Octreotide in the treatment of chylothorax

Traumatic chylothorax: a dilemma to surgeons and interventionists

Chylothorax is generally seen due to iatrogenic injury to the thoracic duct during thoracic or neck surgery. It can also be encountered secondary to chest trauma either blunt or penetrating. Percutaneous thoracic duct embolisation is an alternative to surgical treatment and is considered an effective and safe minimally invasive treatment option for chylothorax with a success rate of about 80%. We present a case of blunt trauma to the chest with chylothorax, which was successfully managed with transvenous retrograde thoracic duct embolisation.

Chylothorax: complication attributed to dasatinib use

A 63-year-old woman with a medical history of chronic myelogenous leukaemia treated with dasatinib, chronic obstructive pulmonary disease and heart failure with preserved ejection fraction presented with difficulty in breathing. Chest X-ray showed large right-sided pleural effusion, which was confirmed on a CT angiogram of the chest. Echocardiogram showed an ejection fraction of 61% with moderate to severely dilated right ventricle and right ventricular systolic pressure of 60 mm Hg. Diagnostic and therapeutic thoracentesis was performed, and 2.2 L of pleural fluid was removed. Pleural fluid analysis was consistent with chylothorax. Significant symptomatic improvement was noted after thoracentesis. In the absence of an alternate explanation, chylothorax was attributed to dasatinib, which was switched to nilotinib. This resulted in resolution of her pleural effusions.

Evaluating the Use of Octreotide for Acquired Chylothorax in Pediatric Critically Ill Patients Following Cardiac Surgery

OBJECTIVES

To evaluate the impact of octreotide on time to resolution of chylothorax compared with conventional therapy. Secondary outcomes include the following: time to reduction of chest tube output by 20%, additional surgeries for chylothorax, hospital length of stay, in-hospital mortality, and adverse drug reactions.

METHODS

We retrospectively evaluated the efficacy of octreotide vs conventional therapy for treatment postoperative chylothorax in pediatric patients in the cardiac ICU following surgery for congenital heart disease between October 2008 and June 2017.

RESULTS

Final analysis included 32 patients with chylothorax who met inclusion criteria. Patients who received octreotide had a longer duration of chest tube drainage than those who received conventional therapy (24 vs 9 days, p < 0.001). Resolution of chylothorax was achieved in 13 of 16 (81.3%) octreotide patients and 16 of 16 (100%) conventional patients (p = 0.178). There was a comparable time to reduction by 20% in drainage (6 vs 8 days, p = 0.337). There was no significant correlation between time after starting conventional management and reduction chylous output in either the octreotide or conventional therapy group (p = 0.809, p = 0.107, respectively). However, there was a significant and moderate correlation between octreotide and reduction in a chylous output following initiation of octreotide (R ² = 0.464, p = 0.021).

CONCLUSIONS

Octreotide is potentially a safe and effective therapy for treatment in pediatric patients with refractory chylothorax following surgery for congenital heart disease.

Chylopericardium in a child with IgA nephropathy: a case report

BACKGROUND

Chylopericardium effusion is characterized by the accumulation of milky effusion in the pericardium. It is often idiopathic but it can be secondary to trauma, chest radiation, tuberculosis and malignancy. If cardiac tamponade ensues, it becomes life-threatening. Herein we describe chylopericardium tamponade in a child with IgA nephropathy. To the best of our knowledge, this is the first reported case of chylopericardium tamponade in IgA nephropathy.

CASE PRESENTATION

A 6 years old boy with IgA nephropathy presented with dyspnea, orthopnea, pretibial pitting edema, ascites and fever. Muffled heart sounds and hepatomegaly were also noted. Echocardiography and thoracic CT revealed that there was a large volume of hydropericardium. Moreover, the pericardial milky fluid by pericardiocentesis was analyzed and chylopericardium effusion was eventually confirmed. Pericardial drainage was continued and his diet was modified to low fat, rich MCT and high protein. Complete remission was achieved after 3 weeks of this combined treatment.

