Somatostatin or octreotide as treatment options for chylothorax in young children: a systematic review

A staged management of prolonged chylothorax in a patient with yellow nail syndrome

Spontaneous chylothorax remains an unusual condition with diverse aetiologies and non-unified management strategies. Owing to the rarity of the condition, the evidence of management remains from case reports and limited retrospective studies. This case represents a difficult-to-manage chylothorax secondary to yellow nail syndrome with initial failure of both surgical and conservative treatment methods. Pleurovenous shunting represents a surgical management approach allowing the patient to live with and control an ongoing chyle leak.

A patient with traumatic chylothorax

Chylothorax refers to the accumulation of chyle in the pleural cavity. Although rare, it is the most frequent cause of pleural effusion in the neonatal period. Its incidence is estimated at one in 15,000 neonates. The causes of chylothorax are multiple, and there are several major types of chylothorax defined by origin, ie, traumatic (and iatrogenic) chylothorax, medical (spontaneous) chylothorax, and congenital chylothorax. A case of neonatal chylothorax following surgery for esophageal atresia and our therapeutic approach to this entity are presented. Conservative therapy with total enteral nutrition and drainage were sufficient. Treatment for chylothorax is essentially medical, ie, pleural drainage, removal of dietary fats, treatment of any medical cause, and use of drugs to reduce production of chyle. In the event of failure or reappearance of a large effusion, surgical treatment is needed.

Octreotide infusion for malignant duodenal obstruction in a 12-year-old girl with metastatic peripheral nerve sheath tumor

Malignant bowel obstruction is a common complication of some adult malignancies. In childhood cancer, malignant bowel obstruction is relatively rare. Octreotide, an analogue of the hormone somatostatin, has been shown to be an effective treatment for this condition in adults. However, explicit description of its use for this indication in children was not discovered in the pediatric literature by this group of authors. The following report is that of a 12-year-old female who had copious bilious emesis secondary to malignant obstruction of the distal duodenum, which abated after treatment with a continuous intravenous octreotide infusion.

Chylothorax after surgery for congenital heart disease

PURPOSE OF REVIEW

Postoperative chylothorax is a frequently encountered pathology in the cardiac intensive care unit. The continuous loss of chyle is a challenging problem to treat and is associated with increased morbidity and mortality. The purpose of this article is to review the pathophysiology of chylothorax in patients after surgery for congenital heart disease, its implications and the current therapies available.

RECENT FINDINGS

The incidence of chylothorax has been increasing over the last two decades. Multiple uncontrolled case series describe octreotide as an effective treatment, and octreotide usage is increasing around the world for patients nonresponsive to dietary modifications. Most centers reserve surgical treatment for patients nonresponsive after 4 weeks of medical treatment. Less-invasive surgical procedures such as thoracic duct ligation by video-assisted thoracoscopy are gaining popularity.

SUMMARY

Chylothorax is commonly seen in children after surgery for congenital heart disease. The multiple and serious complications associated with chylous effusions are well known. Conservative therapy with diet modification and octreotide remain the standard initial approach. Thoracic duct ligation has been reported as a highly successful treatment but has considerable risk. Thus, this procedure should be reserved for patients nonresponsive to conservative therapy.

Chylous ascites occurring after low anterior resection of the rectum successfully treated with an oral fat-free elemental diet (Elental(®))

Chylous ascites occurring after abdominal surgery is rare. Despite being potentially critical, there is no definite treatment guideline because of its rarity. Here we present a case of massive chylous ascites occurring after rectal surgery which was successfully treated with an oral fat-free elemental diet (ED). A 67-year-old man underwent low anterior resection with para-aortic lymphadenectomy for advanced rectal cancer. Early postoperative course was uneventful and the patient was discharged from hospital 10 days after surgery; however, after discharge, abdominal distension rapidly developed. Abdominal computed tomography (CT) performed 3 weeks after surgery revealed massive ascites and laboratory findings showed remarkable hypoproteinemia and lymphopenia. Urgent diagnostic paracentesis showed the ascites to be a white milky fluid containing high levels of triglycerides (564 mg/dl), leading to a diagnosis of chyloperitoneum. Daily nutrition of the patient was entirely with a fat-free ED (30 kcal/kg/day of Elental(®), Ajinomoto Pharmaceutical Co. Ltd, Tokyo, Japan). After the initiation of oral Elental(®), abdominal distension, hypoproteinemia, and lymphopenia gradually improved. Abdominal CT performed 7 weeks after surgery showed no ascitic fluid in the abdomen, and thereafter a normal diet was initiated. Since then, no relapse of chyloperitoneum has been proven. As a result, the chylous ascites was successfully treated in the outpatient clinic.

