, Bristol, UK
| | - Simon C Langton Hewer
- Dept of Paediatric Respiratory Medicine, Bristol Royal Hospital for Children, Bristol, UK
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Ngeow AJH, Chan MY, Teoh OH, Sanamandra SK, Chan DKL. Non-immune hydrops fetalis secondary to congenital chylothorax with diffuse interstitial lung disease: a diagnostic conundrum. BMJ Case Rep 2021; 14:14/4/e240688. [PMID: 33863770 PMCID: PMC8055142 DOI: 10.1136/bcr-2020-240688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A Chinese male infant was born at 35 weeks weighing 2935 g to a mother with polyhydramnios and prenatal hydrops fetalis. He developed marked respiratory distress secondary to bilateral congenital chylothorax and required pleural drainage, high frequency oscillation and inhaled nitric oxide therapy. He was extubated to non-invasive ventilation by day 14. There was no bacterial or intrauterine infection, haematologic, chromosomal or cardiac disorder. He was exclusively fed medium-chain triglyceride formula. High-resolution CT showed diffuse interstitial lung disease. He received a dexamethasone course for chronic lung disease to facilitate supplemental oxygen weaning. A multidisciplinary team comprising neonatology, pulmonology, haematology, interventional radiology and thoracic surgery considered congenital pulmonary lymphangiectasia as the most likely diagnosis and advised open lung biopsy, lymphangiography or scintigraphy for diagnostic confirmation should symptoms of chylothorax recur. Fortunately, he was weaned off oxygen at 5 months of life, and tolerated human milk challenge at 6 months of life and grew well.
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Affiliation(s)
- Alvin Jia Hao Ngeow
- Department of Neonatal and Developmental Medicine, Singapore General Hospital, Singapore
| | - Mei Yoke Chan
- Haematology/Oncology Service, Department of Paediatric Subspecialties, KK Women's and Children's Hospital, Singapore
| | - Oon Hoe Teoh
- Respiratory Medicine Service, Department of Paediatrics, KK Women's and Children's Hospital, Singapore
| | | | - Daisy Kwai Lin Chan
- Department of Neonatal and Developmental Medicine, Singapore General Hospital, Singapore
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Liu J, Xia RM, Ren XL, Li JJ. The new application of point-of-care lung ultrasound in guiding or assisting neonatal severe lung disease treatment based on a case series. J Matern Fetal Neonatal Med 2020; 33:3907-3915. [PMID: 30835592 DOI: 10.1080/14767058.2019.1590332] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Objective: Lung ultrasound (LUS) has been successfully used for neonatal lung disease diagnosis, as a non-invasive, free of radiation tool, the application of point-of-care LUS (POC-LUS) to diagnose lung disease has become a new trend worldwide. This paper was to introduce the new application of LUS to guide or assist the neonatal lung diseases treatment.Methods: Based on case series of our daily routine clinical work, in combining with the latest literatures, we introducing the new using field of POC-LUS in guiding the treatment of uninflated lung disease by bronchoalveolar lavage (BAL), guiding the treatment of severe pleural effusion and pneumothorax, guide the use of and weaning from mechanical ventilation, and in assessing the efficacy of exogenous pulmonary surfactant (PS) therapy.Results: The results of this study showed that the using rate of invasive ventilation and PS were decreased significantly, the duration of invasive ventilation was shortened significantly, the recovery of pleural effusion and pneumothorax were more quickly and safety, and finally a significantly shortened length of hospitalizations was obtained.Conclusions: LUS monitoring had significant effects in guiding the management of neonatal severe lung diseases, which with the worthy of extensive clinical application.
