Medical Treatment Approach in Children with Chylothorax After Congenital Heart Surgery

Year 2023, Volume: 20 Issue: 2, 232 - 237, 31.08.2023

Onur Doyurgan , Osman Akdeniz , Yiğit Kılıç , Ahmet Kuddusi İrdem , Eşe Eda Turanlı , Rezzan Ezgi Ekin , Süleyman Geter , Mehmet Nur Talay

https://doi.org/10.35440/hutfd.1254212

Abstract

Background: Chylothorax following congenital heart surgery is a potentially serious complication that requi-res early diagnosis and treatment. The aim of this study is to review our experience with the treatment of chylothorax occurring in the early period after congenital heart surgery.
Materials and Methods: The records of patients who developed postoperative chylothorax among 1215 patients who underwent surgery for congenital heart disease in our hospital between March 2017 and February 2023 were retrospectively reviewed.
Results: Seventeen patients, 11 of whom were male, who developed postoperative chylothorax were inclu-ded in the study. The median age was 7.5 months, and the median body weight was 6.4 kilograms. Surgical procedures were aortic coarctation repair (five), Glenn operation (four), Tetralogy of Fallot repair (two), Fontan operation (one), atrioventricular canal defect repair (one), ventricular septal defect closure (one), vascular ring repair (one), patent ductus arteriosus ligation (one), and right modified Blalock-Taussig shunt in one patient. The median amount of lymphatic drainage was 4.6 ml/kg/day (2.3 to 8.1 ml/kg/day) and the median lymphatic drainage time was 16.5 days (5 to 38 days). After the chylous fluid drained, total parenteral nutrition and enteral medium-chain triglyceride diet were given. Octreotide was used additionally in 82.4% of the patients. After the chylous fluid drainage stopped, the patients were given a medium chain triglyceri-de diet for 6 weeks. One patient died due to sepsis.
Conclusions: Chylothorax is a complication that causes morbidity after cardiac surgery. Morbidity can be reduced if a correct algorithm determined by the clinic is followed.

Key Words: Chylothorax, Congenital heart defects, Heart surgery, Postoperative period

Konjenital Kalp Cerrahisi Sonrasında Şilotoraks Meydana Gelen Çocuklarda Medikal Tedavi Yaklaşımı

Abstract

Amaç: Konjenital kalp cerrahisini takiben görülen şilotoraks erken tanı ve tedavi gerektiren potansiyel olarak ciddi bir komplikasyondur. Bu çalışmanın amacı konjenital kalp cerrahisi sonrası erken dönemde ortaya çıkan şilotoraks tedavisi ile ilgili deneyimlerimizi gözden geçirmektir.
Materyal ve metod: Hastanemizde Mart 2017-Şubat 2023 tarihleri arasında konjenital kalp hastalığı nede-niyle ameliyat yapılan 1215 hastadan postoperatif şilotoraks gelişen hastaların kayıtları retrospektif olarak incelendi.
Bulgular: Çalışmaya postoperatif şilotoraks gelişen 11’i erkek 17 hasta dahil edildi. Ortanca yaş 7.5 ay, ortanca vücut ağırlığı 6.4 kilogram olarak saptandı. Cerrahi prosedürler aort koarktasyonu tamiri (beş), Glenn operas-yonu (dört), Fallot tetralojisi tamiri (iki), Fontan operasyonu (bir), atriyoventriküler kanal defekti tamiri (bir), ventriküler septal defekt kapatılması (bir), vasküler ring tamiri (bir), patent duktus arteriyozus ligasyonu (bir) ve bir hastada sağ modifiye Blalock-Taussig şantı idi. Lenfatik drenaj miktarı ortanca 4.6 ml/kg/gün (2.3 ile 8.1 ml/kg/gün) ve lenfatik drenaj süresi ortanca 16.5 gün (5 ile 38 gün) arasındaydı. Şilöz sıvının boşaltılmasının ardından total parenteral nutrisyon ve enteral orta zincirli trigliserid diyeti verildi. On dört (%82.4) hastada ek olarak ‘oktreotid’ kullanıldı. Şilöz sıvı drenajının sona ermesini takiben hastalara 6 hafta orta zincirli trigliserid diyeti verildi. Bir hasta sepsis nedeniyle kaybedildi.
Sonuç: Şilotoraks kalp cerrahisi sonrasında morbiditeye neden olan bir komplikasyondur. Kliniğin belirlediği doğru bir algoritma izlendiğinde morbidite azaltılabilir.