CONCLUSION

Chylopericardial tamponade could be a rare and life-threatening complication of IgA nephropathy. Etiological analysis is critical for determining the therapeutic approach in patients with pericardial effusion.

[Chylothorax in practice of thoracic and cardiovascular surgeon]

AIM

to improve the results and current pathogenetic treatment of chylorrhea.

MATERIAL AND METHODS

Thirty seven patients with chylothorax have been treated for the period 2004-2014. In 34 cases traumatic chylothorax developed after surgery and in 3 cases - after intensive care for therapeutic diseases and great veins catheterization. Chylothorax was predominantly diagnosed by X-ray method. Herewith, hydrothorax was established and its nature was defined using laboratory survey. Presence of neutral fat in pleural drainage is the sign of chylothorax. Pathogenetic treatment was often delayed (up to 4.5 months) due to poor awareness of physicians about this pathological process. 6 patients underwent thoracic duct ligation above diaphragm due to ineffective therapy.

RESULTS

Medical therapy had good clinical effect in 83.8% of cases. Postoperatively 1 patient died for single lung inflammation on background of postoperative chylothorax after right-sided pneumonectomy. In other cases chylothora was eliminated with no recurrence in remote postoperative period. It is difficult to recognize injury of thoracic duct or its great branches during surgery. In these cases prolonged thoracic duct ligation above diaphragm is indicated.

Management of lymphangioleiomyomatosis

Lymphangioleiomyomatosis (LAM), a multisystem disease affecting almost exclusively women, is characterized by cystic lung destruction and presents with dyspnea, recurrent pneumothoraxes, chylous effusions, lymphangioleiomyomas, and angiomyolipomas. It is caused by the proliferation of a cancer-like LAM cell that possesses a mutation in either the tuberous sclerosis complex (TSC)1 or TSC2 genes. This article reviews current therapies and new potential treatments that are currently undergoing investigation. The major development in the treatment of LAM is the discovery of two mammalian target of rapamycin (mTOR) inhibitors, sirolimus and everolimus, as effective drugs. However, inhibition of mTOR increases autophagy, which may lead to enhanced LAM cell survival. Use of autophagy inhibitors, for example, hydroxychloroquine, in combination with sirolimus is now the subject of an ongoing drug trial (SAIL trial). Another consequence of mTOR inhibition by sirolimus is an increase in Rho activity, resulting in reduced programmed cell death. From these data, the concept evolved that a combination of sirolimus with disruption of Rho activity with statins (e.g. simvastatin) may increase TSC-null cell death and reduce LAM cell survival. A combined trial of sirolimus with simvastatin is under investigation (SOS trial). Since LAM occurs primarily in women and TSC-null cell survival and tumor growth is promoted by estrogens, the inhibition of aromatase to block estrogen synthesis is currently undergoing study (TRAIL trial). Other targets, for example, estrogen receptors, mitogen-activated protein kinase inhibitors, vascular endothelial growth factor-D signaling pathway, and Src kinase, are also being studied in experimental model systems. As in the case of cancer, combination therapy may become the treatment of choice for LAM.

Outcomes in the management of esophageal cancer

Esophageal cancer rates have continued to rise in the Western World. Esophageal cancer will be responsible for an estimated 15,450 deaths in the United States in 2014 alone. Esophageal resection with or without preoperative therapy remains the mainstay of treatment. Advances in surgical technique and perioperative care have improved short-term outcomes considerably by decreasing operative mortality. Despite these advances though, esophagectomy remains a procedure associated with considerable morbidity from a wide range of complications. Prompt recognition and treatment of complications can lower overall morbidity and mortality. Unfortunately, long-term outcomes remain poor as the vast majority of patients present with loco-regionally advanced or metastatic disease. Surgery by itself provides poor loco-regional control and fails to address micrometastatic disease. Neoadjuvant chemotherapy or chemoradiation provides a modest survival advantage compared to surgical resection alone. Future gains in understanding the molecular biology of esophageal cancer will hopefully lead to improved therapeutics and resultant outcomes.