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Affiliation(s)
- Jing Liu
- Department of Neonatology and NICU, Beijing Chaoyang District Maternal and Child Healthcare Hospital, Beijing, China
| | - Rong-Ming Xia
- Department of Neonatology and NICU, Beijing Chaoyang District Maternal and Child Healthcare Hospital, Beijing, China
| | - Xiao-Ling Ren
- Department of Neonatology and NICU, Beijing Chaoyang District Maternal and Child Healthcare Hospital, Beijing, China
| | - Jian-Jun Li
- Department of Neonatology and NICU, Beijing Chaoyang District Maternal and Child Healthcare Hospital, Beijing, China
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Liu J, Ren XL, Li JJ. POC-LUS guiding pleural puncture drainage to treat neonatal pulmonary atelectasis caused by congenital massive effusion. J Matern Fetal Neonatal Med 2020; 33:174-176. [PMID: 30244617 DOI: 10.1080/14767058.2018.1526921] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Point of care lung ultrasound (POC-LUS) has played important roles in diagnosing neonatal lung diseases and assisting in their treatment. A newborn infant with severe respiratory distress diagnosed as pulmonary atelectasis caused by congenital massive pleural effusion, whose consolidated lung recruitment after pleural puncture drainage under POC-LUS guidance. Lung ultrasound can be performed easily and timely at bed-side with free of radiation exposure, thus it should be used extensively in the neonatal department.
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Affiliation(s)
- Jing Liu
- Department of Neonatology and NICU, Beijing Chaoyang District Maternal and Child Healthcare Hospital, Beijing, China
| | - Xiao-Ling Ren
- Department of Neonatology and NICU, Beijing Chaoyang District Maternal and Child Healthcare Hospital, Beijing, China
| | - Jian-Jun Li
- Department of Neonatology and NICU, Beijing Chaoyang District Maternal and Child Healthcare Hospital, Beijing, China
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Neumann L, Springer T, Nieschke K, Kostelka M, Dähnert I. ChyloBEST: Chylothorax in Infants and Nutrition with Low-Fat Breast Milk. Pediatr Cardiol 2020; 41:108-113. [PMID: 31729543 DOI: 10.1007/s00246-019-02230-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Accepted: 10/17/2019] [Indexed: 11/27/2022]
Abstract
Chylothorax occurs in 2.8-5% of infants after cardiac surgery and can increase morbidity and mortality. First-line conservative treatment consists of a chest tube drainage and a fat-free and medium-chain triglyceride (MCT)-enriched diet. This typically leads to a discontinuity of breast milk feeding due to high content of long-chain triglycerides within the breast milk. Modified breast milk with low fat content (LFBM) could provide numerous benefits like immunological properties of breast milk even for patients with chylothorax. This study was conducted at Herzzentrum Leipzig comparing clinical and growth outcomes between infants with chylothorax after surgery for congenital heart disease treated with LFBM (n = 13) versus MCT-Formula (n = 10). LFBM was prepared by centrifugation of native breast milk added with MCT-oil and fortifier. There were no differences in volume and duration of chest tube drainage between LFBM and MCT-formula treatment groups. Furthermore, no statistically significant differences with regard to weight and length gains could be observed between both feeding groups. LFBM is an efficient and unharmful treatment for chylothorax following cardiac surgery in young children.
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Affiliation(s)
- Lisa Neumann
- Klinik für Kinderkardiologie, Herzzentrum Leipzig, Strümpellstraße 39, 04289, Leipzig, Germany.
| | - Tina Springer
- Klinik für Kinderkardiologie, Herzzentrum Leipzig, Strümpellstraße 39, 04289, Leipzig, Germany
| | - Kathleen Nieschke
- Klinik für Kinderkardiologie, Herzzentrum Leipzig, Strümpellstraße 39, 04289, Leipzig, Germany
| | - Martin Kostelka
- Klinik für Herzchirurgie, Herzzentrum Leipzig, Stümpellstraße 39, 04289, Leipzig, Germany
| | - Ingo Dähnert
- Klinik für Kinderkardiologie, Herzzentrum Leipzig, Strümpellstraße 39, 04289, Leipzig, Germany
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Abstract
INTRODUCTION Although chylothorax is an uncommon complication following paediatric cardiothoracic surgery, it has significant associated morbidities and increased in-hospital mortality, as well as results in higher costs. A lack of prospective evidence or consensus guidelines for management of chylothorax further hinders optimal management. The aim of this survey was to characterise variations in practice in the management of chylothorax and to identify areas for future research. MATERIALS AND METHODS A descriptive, observational survey investigating conservative management practices of chylothorax was distributed internationally to health-care professionals in paediatric intensive care and cardiology units. The survey investigated five domains: the first providing general information about health-care professionals and four domains focusing on clinical practice including diet composition and duration. RESULTS In total, sixty-four health-care professionals completed the survey, representing 38 organisations from 16 countries. The respondents were dietitians (80%), physicians (19%), and nurses (1%). In Australia and New Zealand, management was most commonly directed by physicians' preference (67%) as compared to unit protocols in Europe (67%), United States of America (67%), and Other regions (55%). Dietitians in Australia/New Zealand, United Kingdom, and Ireland followed the most restrictive diet therapy recommending <5 g long chain triglyceride fat per day (p < 0.00001). The duration of diet therapy significantly varied between regions: Australia/New Zealand: 4 weeks (36%) and 6 weeks (43%); Europe: 4 weeks (25%) and 6 weeks (57%); and North America: 4 weeks (18%) and 6 weeks (75%) (p < 0.00001). CONCLUSIONS This survey highlights international variations in practice in the management of chylothorax, particularly with respect to treatment duration and dietary fat restriction. Future research should include a multi-centre randomised controlled trial to inform evidence-based practice and reduce morbidity, particularly poor growth.