Keywords

şilotoraks, doğumsal kalp kusurları, kalp cerrahisi, postoperatif dönem

References

• .Lin CH, Lin WC, Changd JS. Presentations and management of different causes of chylothorax in children: one medical center’s experience. BioMedicine. 2017;7:30-4. doi: 10.1051/bmdcn/2017070105.
• Büttiker V, Fanconi S, Burger R. Chylothorax in children: guidelines for diagnosis and management. Chest. 1999;116:682-7. doi: 10.1378/chest.116.3.682.
• 3. 3.Agrawal V, Doelken P, Sahn SA. Pleural fluid analysis in chylous pleural effusion. Chest. 2008;133:1436-41. doi: 10.1378/chest.07-2232.
• 4. 4.Milsom JW, Kron IL, Rheuban KS, Rodgers BM. Chylothorax: an assessment of current surgical management. J Thorac Car-diovasc Surg. 1985;89:221-7.
• 5. 5.Milonakis M, Chatzis AC, Giannopoulos NM, et al. Etiology and management of chylothorax following pediatric heart surgery. J Card Surg. 2009;24:369-73. doi: 10.1111/j.1540-8191.2008.00781.x.
• 6. 6.Panthongviriyakul C, Bines JE. Post-operative chylothorax in children: an evidence-based management algorithm. J Paedi-atr Child Health. 2008;44:716-21. doi: 10.1111/j.1440-1754.2008.01412.x.
• 7. 7.Chan EH, Russell JL, Williams WG, Van Arsdell GS, Coles JG, McCrindle BW. Postoperative chylothorax after cardiothora-cic surgery in children. Ann Thorac Surg. 2005;80:1864-70. doi: 10.1016/j.athoracsur.2005.04.048.
• 8. 8.Cannizzaro V, Frey B, Bernet-Buettiker V. The role of soma-tostatin in the treatment of persistent chylothorax in child-ren. Eur J Cardiothorac Surg. 2006;30:49-53. doi: 10.1016/j.ejcts.2006.03.039.
• 9. 9.Le Coultre C, Oberhansli I, Mossaz A, Bugmann P, Faidutti B, Belli DC. Postoperative chylothorax in children: differences between vascular and traumatic origin. J Pediatr Surg. 1991;26:519-23.
• 10. 10.Mery CM, Moffett BS, Khan MS, et al. Incidence and tre-atment of chylothorax after cardiac surgery in children: analy-sis of a large multi-institution database. J Thorac Cardiovasc Surg. 2014;147:678-86. doi: 10.1016/j.jtcvs.2013.09.068.
• 11. 11.Chan SY, Lau W, Wong WHS, Cheng LC, Chau AKT, Cheung YF. Chylothorax in children after congenital heart surgery. Ann Thorac Surg. 2006;85:1650-6. doi:10.1016/j.athoracsur.2006.05.116.
• 12. 12.Ismail SR, Kabbani MS, Najm HK, Shaath GA, Jijeh AMZ, Hijazi OM. Impact of chylothorax on the early post operative outcome after pediatric cardiovascular surgery. J Saudi Heart Assoc. 2014;26:87-92. doi: 10.1016/j.jsha.2014.01.001.
• 13. 13.Yıldız O, Öztürk E, Altın HF, et al. Chylothorax following pediatric cardiac surgery. Turk Gogus Kalp Dama. 2015;23:434-40. doi: 10.5606/tgkdc.dergisi.2015.10912.
• 14. 14.Goens MB, Campbell D, Wiggins JW. Spontaneous chylothorax in Noonan syndrome. Treatment with predniso-ne. Am J Dis Child. 1992;146:1453-6. doi: 10.1001/archpedi.1992.02160240063021.
• 15. 15.Brown KL, Ridout DA, Goldman AP, Hoskote A, Penny DJ. Risk factors for long intensive care unit stay after cardiopul-monary bypass in children. Crit Care Med. 2003;31:28-33. doi: 10.1097/00003246-200301000-00004.
