Octreotide and chylothorax

Common etiologies of neonatal pleural effusion

BACKGROUND

Pleural effusion is rare and includes several disease entities in the neonatal period. The aim of this study was to investigate the etiology, management, and outcome of neonatal pleural effusions.

METHODS

We retrospectively collected all neonates who were admitted to the neonatal intensive care unit of Chung Shan Medical University Hospital, Taichung, Taiwan, with discharge diagnosis of pleural effusion, chylothorax, hydrothorax, hemothorax, and empyema, from January 1999 to December 2009. The characteristics, etiology, management, and outcome were analyzed.

RESULTS

There were 21 patients identified, 16 males (76%) and 5 females (24%). Eight patients (38%) had primary and 13 patients (62%) had secondary etiologies. The etiologies included four parapneumonic effusions or empyema (19%); nine chylothorax (42.8%) with four congenital and five iatrogenic after thoracic surgery; three percutaneously inserted central venous catheter extravasation (14%); one umbilical venous catheter extravasation (4.7%); three hydrops fetalis (14%); and one congestive heart failure (4.7%). Fifteen patients (71%) needed chest tube placement. Conservative management with complete cessation of enteral feedings and use of total parenteral nutrition followed with infant formula containing medium-chain triglyceride was successful in six of the patients (67%) with chylothorax. There were two patients (22%) with chylothorax who received somatostatin administration; one was successful and the other one failed. Thoracic duct ligation was performed uneventfully in two patients with acquired chylothorax. There were three mortalities (14.3%) in this study, which were related to causes other than pleural effusion.

CONCLUSIONS

Pleural effusions in the neonatal stage may result from chylothorax, hydrops fetalis, extravasation of percutaneously inserted central venous catheter, parapneumonic effusion, congestive heart failure, or other less frequently occurring conditions. Diagnostic chest tap is required for subsequent management. Good outcome is the rule except in hydrops fetalis, which carries high mortality rate.

Lymphangioleiomyomatosis: what do we know and what are we looking for?

Lymphangioleiomyomatosis (LAM) is a rare disease characterised by proliferation of abnormal smooth muscle-like cells (LAM cells) leading to progressive cystic destruction of the lung, lymphatic abnormalities and abdominal tumours. It affects predominantly females and can occur sporadically or in patients with tuberous sclerosis complex. This review describes the recent progress in our understanding of the molecular pathogenesis of the disease and LAM cell biology. It also summarises current therapeutic approaches and the most promising areas of research for future therapeutic strategies.

Lymphangioleiomyomatosis

Lymphangioleiomyomatosis (LAM) is a rare disease that mainly affects women, particularly at fertile age. It is sporadic or associated with tuberous sclerosis complex. It is characterised by an abnormal proliferation of immature smooth muscle cells (SMC), which grow aberrantly in the airway, parenchyma, lymphatics and pulmonary blood vessels and which can gradually lead to respiratory failure. It affects several systems, affecting the lymphatic ganglia and causing abdominal tumours. Given its very low prevalence, a difficult to establish early diagnosis, absence of curative treatment and the difficulty in obtaining information, places LAM under the heading of the so-called Rare Diseases. There is a growing interest in the study of this disease which has led to the setting up of patient registers and an exponential growth in LAM research, both at a clinical level and cellular level.

Chyle leak following laparoscopic cholecystectomy: a rare complication

Gallstone disease is a highly prevalent condition which is commonly and safely treated by laparoscopic cholecystectomy. We present the third reported case of chyle leakage following laparoscopic cholecystectomy in the setting of acute cholecystitis. The report reviews current literature on the prevalence, diagnosis and management of this condition.

Use of octreotide in the treatment of chylopericardium

Chylopericardium involves the pericardial effusion of chyle, which can be a primary (idiopathic) or secondary condition to injury or obstruction of the thoracic duct. We present a case of isolated chylopericardium that appeared after coronary artery bypass grafting in a 46-year-old woman. After failure of the usual conservative therapy for chylopericardium, ie, pericardial drainage and a low-fat, medium-chain triglyceride diet, her treatment was completed with octreotide, a long-acting somatostatin analog. Octreotide was used subcutaneously at a 3 × 100 μg daily dose for 2 weeks. The production of pericardial fluid decreased gradually, and had normalized by the end of treatment. No side effects were evident during therapy.

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.

[A rare leak after mastectomy]

Chylous leak is a rare complication after breast cancer surgery. We present the case of a patient with a chylous leak and discuss the management options.