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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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Buchwald MA, Laasner U, Balmer C, Cannizzaro V, Latal B, Bernet V. Comparison of postoperative chylothorax in infants and children with trisomy 21 and without dysmorphic syndrome: Is there a difference in clinical outcome? J Pediatr Surg 2019; 54:1298-1302. [PMID: 30057209 DOI: 10.1016/j.jpedsurg.2018.06.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 06/25/2018] [Accepted: 06/25/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Children with trisomy 21 are prone to postoperative chylothorax, caused by malformation of the lymphatic system, after cardiac surgery. The clinical course of patients diagnosed with postoperative chylothorax and trisomy 21 was compared to that of patients without dysmorphic syndromes. Additionally, differences between the groups in composition, amount, and duration of chyle were analyzed to better understand chylothorax in patients with trisomy 21. MATERIALS AND METHODS Retrospective cohort study using inpatient clinical databases during a 10-year period. RESULTS A total of 2255 patients underwent cardiac operations during the period, of whom 160 (7.1%) patients were diagnosed with trisomy 21. Chylothorax developed in 122 children; 89 patients were included in our study. Of 160 trisomy 21 patients, 27 (16.9%) developed postoperative chylothorax compared to 62 (3%) of 2095 patients without dysmorphic syndromes (p = <0.001). Time on ventilation, stay in intensive care, hospital stay, mortality, and composition of chylous effusion did not differ between groups. The rate of thrombosis was significantly lower (p = 0.02) in the trisomy 21 group. CONCLUSION Children with trisomy 21 and congenital heart disease are more prone to developing chylothorax after heart surgery than those without dysmorphic syndromes. However if they develop this postoperative complication, mortality, chylous composition, time in ICU, and duration of hospital stay is not different to from that of other infants or children with this complication. This is important information for the medical specialists involved and is helpful in counseling parents of children with trisomy 21 undergoing heart surgery. LEVEL OF EVIDENCE This is a treatment study evidence level III.
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Affiliation(s)
- Marc-André Buchwald
- Department of Neonatology and Pediatric Intensive Care, University Children's Hospital Zurich, Children's Research Center Division, Zurich, Switzerland; Child Development Center, University Children's Hospital Zurich, Children's Research Center Division, Zurich, Switzerland
| | - Ursula Laasner
- Department of Neonatology and Pediatric Intensive Care, University Children's Hospital Zurich, Children's Research Center Division, Zurich, Switzerland
| | - Christian Balmer
- Department of Pediatric Cardiology, University Children's Hospital Zurich, Children's Research Center Division, Zurich, Switzerland
| | - Vincenzo Cannizzaro
- Department of Neonatology and Pediatric Intensive Care, University Children's Hospital Zurich, Children's Research Center Division, Zurich, Switzerland
| | - Beatrice Latal
- Child Development Center, University Children's Hospital Zurich, Children's Research Center Division, Zurich, Switzerland
| | - Vera Bernet
- Department of Neonatology and Pediatric Intensive Care, University Children's Hospital Zurich, Children's Research Center Division, Zurich, Switzerland.