Fluid overload deteriorate chylothorax: evaluation in a canine model

No conservative treatments for chylothorax have yet been established, and surgical ligation of the thoracic duct is required in many cases. In the present study, we investigated the management of body fluid in a canine chylothorax model. Twelve beagle dogs were divided evenly into three groups: A, B, and C. Under general anesthesia, the thoracic duct was cut and opened, and the amount of lymph fluid leakage was measured. Intravenous extracellular fluid infusion was started at 5mL/kg/h for the first 2h, and then between 2 and 4h, the infusion rate was increased to 10 mL/kg/h in group A and to 20mL/kg/h in group B. During the first 2h after cutting the thoracic duct, the mean lymph fluid leakage rates in groups A, B, and C were 0.466, 0.635, and 0.575 mL/kg/h, respectively. The rates of leakage did not differ significantly among the groups. Between 2 and 4h, the mean rates of leakage were 0.750, 1.43, and 0.544mL/kg/h, respectively, being significantly higher in groups A and B than in group C. The amount of lymph fluid ascending the thoracic duct correlates with the amount of intravenous fluid infusion. For the management of chylothorax, it is important to avoid fluid overload.

Octreotide as therapeutic option for congenital idiopathic chylothorax: a case series

BACKGROUND

Octreotide, a somatostatin analogue, is used for the management of patients with refractory chylothorax although its safety and efficacy in neonates have not been evaluated in controlled clinical trials. We present one of the largest case series about the use of octreotide in congenital idiopathic chylothorax.

METHODS

Six cases of congenital chylothorax (CC) were prospectively collected, who were managed with same unit protocol for octreotide. Mean (SD) gestation was 34.5 (±2.2) weeks, and birthweight was 3410 (±840.4) g. All infants required chest drains from day 1 of life, and the mean (SD) duration of insertion was 36.1 (±8.5) days. Octreotide was commenced at a median age of 13.5 days (range 8-22), given for a median duration of 20 days (range 12-27). The starting dose was 0.5-1 μg/kg/h with an increment of 1-2 μg/kg/day to a maximum of 10 μg/kg/day. Resolution of chylothorax was achieved in five patients, being resistant to treatment in the sixth patient. None had adverse effects from octreotide. Full enteral feeds were reached at a mean age of 44 days.

CONCLUSION

Early commencement of octreotide is recommended although further reports to evaluate the safety and efficacy would add to the profile of this medication in the treatment of CC.

Use of somatostatin analogues to treat chylothorax in a child with Generalised Lymphatic Dysplasia

Generalised Lymphatic Dysplasia is a rare condition that may be associated with significant chylothoraces. The management of such effusions is often challenging. We present the case of a 15-year-old girl with bilateral chylothoraces and lymphoedema of her limbs. A clinical diagnosis of Generalised Lymphatic Dysplasia was made and long-term treatment with somatostatin analogues (somatostatin initially followed by monthly octreotide) was initiated. Over 12 months there was symptomatic benefit with some objective improvement in lung function and no adverse effects. After a year of treatment there was some reaccumulation of fluid, however this did not require any intervention. This is the first paediatric report of the use of somatostatin analogues to manage chylothorax in Generalised Lymphatic Dysplasia and we conclude that they represent a potentially useful treatment modality. Experience is only anecdotal however and further studies are required to establish an evidence base with regard to efficacy and safety.

Congenital chylothorax in a late preterm infant and successful treatment with octreotide

Chylothorax is defined as abnormal accumulation of lymphatic fluid in the pleural space and is a rare condition in neonates. Chylothorax causes respiratory and nutritional problems and a significant mortality rate. Octreotide is a long-acting somatostatin analog that can reduce lymphatic fluid production and has been used as a new strategy in the treatment of chylothorax. Here, we report a premature baby with severe bilateral pleural effusion diagnosed by prenatal ultrasound and subsequently confirmed to be congenital chylothorax after birth. This newborn baby was initially treated with bilateral chest tube insertion to relieve severe respiratory distress. However, the chylothorax recurred after a medium-chain-triglyceride-enriched formula was initiated. The accumulation of chylothorax diminished after the administration of octreotide. Therefore, octreotide may allow the patient to avoid invasive procedures, such as reinsertion of chest tubes or surgery.