Transabdominal ligation of the thoracic duct with pericardial-peritoneal shunting in a case of primary idiopathic chylous pericardial effusion

Primary chylous pericardial effusion is a rare entity with few cases reported so far. We report a case of idiopathic etiology in a previously healthy 16-year-old boy. The patient presented with intermittent chest pain and dizziness caused by a chronic pericardial effusion. An echocardiogram revealing a pericardial effusion and open pericardiocentesis with a drainage of approximately of 500 ml of chylous fluid established the diagnosis. Patient had no history of trauma, cardiac surgery, central insertion of subclavian catheters or blunt injury. Computed tomography ruled out malignancies in the abdomen and chest. Clinical, laboratory and radiological investigations for the possible underlying cause of the condition were not determined. Management with a dietary regimen consisting of a medium-chain triglyceride-rich diet, octreotide pharmacological treatment and initial subxiphoid resection with pericardial tube drainage was unsuccessful. Surgical approach was required consisting of pericardio-peritoneal window with trans-abdominal ligation (clipping) of the thoracic duct above the diaphragm. Postoperative outcome was uneventful and there was a rapid recovery after surgical management.

Nonoperative management of traumatic chylothorax

Chylothorax is known for its rarity, and its diagnosis following blunt chest trauma is exceptional. Only a small number of cases have been reported in the literature. Severe consequences, such as cardiopulmonary abnormalities and metabolic, nutritional, and immunologic disorders, can result from chylothorax. Management of chylothorax is challenging. It can either be managed nonoperatively or surgically. Surgical treatment is required in cases of persistent or high output fistulae. We report here in three cases of blunt trauma chest following road traffic crash associated with chylothorax. All of them were successfully managed nonoperatively with inter costal tube drainage and supportive treatment sans need of any operative intervention.

Changes in lung function and chylous effusions in patients with lymphangioleiomyomatosis treated with sirolimus

BACKGROUND

Lymphangioleiomyomatosis (LAM) is a disorder that affects women and is characterized by cystic lung destruction, chylous effusions, lymphangioleiomyomas, and angiomyolipomas. It is caused by proliferation of abnormal smooth muscle-like cells. Sirolimus is a mammalian target of rapamycin inhibitor that has been reported to decrease the size of neoplastic growths in animal models of tuberous sclerosis complex and to reduce the size of angiomyolipomas and stabilize lung function in humans.

OBJECTIVE

To assess whether sirolimus therapy is associated with improvement in lung function and a decrease in the size of chylous effusions and lymphangioleiomyomas in patients with LAM.

DESIGN

Observational study.

SETTING

The National Institutes of Health Clinical Center.

PATIENTS

19 patients with rapidly progressing LAM or chylous effusions.

INTERVENTION

Treatment with sirolimus.

MEASUREMENTS

Lung function and the size of chylous effusions and lymphangioleiomyomas before and during sirolimus therapy.

RESULTS

Over a mean of 2.5 years before beginning sirolimus therapy, the mean (±SE) FEV1 decreased by 2.8%±0.8% predicted and diffusing capacity of the lung for carbon monoxide (Dlco) decreased by 4.8%±0.9% predicted per year. In contrast, over a mean of 2.6 years of sirolimus therapy, the mean (±SE) FEV1 increased by 1.8%±0.5% predicted and Dlco increased by 0.8%±0.5% predicted per year (P<0.001). After beginning sirolimus therapy, 12 patients with chylous effusions and 11 patients with lymphangioleiomyomas experienced almost complete resolution of these conditions. In 2 of the 12 patients, sirolimus therapy enabled discontinuation of pleural fluid drainage.