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Pediatric chylothorax-lymphatic imaging enables targeted surgical treatment. Indian J Thorac Cardiovasc Surg 2019; 35:233-236. [PMID: 33061014 DOI: 10.1007/s12055-018-00779-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 11/20/2018] [Accepted: 11/23/2018] [Indexed: 10/27/2022] Open
Abstract
Chylothorax-the collection of lymphatic fluid in the pleural space-is a rare finding in otherwise healthy adolescents. Initially, clinical signs and symptoms are often non-specific and a wide range of underlying causes necessitates extensive diagnostic workup. Treatment options include dietary measures, medical treatment, and various surgical procedures. We report about a 12-year-old boy with accidental diagnosis of chylothorax. Lymphatic imaging led to visualization of a leakage of an accessory left-sided thoracic duct and thoracoscopic clipping was successfully performed. Lymphatic imaging procedures depict underlying causes of chylothorax allowing targeted therapeutic management.
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Guo Y, Chen J, Xu B, Zheng Y, Shen K. Causes and manifestations of chylothorax in children in China: Experience from a children's medical center, 2007-2017. Pediatr Investig 2018; 2:8-14. [PMID: 32851223 PMCID: PMC7331315 DOI: 10.1002/ped4.12019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Accepted: 03/07/2018] [Indexed: 12/25/2022] Open
Abstract
IMPORTANCE Chylothorax is the most common cause of pleural effusion in neonates and relatively rare in children. It can cause significant respiratory morbidity. Many clinical entities may contribute to chylothorax. OBJECTIVE To investigate the causes and manifestations of chylothorax in infants and children in China. METHODS Case records of 107 cases with chylothorax seen in Beijing Children's Hospital from 2007 to 2017 were retrieved and analyzed; follow-up was carried out by telephone. RESULTS Of 107 cases, 58.9% (63/107) were primary chylothorax (PC) and 41.1% (44/107) were secondary chylothorax (SC). Also, 36.4% (39/107) were neonatal chylothorax (NC) and 35.5% (38/107) were postoperative chylothorax. In PC with a verified lymphatic anomaly, there was one case of diffuse pulmonary lymphangiomatosis (DPL) and six cases of generalized lymphatic anomaly (GLA), which accounted for 6.5% (7/107) of cases. In most patients, chylothorax was alleviated by conservative treatment based on total parenteral nutrition (TPN); 13.1% (14/107) of cases needed further surgery. In NC, the median duration of TPN was 9 days, but 10 of 20 cases who improved had recurrence upon re-introduction of a fat-free diet, which was alleviated by further TPN. The duration of hospitalization was (23 ± 14) days for congenital chylothorax. Upon long- term follow-up, except for GLA and DPL, most patients were doing well without recurrence. INTERPRETATION NC and postoperative chylothorax are the common subtypes. TPN is effective for most patients. Despite a prolonged and fluctuating clinical course, most patients had a good long-term prognosis.
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Affiliation(s)
- Yan Guo
- National Clinical Research Center for Respiratory DiseasesDepartment of Respiratory MedicineBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
| | - Jiehua Chen
- Department of Respiratory MedicineShenzhen Children's HospitalShenzhenChina
| | - Baoping Xu
- National Clinical Research Center for Respiratory DiseasesDepartment of Respiratory MedicineBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
| | - Yuejie Zheng
- Department of Respiratory MedicineShenzhen Children's HospitalShenzhenChina
| | - Kunling Shen
- National Clinical Research Center for Respiratory DiseasesDepartment of Respiratory MedicineBeijing Children's HospitalCapital Medical UniversityNational Center for Children's HealthBeijingChina
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Abstract
OBJECTIVES The aims of this study were to investigate risk factors for the development of postoperative chylothorax following paediatric congenital heart surgery and to investigate the impact of a management guideline on management strategies and patient outcome. METHODS All patients with chylothorax following cardiac surgery at the Royal Children's Hospital, Melbourne, over a 48-month period beginning in January 2008 were identified. A control group, matched for age, date of surgery, and sex, was identified. To investigate potential risk factors, univariable and multivariable logistic regression models were constructed with paired analysis. To examine the effect of a standardised management protocol, data before and after the implementation of the guideline were compared. RESULTS In total, 121 cases of chylothorax were identified, with 121 controls, matched for age at surgery, date of surgery, and sex. The incidence of chylothorax was 5.23%. Increasing surgical complexity (univariable OR 0.17 for the least complex versus the most complex group, p=0.02), closed-heart surgeries (OR 0.07 for open versus closed, p<0.001), and redo chest incisions (OR 10.0 for redo versus virgin, p<0.001) were significantly associated with chylothorax. The standardised management protocol had no significant impact on either drainage duration or management strategy. CONCLUSIONS We have replicated the previously reported association between surgical complexity and chylothorax risk, and have shown, for the first time, that redo chest openings are also associated with a significantly increased risk. The implementation of a standardised management protocol in our institution did not result in a significant change in either chylothorax drainage duration or management strategy.