Tension chylothorax complicating acute malignant airway obstruction

Acute upper airway obstruction represents one of the most challenging emergencies in pediatric practice. In particular, a tension chylothorax complicating a malignant airway obstruction is a rare and life-threatening complication. We report a rapidly progressing tension chylothorax associated with a cervical mass in a 10-month-old male infant. To our knowledge, the extension of a cervical mass to the supraclavear region resulting in a compressive chylothorax represents an exceptional event in pediatrics. Early recognition and prompt treatment resulted to be essential to relieve the compression and to avoid end-stage hemodynamic and respiratory function derangement.

Chylothorax after surgery on congenital heart disease in newborns and infants -risk factors and efficacy of MCT-diet

Objectives

To analyze risk factors for chylothorax in infants after congenital heart surgery and the efficacy of median chain triglyceride diet (MCT). To develop our therapeutic pathway for the management of chylothorax.

Patients and methods

Retrospective review of the institutional surgical database and patient charts including detailed perioperative informations between 1/2000 and 10/2006. Data analyzing with an elimination regression analysis.

Results

Twenty six out of 282 patients had chylothorax (=9.2%). Secondary chest closure, low body weight, small size, longer cardiopulmonary bypass (242 ± 30 versus 129 ± 5 min) and x-clamp times (111 ± 15 versus 62 ± 3 min) were significantly associated with chylothorax (p < 0.05). One patient was cured with total parenteral nutrition (TPN) and one without any treatment. 24 patients received MCT-diet alone, which was successful in 17 patients within 10 days. After conversion to regular alimentation within one week only one chylothorax relapsed. Out of 7 patients primarily not responsive to MCT-diet, 2 were successfully treated by lysis of a caval vein thrombosis, 2 by TPN + pleurodesis + supradiaphragmatic thoracic duct ligation, one by octreotide treatment, and two patients finally died.

Conclusions

Chylothorax may appear due to injury of the thoracic duct, due to venous or lymphatic congestion, central vein thrombosis, or diffuse injury of mediastinal lymphatic tissue in association with secondary chest closure. Application of MCT alone was effective in 71%, and more invasive treatments like TPN should not be used in primary routine. After resolution of chylothorax, MCT-diet can be converted to regular milk formula within one week and with very low risk of relapse.

Octreotide for the treatment of chylothorax in neonates

BACKGROUND

Routine care for chylothorax in neonate includes either conservative or surgical approaches. Octreotide, a somatostatin analogue, has been used for the management of patients with refractory chylothorax not responding to conservative management.

OBJECTIVES

To assess the efficacy and safety of octreotide in the treatment of chylothorax in neonates.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE and EMBASE (to March 7, 2010). We assessed the reference lists of identified trials and abstracts from the annual meetings of the Pediatric Academic Societies published in Pediatric Research (2002 to 2009) without language restrictions.

SELECTION CRITERIA

We planned to include randomised or quasi-randomised controlled trials of octreotide in the treatment of congenital or acquired chylothorax in term or preterm neonates, with any dose, duration or route of administration.

DATA COLLECTION AND ANALYSIS

Data on primary (amount of fluid drainage, respiratory support, mortality) and secondary outcomes (side effects) were planned to be collected and analysed using mean difference, relative risk and risk difference with 95% confidence intervals.

MAIN RESULTS

No randomised controlled trials were identified. Nineteen case reports of 20 neonates with chylothorax in whom octreotide was used either subcutaneously or intravenously were identified. Fourteen case reports described successful use (resolution of chylothorax), four reported failure (no resolution) and one reported equivocal results following use of octreotide. The timing of initiation, dose, duration and frequency of doses varied markedly. Gastrointestinal intolerance and clinical presentations suggestive of necrotizing enterocolitis and transient hypothyroidism were reported as side effects.

AUTHORS' CONCLUSIONS

No practice recommendation can be made based on the evidence identified in this review. A prospective registry of chylothorax patients and a subsequent multicenter randomised controlled trial are needed to assess the safety and efficacy of octreotide in the treatment of chylothorax in neonates.