LIMITATIONS

This was an observational study. The resolution of effusions may have affected improvements in lung function.

CONCLUSION

Sirolimus therapy is associated with improvement or stabilization of lung function and reduction in the size of chylous effusions and lymphangioleiomyomas in patients with LAM.

PRIMARY FUNDING SOURCE

Intramural Research Program, National Heart, Lung, and Blood Institute, National Institutes of Health.

Delayed Chylothorax Following Blunt Chest Trauma

Chylothorax is a very rare disease, and its diagnosis following blunt chest trauma is exceptional. Only a small number of cases have been reported in the literature. We report a case of a male patient involved in a car accident presenting a delayed chylothorax after blunt chest trauma with a bilateral serial rib fracture and fracture of the ninth thoracic vertebrae. The therapy includes thorax drainage, dietary modifications with total parenteral nutrition and, in severe cases, PEEP ventilation. Hematological monitoring is mandatory to detect metabolic abnormalities resulting from chyle loss. Surgical treatment is only required in cases of persistent or increasing intrathoracal chyle flow. Thoracoscopic ligation of the thoracic duct is then required.Severe consequences, such as cardiopulmonary abnormalities and metabolic, nutritional and immunologic disorders, can result from chylothorax. Our patient was treated successfully by chest drainage and parenteral nutrition.

Therapeutic options for lymphangioleiomyomatosis (LAM): where we are and where we are going

Lymphangioleiomyomatosis (LAM), a multisystem disease affecting predominantly premenopausal and middle-aged women, causes progressive respiratory failure due to cystic lung destruction and is associated with lymphatic and kidney tumors. In the past, the treatment of LAM comprised exclusively anti-estrogen and related hormonal therapies. These treatments, however, have not been proven effective. In this article, we discuss new findings regarding the molecular mechanisms involved in the regulation of LAM cell growth, which may offer opportunities to develop effective and targeted therapeutic agents.

Octreotide and chylothorax

PURPOSE OF REVIEW

This article reviews the current literature concerning the role of somatostatin and its synthetic analogue, octreotide, in the treatment of chylothorax.

RECENT FINDINGS

Management of chylothorax includes evacuation of the pleural cavity through a chest tube to alleviate dyspnoea, and dietary fat restriction aimed at reducing lymph flow. When these measures fail to control lymph flow, surgical interventions are employed to achieve definite closure of the thoracic duct leak. Several case reports and series have shown that octreotide is safe and probably effective in both children and adults with chylothorax of different origins. The property of somatostatin and octreotide to induce leak closure is attributed to a decelerating effect on lymph flow, although their exact mechanism of action is not well defined. In successful cases, a substantial reduction of lymph drainage through the chest tube is evident within the first few days of commencing the drug, and treatment lasts for 1-2 weeks. Treatment failure has been also reported, however.

SUMMARY

Accumulating evidence suggests that octreotide is a putative novel therapeutic intervention for chylothorax. It is imperative that randomized controlled studies are conducted in order to fully elucidate the efficacy and safety of this treatment.

Octreotide therapy for chylothorax in infants and children: A brief review

OBJECTIVES

We review physiology and pharmacology relating to the use of octreotide for chylothorax in infants and children. We review the published experience of octreotide dosing in this context.

DATA SOURCE

Systematic review of the literature, including PubMed (English-only journals), citations from relevant articles, major textbooks, and personal files.

CONCLUSIONS

Octreotide has been used as a successful therapeutic adjunct in a small number of neonatal cases and a larger number of pediatric cases. No consensus has been reached as to the optimal route of administration, dose, duration of therapy, or strategy for discontinuation of therapy. We suggest using higher doses (80-100 microg/kg/day) and initiating therapy early rather than using a low initial dose with upward titration. Duration of therapy required to elicit a significant response may vary between patients.