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Ebrahimi-Fakhari D, Freiman E, Wojcik MH, Krone K, Casey A, Winn AS, Roberts AE, Harper BD. Congenital Chylothorax as the Initial Presentation of PTPN11-Associated Noonan Syndrome. J Pediatr 2017; 185:248-248.e1. [PMID: 28363362 PMCID: PMC5529256 DOI: 10.1016/j.jpeds.2017.02.042] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 02/15/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Darius Ebrahimi-Fakhari
- Division of General Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA,Department of Neurology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA,Corresponding Author: Dr. Darius Ebrahimi-Fakhari, Department of Medicine & Department of Neurology, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115, USA, Phone: 617-919-4377; Fax: 617-738-7066;
| | - Eli Freiman
- Division of General Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Monica H. Wojcik
- Division of Genetics and Genomics, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA,Division of Newborn Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Katie Krone
- Division of Pulmonary and Respiratory Diseases, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Alicia Casey
- Division of Pulmonary and Respiratory Diseases, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Ariel S. Winn
- Division of General Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Amy E. Roberts
- Division of Genetics and Genomics, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA,Department of Cardiology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Beth D. Harper
- Division of General Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
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Lin CH, Lin WC, Chang JS. Presentations and management of different causes of chylothorax in children: one medical center's experience. Biomedicine (Taipei) 2017; 7:5. [PMID: 28474581 PMCID: PMC5439341 DOI: 10.1051/bmdcn/2017070105] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Accepted: 10/17/2016] [Indexed: 01/30/2023] Open
Abstract
Background: Chylothorax in children is a relatively rare cause of pleural effusion. However, it is usually a common complication of cardiothoracic operations like open-heart surgery. Other etiologies for chylothorax, such as trauma or malignancy, occur more common in adults and rare in children. To explore the etiologies of chylothorax in children, this study analyzed the pediatric patients that were admitted in to onea medical center. Methods: We retrospectively reviewed the medical records of the pediatric patients that were admitted to this tertiary transfer center with a diagnosis of chylothorax during the period of 1995 to 2005. Results: A total of 22 patients (15 females and 7 males) with chylothorax were enrolled in our study. The etiologies for chylothorax were the following: a complication of cardiothoracic surgery in 14 patients (63.6%), congenital chylothorax in 5 patients (22.7%), association with neuroblastoma in 2 patients (9.1%), and congenital nephrotic syndrome in 1 patient (4.6%). All patients required medical therapy. Chest tube drainage was necessary to provide for twenty patients (90.9%), and surgical intervention was necessary to perform for 3 patients (13.6%). Four patients (18.2%) expired due to other causes. Conclusion: Cardiothoracic surgery was the most common cause of chylothorax in children at the institution surveyed. Medication and chest tube drainage were effective in treating most of these chylothorax-afflicted patients. In addition, early recognition, medication, and performing surgical intervention when necessary are important measures to avoid a catastrophe.