Chylothorax: diagnosis and management in children

Chylothorax is the accumulation of chyle in the pleural space, as a result of damage to the thoracic duct. Chyle is milky fluid enriched with fat secreted from the intestinal cells and lymphatic fluid. Chylothorax in children, is most commonly seen as a complication of cardiothoracic surgery but may occur in newborns or conditions associated with abnormal lymphatics. The diagnosis is based on biochemical analysis of the pleural fluid, which contains chylomicrons, high levels of triglycerides and lymphocytes. Investigations to outline the lymphatic channels can prove helpful in some cases. Initial treatment consists of drainage, dietary modifications, total parenteral nutrition and time for the thoracic duct to heal. Somatostatin and its analogue octreotide may be useful in some cases. Surgery should be considered for patients who fail these initial steps, or in whom complications such as electrolyte and fluid imbalance, malnutrition or immunodeficiency persist. Surgical intervention may be attempted thoracoscopically with repair or ligation of the thoracic duct.

[Chylothorax: experience in a paediatric intensive care unit]

INTRODUCTION

Chylothorax is a fairly common condition seen in paediatric intensive care units, since it usually appears in the postoperative care of cardiothoracic surgery. Nevertheless, there is still uncertainty on the most effective treatment option and the prognostic factors for a positive response.

OBJECTIVES

To describe our experience in the management of patients with chylothorax admitted to our paediatric intensive care unit (PICU). To look for prognostic factors for a response to the different treatments.

MATERIAL AND METHOD

This is a descriptive and analytical, retrospective study, that includes the period 2000-2007. All cases of chylothorax of any aetiology diagnosed during this period in our PICU were included (excluding congenital neonatal cases). Demographic variables, aetiology, evolution of the debit, complications, type of treatment with results and side effects were recorded, along with the clinical progress. The possible relationship between the different variables (age, aetiology, debit), and progress, as well as response to treatments was analysed.

RESULTS

A total of 24 patients, 12 males and 12 females, were included, of which 70.8% (17) were under 1 year of age. A total of 79.2% (19) were in postoperative care after surgery for a congenital heart disease. The most notable complications were sepsis (3/24 cases, 12.5%), hypoalbuminaemia (3/24, 12.5%), haemodynamic changes (2/24, 8.3%) and catheter-associated sepsis (2/16, 12.5%). The treatment with fat-free or rich in medium chain triglycerides diet was effective in 9/21 cases (43%) and total parenteral nutrition in 3/5 (60%), as opposed to the infusion of somatostatin in 8/11 (73%), used in second or third line. Somatostatin side effects were hypoglycaemia, hyperglycaemia and digestive disturbances, one patient in each case, and not causing complications. We did not find prognostic factors as regards progression or for the response to the different treatments.

CONCLUSIONS

Sepsis, hypoalbuminaemia and haemodynamic disturbances were found to be complications associated to chylothorax. The treatment with somatostatin did not produce severe side effects, and there was a positive response in 73% of those treated with it.

Post-operative chylothorax in children: an evidence-based management algorithm

AIM

To develop an evidence-based algorithm for the therapeutic approach to the management of post-operative chylothorax.

METHODS

Review and analysis of published literature sourced from Medline from 1964-2007.

RESULTS

Understanding the pathophysiology of chylothorax and the anatomical structure of the thoracic duct assisted clinical decision making in the management of a patient with chylothorax. Treatment options for post-operative chlothorax include conservative management with medium chain triglyceride-enriched diet or total parenteral nutrition in combination with adequate drainage of pleural fluid, somatostatin or octreotide therapy or surgical intervention. Based on analysis of the available evidence an algorithm for therapeutic approach to the management of post-operative chylothorax has been developed.

CONCLUSION

Post-operative chylothorax is associated with significant morbidity and prolonged hospitalization. An evidence based algorithm to guide the therapeutic approach to management of post-operative chylolthorax is proposed.

