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Ann Thorac Surg 2001;72:1740-1742
© 2001 The Society of Thoracic Surgeons

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Case report

Octreotide to treat postoperative chylothorax after cardiac operations in children

^a Paediatric Surgical Unit, Harefield Hospital, Royal Brompton and Harefield NHS Trust, Harefield, Middlesex, United Kingdom

Accepted for publication December 28, 2000.

* Address reprint requests to Dr Franklin, Pediatric Cardiology, Harefield Hospital, Hill End Rd, Harefield, Middlesex UB9 6JH, United Kingdom
e-mail: r.franklin{at}rbh.nthames.nhs.uk

	Abstract

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Chylothorax after pediatric cardiac operations is associated with significant morbidity and increased hospitalization. An octreotide (a synthetic somatostatin analogue) infusion (1 to 4 µg/kg per hour) with medium-chain triglyceride diet or parenteral nutrition was used in 4 pediatric cardiac surgical patients after chylothorax was diagnosed. Resolution followed within 5 days in all without recurrence, while on a normal diet.

	Introduction

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Chylothorax is a well-recognized complication after pediatric cardiac operations with an incidence of 0.56% to 1.9% [1]. We report our experience with the novel use of octreotide (Sandostatin; Novartis Pharmaceuticals, Camberley, United Kingdom) a synthetic somatostatin analogue, in the treatment of 4 consecutive children with chylothorax after cardiac operation. Diagnoses, operations, and octreotide details are given in Table 1.

	Case reports

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View larger version (26K): [in this window] [in a new window]   Fig 1. Mean daily chest drain losses 1 week before and after octreotide infusion.

Patient 3
A 4-year-old boy was diagnosed as having a right chylothorax on day 6 postoperatively. He was immediately started on octreotide and an MCT diet. The chest drain was removed 5 days later. The octreotide was weaned after 4 days and diet continued for 3 weeks before successful challenge with a normal diet.

Patient 4
A 3-year-old girl had delayed postoperative enteral absorption requiring total parenteral nutrition for 5 days before oral feeding was begun. This led to chylous drain losses from her right pleural drain. Octreotide and an MCT diet were started. Chest drains were removed 4 days later, and the diet continued for 4 weeks with no evidence of effusions thereafter when on a normal diet.

	Comment

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Cardiothoracic operations are the most common cause of chylothorax in children (69% to 85%) [1–3]. Direct trauma to the thoracic duct or adjacent lymphatic pathways is believed to be the usual cause.

Initial treatment of chylothorax is pleural drainage and use of a diet (such as MCT) that lacks long chain fatty acids or total gut rest with total parenteral nutrition [2]. However a significant increase in triglyceride and chylomicron concentrations can occur after MCT oil intake, and water alone can increase chyle flow by 20% [4]. These findings perhaps explain the poor resolution of chylothorax in a study of 49 patients on an MCT diet (38% after 14 days, 77% after 45 days [3]). With total parenteral nutrition chylothorax resolved in 77% of patients in another study but at the cost of a mean pleural drainage time of 11.9 days [2]. Total parenteral nutrition itself might engender problems related to infection, thrombosis, or cholestasis. In the subgroup of patients with either high central venous pressure or a bidirectional superior cavopulmonary (Glenn) anastomosis, conservative treatment of chylothorax failed without exception [1, 2]. All our patients had high central venous pressures (14 to 24 mm Hg), 3 after bidirectional superior cavopulmonary anastomosis.

Surgical treatment of chylothorax is neither straightforward nor well established and is recommended after the failure of dietary management, usually after 3 to 4 weeks [1]. Ligation of the thoracic duct with adjacent leaking lymphatics [1] is the preferred surgical option but can involve an extensive thoracotomy. Ligation of the duct at the diaphragmatic hiatus through an abdominal approach avoids a thoracotomy, as does chemical pleurodesis using talc. The insertion of an externalized pleuroperitoneal shunt for up to 3 months was followed by resolution of chylothoraces in 84% of children.

As medical treatment is prolonged and surgical options are difficult, other treatments have been explored. Rimensberger and colleagues [5] successfully used a 14-day somatostatin infusion in an infant with persistent bilateral chylothoraces after cardiac operation.

Octreotide is a parenteral synthetic analogue of the naturally occurring hormone somatostatin; it has similar activity, greater selectivity, and a longer half-life. Somatostatin inhibits several pituitary and gastrointestinal hormones. The inhibition of serotonin and other gastrointestinal peptides results in increased intestinal absorption of water, decreased pancreatic and gastric acid, and increased intestinal transit time. Importantly it also increases splanchnic arteriolar resistance and decreases gastrointestinal blood flow and thus secondarily reduces lymph flow. Indications for octreotide therapy are endocrine tumors, variceal bleeding in portal hypertension, and reduction of lymph flow in chylous ascites [6]. We used octreotide (1 to 4 µg/kg per hour) in children with postoperative chylothorax in addition to an MCT diet in the hope that decreasing lymph production by nondietary means would hasten its resolution. All 4 patients responded to the infusion (Fig 1), and drains could be removed within 5 days of treatment. Octreotide was discontinued within 10 days with no recurrence of the chylothoraces and without side effects or complications.

Although it is impossible to determine the timescale of chylothorax resolution had octreotide not been used, our preliminary experience strongly suggests that octreotide is an effective, noninvasive, and safe adjunct to standard medical treatment of postoperative chylothorax in children. Octreotide appears to reduce the morbidity, hospitalization, and costs related to this troublesome complication, particularly in patients with high systemic venous pressures.

	Addendum

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Since writing this report, we have had two more cases of chylothorax after cardiac operations. Both cases were children (a 1.2 year old with bidirectional superior cavopulmonary anastomosis and a 10 year old with tetralogy of Fallot) who had high systemic venous pressures (greater than 18 mm Hg). The diagnoses were made on the second and sixth postoperative days, respectively. Octrotide infusion was started immediately at 4 µg/kg per hour, and the drains were removed within 4 days.

	References

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1. Le Coultre C., Oberhansli I., Mossaz A., et al. Postoperative chylothorax in children: differences between vascular and traumatic origin. J Pediatr Surg 1991;26:519-523.[Medline]
2. Bond J.S., Guzzetta P.C., Snyder M.L., Randolph J.G. Management of pediatric postoperative chylothorax. Ann Thorac Surg 1993;56:469-473.[Abstract]
3. Buttiker V., Fanconi S., Burger R. Chylothorax in children—guidelines for diagnosis and management. Chest 1999;116:682-687.[Abstract/Free Full Text]
4. Pieterson B., Jacobsen B. Medium chain triglyceride for treatment of spontaneous neonatal chylothorax. Acta Paediatr Scand 1977;66:121-125.[Medline]
5. Rimensberger P.C., Muller-Schenker B., Kalangos A., Beghetti M. Treatment of a persistent postoperative chylothorax with somatostatin. Ann Thorac Surg 1998;66:253-254.[Abstract/Free Full Text]
6. Shapiro A.M., Bain V.G., Sigalet D.L., Kneteman N.M. Rapid resolution of chylous ascites after liver transplantation using somatostatin analog and total parenteral nutrition. Transplantation 1996;61:1410-1411.[Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Rodney C.G. Franklin Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Pratap, U. Articles by Franklin, R. C.G. Search for Related Content PubMed PubMed Citation Articles by Pratap, U. Articles by Franklin, R. C.G. Related Collections Cardiac - other