The role of pleurodesis in the management of chylous pleural effusion after surgery for congenital heart disease

This study aimed to determine the incidence and outcome of postoperative chylous pleural effusion as well as the efficacy of pleurodesis for its management after surgery for congenital heart disease. Medical and surgical databases were used to identify all patients who had surgery for congenital heart disease and subsequently experienced postoperative chylous pleural effusion. Medical records were reviewed and daily chest drainage and management strategies were recorded. From January 2000 to June 2006, 1,166 cardiac operations were followed by 19 cases of chylous pleural effusion, for an incidence of 1.6%. The diagnosis was made a mean of 9 days after the operation. The patients were divided into two groups according to treatment strategy. Group 1 included 9 patients who had received only conventional medical treatment consisting of parenteral nutrition and/or medium-chain triglyceride formula and/or a low-fat diet and/or somatostatin. Group 2 included 10 patients who initially received conventional medical treatment, then subsequently received chemical or mechanical pleurodesis. The amount of the chylous drainage was significantly less in group 1 (14 ml/kg/day) than in group 2 (24 ml/kg/day) (P < 0.05), suggesting a more severe problem in group 2. For group 2, the amount of drainage was significantly less after chemical or mechanical pleurodesis (8 vs 24 ml/kg/day; P < 0.05) than before. Seven patients (70%) responded favorably to the first pleurodesis, and two patients (20%) required more than one pleurodesis. One patient (10%) did not respond to pleurodesis but was treated successfully with thoracic duct ligation. There were no deaths. Pleurodesis is a safe and effective method for treating chylous effusion after surgical treatment of congenital heart disease, especially after failed conservative treatment. However, some patients may need more than one pleurodesis.

Bilateral chylothorax following neck dissection for thyroid cancer

Bilateral chylothorax is mainly encountered following certain thoracic procedures. It is a rare complication following neck dissection, but can be serious and life threatening. The authors report a case of bilateral chylothorax following left modified radical neck dissection, right modified neck dissection and superior mediastinal dissection for bilateral medullary thyroid cancer. The patient was treated successfully with conservative management. The pathophysiology of this complication is discussed and multidisciplinary approach is advocated.

[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.

Chyle leaks: consensus on management?

Lymphatic injury leading to leakage of chyle is a potential complication that may arise from trauma or surgery in the chest, abdomen, or neck. Although the incidence of chyle leak post surgery is low (1%-4%), this complication can present significant challenges. Multiple approaches to the treatment of chyle leak have emerged, including nutrition, surgical, and pharmacological therapies. Although there are strong feelings among clinicians about the use of bowel rest, parenteral nutrition, or a low-fat enteral formula for the treatment of chyle leak, definitive evidence supporting one nutrition therapy over another does not exist. The lack of a clear consensus on the optimal management of chyle leaks makes this an area that is ripe for prospective analysis.

Chyloretroperitoneum following anterior spinal deformity correction

✓ Chyloretroperitoneum is an uncommon complication following spinal surgery. The authors present the case of a patient in whom conservative treatment and initial surgical measures failed to relieve varied symptoms of postsurgical chyloretroperitoneum. Following attempts at conservative management, a peritoneal window was surgically created to divert lymphatic flow from the retroperitoneal space into the peritoneal space, where it was resorbed. This unique surgical technique provides yet another option in the treatment of refractory chyloretroperitoneum following anterior lumbar spinal surgery. The authors describe their technique and review retroperitoneal lymphatic anatomy along with similar case reports in the literature.

Pleural effusions in the neonate

PURPOSE OF REVIEW

This review highlights the pathophysiological mechanisms, incidence, clinical features, as well as the diagnosis and treatment of pleural effusions in the neonate.

RECENT FINDINGS

Pleural effusions are rare except in hydropic neonates. Elevated pleural fluid/serum immunoglobulin G ratio may be a diagnostic marker for congenital chylothorax in utero. Chylothorax may be congenital or acquired. Hydrothoraces may appear at any time during the neonatal period and are related to infectious and noninfectious aetiologies. Haemothorax is defined as the presence of blood in the pleural space. Parenteral nutrition leakage may occur in a newborn with a venous central catheter leading to an effusion that looks like a chylothorax. The value of elevated pleural fluid N-terminal pro-brain natriuretic peptide levels as a marker of congestive heart failure is not yet established in neonates. More recently, in cases of chylothorax that did not resolve with drainage and bowel rest, the use of somatostatin or its analogue octreotide has been described with success. If conservative management fails after 5 weeks, surgical intervention is indicated.

SUMMARY

Clinicians must be aware of the wide range of disorders causing pleural effusions, the different types and clinical presentations, differential diagnosis, and how to treat each specific case.

Bilateral chylothoraces without chyle leakage after left-sided neck dissection for thyroid cancer: report of two cases

Bilateral chylothorax is a rare complication of neck dissection, but it is potentially serious and sometimes life threatening. Because of the rarity of chylothorax, surgeons are unfamiliar with its early signs, which allow a prompt diagnosis and effective management. Most cases reported in the literature were associated with a concurrent external chyle leakage, which occurred either during or after surgery. We report two cases of bilateral chylothoraces without concurrent external chyle leakage, which occurred after left-sided neck dissections for thyroid cancer. We treated both patients successfully with conservative management.