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Ann Thorac Surg 2004;77:2215-2217
© 2004 The Society of Thoracic Surgeons

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Case report

Octreotide and low-fat breast milk in postoperative chylothorax

^a Department of Pediatrics, King Abdulaziz Medical City, Al Ahsa, Saudi Arabia
^b Section of Pediatric Critical Care and Applied Physiology, Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA

Accepted for publication June 6, 2003.

^* Address reprint requests to Dr Hamdan, Department of Pediatrics, King Abdulaziz Medical City, PO Box 2477, Al Ahsa 31982, Saudi Arabia
e-mail: hamdanma{at}ngha.med.sa

	Abstract

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Chylothorax is a rare complication following cavo-pulmonary connection and can lead to significant morbidity in infants and young children. We report here the case of a 3-month-old infant who underwent bilateral cavo-pulmonary connections, and developed severe chylothorax refractory to the usual conservative and surgical treatments. His chylothorax resolved after using a combination of parenteral octreotide (Sandostatin, Novartis Pharmaceuticals, East Hanover, NJ) and low-fat breast milk.

	Introduction

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Chylothorax occurs in 0.9% to 1.5% of pediatric patients following cardiac surgery [1, 2]. It leads to fluid and electrolyte disturbances, protein-calorie malnutrition, coagulopathy, and increased susceptibility to infections [1]. Conservative management includes pleural drainage for greater than or equal to 2 to 3 weeks combined with either enteral low-fat formula, or enteric rest with total parenteral nutrition (TPN). Surgery is advocated if conservative therapy, which is not always effective and may add to the morbidity, fails.

A 3-month-old male infant was diagnosed at birth with complex cyanotic congenital heart disease consisting of: hypoplastic left ventricle and left atrioventricular valve, double outlet right ventricle, D-malposed great arteries, pulmonary obstruction, and left superior vena cava to the coronary sinus. A central aorto-pulmonary shunt was placed at 5 days of age, followed by bilateral cavo-pulmonary connections at 3 months of age, keeping the shunt patent due to desaturation. At postoperative day (POD) 6 and shortly after starting enteral feeds with breast milk (BM), he developed severe respiratory distress and was diagnosed with bilateral chylothoraces. Chest tubes were placed, and enteric rest and TPN were started (Fig 1). Catheterization done on POD 18 showed ventricular end-diastolic pressure of 5 mm Hg, mean venous pressure within the cavo-pulmonary connections of 8 mm Hg, pulmonary-to-systemic flow ratio of 2, and no anatomic obstruction. He underwent surgical ligation of his shunt and mechanical pleurodesis of both pleural spaces, but continued to have chylous drainage, resulting in weight loss (from 5.9 kg before surgery to 4.1 kg) (Fig 2), hyponatremia, hypoproteinemia, and several episodes of bacterial and fungal infections. He required multiple infusions of albumin and immunoglobulins, replacement of fluid losses, as well as multiple courses of antibiotics and antifungals. Intolerance to enteral Portagen (Mead-Johnson, Evansville, IN) precluded its use. On POD 28, octreotide (Sandostatin, Novartis Pharmaceuticals, East Hanover, NJ), a somatostatin synthetic analogue, was started at infusion rate of 0.5 µg · kg^–1 · h^–1, increasing to 1 then 2 µg · kg^–1 · h^–1 over 4 days. At 2 µg · kg^–1 · h^–1, the chylous drainage decreased from 270 mL/d to 30 mL/d over 4 days (Fig 1). By POD 37, the pleural drainage decreased to 2 to 11 mL/d, steady weight gain was achieved, and serum albumin and globulin were normalized (Fig 2). Five days after starting octreotide, enteral feeding was started using low-fat BM, prepared by fat removal following centrifugation. It was supplemented with medium-chain fatty acids, complex sugars, and protein. The pleural drainage increased dramatically on POD 37 when octreotide was interrupted transiently, where it was restarted at 20 µg/kg per day intravenously in three divided doses, decreasing the drainage (Fig 1). Octreotide was finally discontinued on POD 49, and the chest tubes were removed. No side effects were encountered during the use of octreotide.