Very unusual case of post-traumatic chylothorax

Chylothorax is a rare disease caused by both traumatic and nontraumatic events. Chylothorax can cause cardiopulmonary abnormalities and significant nutritional, metabolic, and immunologic consequences. We present an exceptional case of chylothorax due to penetrating chest trauma. The diagnosis was made by thoracentesis. Conservative management with nothing by mouth and total parenteral nutrition failed; therefore the patient needed surgical closure of the duct leak.

Postoperative Chylothorax After Cardiothoracic Surgery in Children

BACKGROUND

The purpose of this study is to determine the incidence, risk factors, and outcomes for chylothorax in children undergoing cardiothoracic surgery.

METHODS

Hospital databases were used to identify chylothorax cases. Surgical databases were used to identify all patients undergoing cardiothoracic surgery. Medical records were reviewed, including daily records of drainage volumes and management.

RESULTS

From September 2000 to December 2002, there were 48 cases of chylothorax in 1,257 surgeries--an incidence of 3.8% (95% confidence interval: 2.8% to 4.8%). Overall mortality rate was similar, but cases had longer postoperative hospital stays (median, 22 versus 8 days; p < 0.001). Incidence of chylothorax was significantly higher with heart transplantation and Fontan procedures. Diagnosis was made at a median of 6 days after surgery. Duration of drainage was a median of 15 days, with 11 patients draining more than 30 days. Longer duration of drainage was associated with cavopulmonary anastomosis procedures and longer time to diagnosis of chylothorax. Nutritional management included low fat diet, enteral feeds enriched with medium-chain triglycerides, and parenteral nutrition. Five patients were treated with octreotide, 4 with thoracic duct ligation, and 1 with pleurodesis. Octreotide was associated with a variable effect on drainage. Thoracic duct ligation reduced, but did not stop drainage.

CONCLUSIONS

Chylothorax increases duration of hospitalization after cardiovascular surgery in children. Early diagnosis may reduce the duration of chylothorax. Nutritional strategies remain the cornerstone for management of postoperative chylothorax. The impact of octreotide and surgical intervention is limited when reserved for patients with severe or prolonged drainage.

The successful treatment of chylous effusions in malignant disease with octreotide

Chylous effusions in adults are commonly associated with malignant disease. Although the condition is rare, their occurrence presents a significant management problem. A review of the literature demonstrates the high mortality of this condition in the past from cachexia and infection or after surgical attempts at correction. The first report of somatostatin use in chylous effusions was a decade ago. Since 2000, case reports of successful treatment in infants and neonates with intravenous somatostatin or octreotide have been published. For adults, few reports exist. We describe a case series of seven patients, all with malignancy. In each case, there was a systematic approach to treatment using subcutaneous octreotide and a fat-free diet, resulting in complete resolution of the condition. Although no guidelines are available for the management of chylous effusions, our non-invasive approach avoided lymphangiogram, surgery and allowed early discharge.

Management of newborn lymphangiectasia and chylothorax after cardiac surgery with octreotide infusion

Postoperative chylothorax compromises nutrition, immune function, coagulation, and fluid status. We report rapid short-term suppression of chylothorax by octreotide in an infant after surgery for complex congenital heart disease complicated by lymphangiectasia.

Isolated chylopericardium

A 25-year-old male was discovered to have an asymptomatic pericardial effusion during routine pre-employment medical evaluation. During pericardiocentesis 1200 ml of milky-white fluid was obtained; subsequent biochemical evaluation confirmed the chylous nature of this fluid. Following thorough evaluation a diagnosis of isolated chylopericardium was made. Following several recurrences he underwent thoracotomy with ligation of the thoracic duct and creation of a pericardial window. There are relatively few published reports of true isolated chylopericardium and the aetiology and pathogenesis remain unknown. A primary abnormality of the thoracic lymphatic valve system is postulated. The most effective treatment is surgical with ligation of the thoracic duct above the diaphragm and creation of a pericardial window