Pericardial and abdominal fluid accumulation in congenital disorder of glycosylation type Ia

The association of fetal hydrops with Congenital Disorders of Glycosylation (CDG) has been reported previously. Pericardial fluid accumulation and ascites were also observed in a few young patients with CDG type Ia. Here we describe the clinical and biochemical features in three children developing life-threatening extravascular fluid accumulation. All patients carried severe PMM2 mutations comparable to the earlier reported patients with fetal hydrops. One patient was successfully treated with a pericardial-pleural shunt placement. Pericardial fluid accumulation and generalized oedema resolved temporarily in the other two children on regular albumin infusions and the use of diuretics. Sequential abdominal punctures were unsuccessful in the treatment of the extensive ascites production. The use of non-steroid anti-inflammatory agents and the application of high dose steroids had no clinical effect. Severe extravascular fluid accumulation progressed to decompensation and death. Biochemical investigations of the abdominal fluid and pericardial fluid demonstrated a high extracellular protein concentration, increased cytokine concentrations and an abnormal transferrin isoelectric focusing pattern characteristic of CDG type I. Our results are consistent with a local activation of the cytokine pathways and subsequent protein transport through the endothelial surface to the extravascular space. Normal glycosylation of cell surface proteins is essential for the normal fluid balance and protein transport through the pericardial and peritoneal membrane. Future therapeutic efforts should be directed to inhibit the abnormal immune response and excessive protein transport in this life-threatening complication of CDG syndrome.

An unusual case of chylothorax complicating childhood tuberculosis

Endobronchial tuberculosis (EBTB) and chylothorax are rare clinical disorders. The concurrence of these two disorders as manifestations of childhood pulmonary tuberculosis has not been reported. We report a 4-month-old boy presenting with chylothorax as the initial presentation of tuberculosis that has been successfully treated with octreotide, antituberculosis drugs and steroid therapy.

Is octreotide a risk factor in necrotizing enterocolitis?

Octreotide is used as a second-line treatment for hyerinsulinemic hypoglycemia in neonates who do not respond to diazoxide. We present a case of a full-term newborn with massive enterocolitis that developed after octreotide was started for the treatment of refractory hypoglycemia. Multiple intestinal resections were necessary to save intestinal length and restore intestinal function. One case has previously been reported linking the use of octreotide to the development of necrotizing enterocolitis in an infant.

Anatomy of coarctation, hypoplastic and interrupted aortic arch: relevance to interventional/surgical treatment

Obstructive lesions in the aortic arch are comprised of discrete coarctation, tubular hypoplasia and interruption. This review discusses the anatomy of the lesions relevant to interventional treatment. Catheter intervention, using not only balloon angioplasty but also stent implantation for coarctation, has been developed over the past couple of decades as an alternative treatment to surgery. Several studies have reported long-term outcome and the benefits of surgery and catheter intervention for treating obstructive lesions in the aortic arch but more studies are needed for comparable evaluations. The development of imaging and further improvement of surgical and catheter intervention, such as hybrid intervention or new devices, will help in removing the obstruction safely.

Chylothorax in Children After Congenital Heart Surgery

BACKGROUND

A definitive management strategy for postoperative chylothorax remains elusive. We reviewed our experience in the management of chylothorax in children after congenital heart surgery.

METHODS

The case records of 51 patients, with a median age of 11 months (range, 4 days to 19.6 years), diagnosed to have postoperative chylothorax between 1981 and 2004 were reviewed. The responses of patients to nutritional modifications, octreotide therapy, and surgical interventions were noted.

RESULTS

The prevalence of postoperative chylothorax, which developed at a median of 9 days after operation (range, 0 to 24 days), was 0.85% (51 of 5,995). Four patients died, and among the 47 survivors the median duration and total volume of chylous drainage was 15 days (range, 1 to 89 days) and 156 mL/kg (range, 3 to 6,476), respectively. The duration of chyle output was significantly longer after the Fontan-type procedures (p = 0.0006). Twenty-one patients were diagnosed between 1981 and 1999 and managed by nutritional modifications, 2 of whom required further surgical interventions. Of the 30 patients diagnosed between 2000 and 2004, 12 responded to nutritional modifications alone while 18 were started on octreotide therapy at a median of 19.5 days (range, 7 to 35 days) after the onset of chylothorax. Fifteen of the 18 (83%) patients responded to octreotide therapy at 15.3 +/- 5.5 days after starting octreotide, while 3 required further surgical interventions. None developed side effects from octreotide therapy.

CONCLUSIONS

Octreotide has been incorporated into the management algorithm of postoperative chylothorax and appears to be a useful adjunctive therapy.