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Ann Thorac Surg 2003;76:340-341
© 2003 The Society of Thoracic Surgeons
a Department of Cardiovascular Surgery, Kokura Memorial Hospital, 1-1 Kifune-cho, Kokurakita-ku, Kitakyushu-shi, Fukuoka 802-8555 Japan
* Department of Cardiovascular Surgery, Kokura Memorial Hospital, 1-1 Kifune-cho, Kokurakita-ku, Kitakyushu-shi, Fukuoka 802-8555 Japan.
e-mail: tmatsu{at}xa3.so-net.ne.jp
To the Editor:
We read with special interest the case report by Pettitt and colleagues [1]. In their treatment of persistent postoperative chylothorax after surgery for congenital heart disease, they used an intravenous infusion of somatostatin in the neonate. Subsequently, the patient’s chest tube drainage stopped without significant adverse effects. We would like to add a few comments on some aspects of their case report.
The authors mentioned that their patient showed no apparent adverse effects except for some transient cutaneous flushing. However, they also documented an elevation of liver function tests with vomiting in 1 patient, and flu-like symptoms in another patient. Fortunately, the side effects in their cases were not fatal. Unfortunately, we have experienced significant complications associated with the use of somatostatin.
Our patient had asplenia syndrome with total anomalous pulmonary venous connection (TAPVC) and underwent repair of the TAPVC and pulmonary artery banding at 1 month of age. As her cyanosis recurred, she underwent a total cavo-pulmonary shunt at 18 months. Excessive chest tube drainage persisted 3 weeks after this operation. On postoperative day 22, we initiated intravenous injections of 25 µg (5 µg/kg) of somatostatin every 12 hours. Within the next 3 days, chest tube drainage decreased drastically, as mentioned by Rimensberger and colleagues [2]. Because the chest tube drainage decreased to less than 4 mL/kg/day over 2 days, we withdrew the somatostatin injection and removed her chest tube. However, our patient developed a strangulation ileus caused by malrotation of the gut and a volvulus of the small intestine 6 days after initiation of somatostatin. Phoon and Neill [3] reported that 9% of patients with asplenia syndrome have malrotation of the gut and that the frequency of total heterotaxy is 72%. Because somatostatin inhibits serotonin and other gastrointestinal peptides, this results in increased intestinal absorption of water, decreased pancreatic and gastric acid, and increased intestinal transit time. Consequently, splanchnic arteriolar resistance is increased and gastrointestinal blood flow is decreased [4]. Thus, although somatostatin reduced lymph flow and chest tube output, it also caused a strangulation of the ileus in our case. An emergency operation to repair the ileus was performed by a general surgeon, and the patient was discharged from hospital. She is now 2 years old and is gaining weight appropriately.
Thus, we agree with the authors that somatostatin should be considered as a useful adjunct to conventional therapy for postoperative chylothorax after cardiac operation in neonates and infants, because surgical interventions like thoracic duct ligation, pleurodesis, and pleuroperitoneal shunt will not necessarily resolve the problem. However, we believe that special care should be taken to avoid significant complications, such as a strangulation ileus, when using somatostatin infusion in patients with asplenia syndrome associated with visceral abnormalities.
References
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