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Affiliation(s)
- Chien-Heng Lin
- Division of Pediatric Pulmonology, China Medical University Children's Hospital, Taichung 404, Taiwan - Department of Biomedical Imaging and Radiological Science, College of Health Care to College of Medicine, China Medical University, Taichung 404, Taiwan
| | - Wei-Ching Lin
- Department of Biomedical Imaging and Radiological Science, College of Health Care to College of Medicine, China Medical University, Taichung 404, Taiwan - Department of Radiology, China Medical University Hospital, Taichung 404, Taiwan - School of Medicine, College of Medicine, China Medical University, Taichung 404, Taiwan
| | - Jeng-Sheng Chang
- School of Medicine, College of Medicine, China Medical University, Taichung 404, Taiwan - Division of Pediatric Cardiology, China Medical University Children's Hospital, Taichung 404, Taiwan
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Borasino S, Diaz F, El Masri K, Dabal RJ, Alten JA. Central venous lines are a risk factor for chylothorax in infants after cardiac surgery. World J Pediatr Congenit Heart Surg 2015; 5:522-6. [PMID: 25324248 DOI: 10.1177/2150135114550723] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Chylothorax complicates congenital heart disease (CHD) surgery and may be associated with significant morbidity. Etiology of chylothorax is multifactorial, and it has been associated with deep venous thrombosis and obstruction from central venous lines (CVLs) in patients without CHD. We sought to determine whether CVL insertion site was associated with the occurrence of chylothorax in infants after cardiac surgery. DESIGN Retrospective cohort of patients less than one year of age who underwent CHD surgery requiring cardiopulmonary bypass from 2008 to 2012. Chylothorax was identified by clinical diagnosis and/or laboratory findings (milky effusion, fluid with >100 mg/dL of triglycerides and/or >80% of lymphocytes). Central venous lines insertion site was verified by reviewing procedure notes and chest x-rays. Internal jugular (IJ), subclavian vein, and femoral vein (FV) CVLs were used during the study period. RESULTS Three hundred and ninety-two patients were included (mean age 97 days, mean weight 4.5 kg). Sixty-two (15.8%) of these patients developed chylothorax after surgery. Patients with chylothorax had longer bypass time (P=.02), longer cross-clamp time (P=.03), higher RACHS-1 category (P=.03), and more frequent upper body CVLs (IJ or subclavian vein; P=.03). There was no significant association with age, gender, preoperative weight, and height. Multivariate analysis showed patients with a CVL in the upper body (IJ or subclavian vein) were almost two times more likely to develop a chylothorax than patients who had FV CVL, (odds ratio=1.9, 95% confidence interval=1.05-5.60; P=.044). CONCLUSION Postoperative chylothorax is associated with line insertion in the upper body (subclavian vein and IJ). Avoidance of CVLs in these locations may decrease its incidence.
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Affiliation(s)
- Santiago Borasino
- Department of Pediatrics, Division of Critical Care, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Franco Diaz
- Department of Pediatrics, Division of Critical Care, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kamal El Masri
- Department of Pediatrics, Division of Critical Care, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Robert J Dabal
- Department of Surgery, Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jeffrey A Alten
- Department of Pediatrics, Division of Critical Care, University of Alabama at Birmingham, Birmingham, AL, USA
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Bialkowski A, Poets CF, Franz AR. Congenital chylothorax: a prospective nationwide epidemiological study in Germany. Arch Dis Child Fetal Neonatal Ed 2015; 100:F169-72. [PMID: 25480460 DOI: 10.1136/archdischild-2014-307274] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Congenital chylothorax (CCT) is a rare disease of unknown aetiology. Treatment approaches vary; none has been evaluated prospectively. OBJECTIVE To prospectively determine incidence, treatment and outcome of infants with CCT born in Germany in 2012. DESIGN CCT was defined as non-traumatic chylous pleural effusion within 28 days after birth. As part of the Surveillance Unit for Rare Pediatric Conditions in Germany (Erhebungseinheit für seltene pädiatrische Erkrankungen in Deutschland), all paediatric departments (n=432) received monthly reporting cards to notify the study centre of CCT cases, which were analysed based on anonymised questionnaires and discharge summaries. Data are shown as median (range) or n/N. RESULTS Of 37 cases reported, 28 met inclusion criteria. Questionnaires and/or discharge summaries were available for 27/28. Assuming complete reporting, the incidence of CCT was 1:24 000. Nine infants suffered from proven or suspected syndromal anomalies, most frequently Noonan syndrome (5/9). Postnatally, 23 required mechanical ventilation, 3 continuous positive airway pressure; only 1 had no respiratory support. 17 infants were treated with inotropes/vasopressors, 25 required pleural drainage for 11 (1-36) days. In 13 infants, enteral feeds were withheld initially; 25 received medium-chain triglyceride diet at some time, 9 were treated with octreotide or somatostatin. 18 infants survived without, 6 with sequelae attributable to the underlying disorder; 3 infants died (median age at death 37 (2-144) days). Duration of hospital stay in survivors was 51 (20-127) days. Infants treated with octreotide or somatostatin had similar outcomes compared with those not treated. CONCLUSIONS Based on this small observational study, CCT seems to have a favourable prognosis if not associated with genetic disorders.