• 16. 16.Allen EM, van Heeckeren DW, Spector ML, Blumer JL. Management of nutritional and infectious complications of postoperative chylothorax in children. J Pediatr Surg. 1991;26:1169-74. doi: 10.1016/0022-3468(91)90325-n.
• 17. 17.Medoff-Cooper B, Naim M, Torowicz D, Mott A. Feeding, growth, and nutrition in children with congenitally malformed hearts. Cardiol Young. 2010;20:149-53. doi: 10.1017/S1047951110001228.
• 18. 18.McWilliams BC, Fan LL, Murphy SA. Transient T-cell dep-ression in postoperative chylothorax. J Pediatr. 1981;99:595-7. doi: 10.1016/s0022-3476(81)80267-3.
• 19. 19.Işık O, Akyüz M, Ayık MF, Atay Y. Current management for diagnosis and treatment of chylothorax after congenital heart surgery. Ege Tıp Dergisi. 2016;55:46-9.
• 20. 20.Cormack BE, Wilson NJ, Finucane K, West TM. Use of monogen for pediatric postoperative chylothorax. Ann Tho-rac Surg. 2004;77:301-5. doi: 10.1016/s0003-4975(03)01189-5.
• 21. 21.Biewer ES, Zürn C, Arnold R, et al. Chylothorax after sur-gery on congenital heart disease in newborns and infants-risk factors and efficacy of MCT-diet. J Cardiothorac Surg. 2010;5:127. doi: 10.1186/1749-8090-5-127.
• 22. 22.Rosti L, De Battisti F, Butera G, et al. Octreotide in the management of postoperative chylothorax. Pediatr Cardiol. 2005;26:440-3. doi: 10.1007/s00246-004-0820-4.
• 23. 23.Bac DJ, Van Hagen PM, Postema PT, ten Bokum AM, Zon-dervan PE, van Blankenstein M. Octreotide for protein-losing enteropathy with intestinal lymphangiectasia. Lancet. 1995;345:1639. doi: 10.1016/s0140-6736(95)90145-0.
• 24. 24.Grosman I, Simon D. Potential gastrointestinal uses of somatostatin and its synthetic analogue octreotide. Am J Gastroenterol. 1990;85:1061-72.
• 25. 25.Caverly L, Rausch CM, da Cruz E, Kaufman J. Octreotide treatment of chylothorax in pediatric patients following car-diothoracic surgery. Congenit Heart Dis. 2010;5:573-8. doi: 10.1111/j.1747-0803.2010.00464.x.
• 26. 26.Das A, Shah PS. Octreotide for the treatment of chylotho-rax in neonates. Cochrane Database Syst Rev. 2010;8:CD006388. doi: 10.1002/14651858.CD006388.pub2.
• 27. 27.Lim KA, Kim SH, Huh J, et al. Somatostatin for postoperati-ve chylothorax after surgery for children with congenital he-art disease. J Korean Med Sci. 2005;20:947-51. doi: 10.3346/jkms.2005.20.6.947.
• 28. 28.Nguyen DM, Shum-Tim D, Dobell AR, Tchervenkov CI. The management of chylothorax/chylopericardium following pe-diatric cardiac surgery: a 10-year experience. J Card Surg. 1995;10:302-8. doi: 10.1111/j.1540-8191.1995.tb00616.x.
• 29. 29.Nath DS, Savla J, Khemani RG, Nussbaum DP, Greene CL, Wells WJ. Thoracic duct ligation for persistent chylothorax af-ter pediatric cardiothoracic surgery. Ann Thorac Surg. 2009;88:246-51. doi: 10.1016/j.athoracsur.2009.03.083.
• 30. 30.Pego-Fernandes PM, Nascimbem MB, Ranzani OT, Shimo-da MS, Monteiro R, Jatene FB. Video-assisted thoracoscopy as an option in the surgical treatment of chylothorax after cardiac surgery in children. J Bras Pneumol. 2011;37:28-35. doi: 10.1590/s1806-37132011000100006.