View larger version (37K): [in this window] [in a new window]   Fig 1. Total chest tube chylous drainage in relation to the doses of octreotide used. The arrows indicate the time when each of the feeding methods was started. (LFBM = low-fat breast milk; NPO = nothing by mouth; TPN = total parenteral nutrition.)

View larger version (44K): [in this window] [in a new window]   Fig 2. Trends of weight, serum albumin, and globulin in relation to the doses of octreotide used and the type of feeding. The arrows indicate the time when each of the feeding methods was started. (LFBM = low-fat breast milk; NPO = nothing by mouth; TPN = total parenteral nutrition.)

	Comment

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Chylothorax can occur after cavo-pulmonary connection secondary to central venous hypertension, venous thrombosis, or direct trauma to the lymphatic vessels or the thoracic duct [1, 3]. Chyle is formed from lymphatic fluid enriched with fat secreted by intestinal cells [4], and is transported through the thoracic duct into the venous circulation. Surgical treatment is advocated after either excessive (> 10 mL/kg/d or > 100 mL/yr of age), or prolonged ( > 3 to 4 weeks) drainage [1, 3, 4]. Surgical options include pleurodesis, ligation of the thoracic duct and adjacent lymphatic vessels, or pleuro-peritoneal shunts [4]. Somatostatin has been recently used in 3 case reports in the treatment of postoperative and traumatic chylothorax [5–7]. The mechanism of action is not exactly known, but is thought to be through the inhibition of pituitary and gastrointestinal hormone release and the reduction in gastrointestinal blood flow and hepatic venous pressure. Portagen and other low-fat and medium-chain triglyceride (MCT) -enriched formulas have been used to feed infants with chylothorax [2]. Contrary to the long-chain triglycerides, MCT is transported directly into the portal system, bypassing the lymphatic pathways and thus diminishing lymph flow through the thoracic duct [2]. Analysis of the prepared BM showed only 0.02% of fat, compared to 3.5% in the regular human milk, and 3.1% in Portagen. The fat content in Portagen is 85% MCT, and 15% corn oil (which is composed of unsaturated and long-chain fatty acids). Thus, low-fat BM could be used as an alternate to Portagen and other similar formulas. Octreotide can minimize the complications of postoperative chylothorax in infants, and low-fat BM can be used as another mode of enteral nutritional support.

	Acknowledgments

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This case report was written in compliance with the regulations of the Human Investigation Committee at Yale University School of Medicine. Data regarding the patient's clinical status were collected by chart review. The patient's confidentiality was maintained during data collection and manuscript preparation.

	References

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1. Nguyen D.M., Shum-Tim D., Dobell A.R., Tchervenkov C.I. The management of chylothorax/chylopericardium following pediatric cardiac surgery: a 10-year experience. J Card Surg 1995;10:302-308.[Medline]
2. Allen E.M., van Heeckeren D.W., Spector M.L., Blumer J.L. Management of nutritional and infectious complications of postoperative chylothorax in children. J Pediatr Surg 1991;26:1169-1174.[Medline]
3. Beghetti M., La Scala G., Belli D., Bugmann P., Kalangos A., Le Coultre C. Etiology and management of pediatric chylothorax. J Pediatr 2000;136:653-658.[Medline]
4. Buttiker V., Fanconi S., Burger R. Chylothorax in children: guidelines for diagnosis and management. Chest 1999;116:682-687.[Abstract/Free Full Text]
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. Kelly R.F., Shumway S.J. Conservative management of postoperative chylothorax using somatostatin. Ann Thorac Surg 2000;69:1944-1945.[Abstract/Free Full Text]
7. Ulibarri J.I., Sanz Y., Fuentes C., Mancha A., Aramendia M., Sanchez S. Reduction of lymphorrhagia from ruptured thoracic duct by somatostatin. Lancet 1990;336:258.

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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 Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Hamdan, M. A. Articles by Gaeta, M. L. Search for Related Content PubMed PubMed Citation Articles by Hamdan, M. A. Articles by Gaeta, M. L. Related Collections Pleura