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Affiliation(s)
- Anja Bialkowski
- Department of Neonatology, University Children's Hospital of Tübingen, University of Tübingen, Tübingen, Germany
| | - Christian F Poets
- Department of Neonatology, University Children's Hospital of Tübingen, University of Tübingen, Tübingen, Germany
| | - Axel R Franz
- Department of Neonatology, University Children's Hospital of Tübingen, University of Tübingen, Tübingen, Germany Center for Pediatric Clinical Studies, University Children's Hospital of Tübingen, University of Tübingen, Tübingen, Germany
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Law MA, McMahon WS, Hock KM, Zaccagni HJ, Borasino S, Alten JA. Balloon Angioplasty for the Treatment of Left Innominate Vein Obstruction Related Chylothorax after Congenital Heart Surgery. CONGENIT HEART DIS 2015; 10:E155-63. [PMID: 25600286 DOI: 10.1111/chd.12246] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/03/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Chylothorax complicates the postoperative course of patients after congenital heart surgery. Innominate vein thrombosis and stenosis have been associated with postoperative chylothorax. Revascularization and angioplasty can be accomplished using transcatheter techniques. We report our experience with this procedure for the management of postoperative chylothorax. DESIGN This is a retrospective case series of patients who underwent catheter revascularization and/or angioplasty of the innominate vein following cardiac surgery at our institution from January 1, 2008 through April 9, 2014. SETTING The cardiovascular intensive care unit and cardiac catheterization laboratory at the University of Alabama at Birmingham and Benjamin Russell Hospital for Children in Birmingham, Alabama were used as settings for the study. PATIENTS Out of 112 patients with postoperative chylothorax, 7 (6.3%) underwent transcatheter dilation of the innominate vein for occlusion/stenosis. The median age of the cohort was 1 month (15 days-6 years); median weight was 3 kg (2.7-22.2). Diagnosis was made a median 8 days (2-20) and persisted for a median of 24 days (9-44). Most patients failed medical management (low fat diet, nothing by mouth, and/or octreotide). RESULTS Cardiac catheterization occurred at a median 9 days (2-29) after chylothorax diagnosis. Median chest tube output on the day prior to procedure was 63 (12-149) cc/kg/day and decreased to 23 (0-64) cc/kg/day 2 days postprocedure (P = .01). Effusions resolved in a median of 5 days (1-16). There were no clinical complications postcatheterization. All patients who have undergone repeat angiography have maintained patency of the innominate vein. There was no mortality. Complications from chylothorax included prolong hospitalization, hyponatremia, hypoproteinemia, coagulopathy, lymphopenia, and infection. CONCLUSIONS Innominate vein occlusion and stenosis associated with chylous effusion are amenable to transcatheter revascularization and/or angioplasty, consistently leading to improvement, if not full resolution of chylothorax.
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Affiliation(s)
- Mark A Law
- Department of Pediatric Cardiology, University of Alabama at Birmingham, Birmingham, Ala, USA
| | - William S McMahon
- Department of Pediatric Cardiology, University of Alabama at Birmingham, Birmingham, Ala, USA
| | - Kristal M Hock
- Department of Pediatric Cardiac Critical Care, University of Alabama at Birmingham, Birmingham, Ala, USA
| | - Hayden J Zaccagni
- Department of Pediatric Cardiac Critical Care, University of Alabama at Birmingham, Birmingham, Ala, USA
| | - Santiago Borasino
- Department of Pediatric Cardiac Critical Care, University of Alabama at Birmingham, Birmingham, Ala, USA
| | - Jeffrey A Alten
- Department of Pediatric Cardiac Critical Care, University of Alabama at Birmingham, Birmingham, Ala, USA
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Blei F. Update December 2014. Lymphat Res Biol 2014. [DOI: 10.1089/lrb.2014.1242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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