Yenidoğanda Şilotoraks Tanı ve Tedavisinde Güncel Yaklaşımlar

Year 2017, Volume: 11 Issue: 1, 76 - 81, 01.04.2017

Mehmet Büyüktiryaki Nilüfer Okur Nurdan Uraş Şerife Suna Oğuz

Abstract

Şilotoraks plevral aralıkta lenfatik sıvı birikmesi olarak tanımlanır, konjenital ve akkiz nedenlerle ortaya çıkar. Konjenital şilotoraksın etiyolojisi tam anlaşılamamış olmakla birlikte, lenfatik sistemin gelişimsel bozukluğu sonucu olduğu düşünülmektedir. Konjenital şilotoraks sıklıkla hidrops fetalisle birlikte görülür. Tanı plevral sıvıda trigliserit düzeyinin 110 mg/dl ve total hücre sayısının 1000/ml’nin üstünde olması, %80’den fazla lenfosit içermesi ile konulur. Şilotoraksta klinik durumun şiddetini şilöz mayi miktarı belirler. Bazı bebekler asemptomatik veya hafif solunum sıkıntısı ile klinik bulgu verirken, çoğu olguda tedavi edilmezse potansiyel yaşamı tehdit eden solunum sıkıntısı ile bulgu verir. Şilotoraks tedavisinde konservatif ve cerrahi yöntemler kullanılmaktadır. Konservatif yaklaşım altta yatan hastalığın tedavisi, tekrarlanan torasentez veya toraks tüpü ile sürekli drenaj, enteral beslenmeye ara verilerek total parenteral nutrisyon uygulanması ve orta zincirli trigliseritleri içeren diyet uygulanmasını içerir. Bu yöntemlere yanıt alınamazsa oktreotid kullanılması önerilmektedir. Konservatif tedavi başarısızlığını tanımlamak için kullanılan iki parametre devam eden lenfatik drenajın süresi ve hacmidir. Oktreotid tedavisinin yanıtsız olduğu durumlarda kimyasal plörodezis ve cerrahi tedavi denenmelidir. Cerrahi tedavi yaklaşımları torakoskopik plörodezis, cerrahi abrazyon, pleuroperitoneal şant uygulanması, torasik duktus ligasyonunu içerir. Şilotoraksta prognoz altta yatan etiyolojiye göre değişir. Uygun tedavi ile konjenital şilotoraksın prognozu genellikle iyi seyreder. Bununla beraber eşlik eden pulmoner hipoplazinin derecesi, prematürite ve hidropsun varlığı mortaliteyi artıran nedenler olarak bildirilmektedir.

Keywords

Oktreotid, Şilotoraks, Yenidoğan

Current Diagnostic and Treatment Approaches in Neonatal Chylothorax

Abstract

Chylothorax is defined as the accumulation of lymphatic fluid in the pleural cavity. It results from congenital and acquired causes. Although the etiology of congenital chylothorax is not fully understood, it has been suggested to be a developmental disorder of the lymphatic system. Congenital chylothorax is often accompanied by hydrops fetalis. The diagnosis is made by measurement of the triglyceride level in fluid above 110 mg/dl and total cell count above 1000/ml with 80% lymphocyte. The severity of the clinical condition in chylothorax is determined by the amount of accumulated chylous fluid. Whilst some newborns are asymptomatic or have mild respiratory distress as a clinical symptom, the majority of the cases, if not treated, present with potentially life-threatening respiratory distress. Conservative and surgical methods are used in the treatment of chylothorax. Conservative therapy includes the treatment of the underlying disease, continuous drainage through repeated thoracentesis or thoracic tube, total parenteral nutrition following the suspension of enteral nutrition, and a diet containing medium chain triglycerides. Octreotide use is offered if there is no response to these methods. The two parameters used to define failure of conservative therapy are the duration and the volume of the continuing lymphatic drainage. In cases where octreotide therapy fails, chemical pleurodesis and surgical treatment should be tried. Surgical treatment includes thoracoscopic pleurodesis, surgical abrasion, pleuroperitoneal shunt placement, and thoracic ductus ligation. The prognosis of chylothorax varies depending on the underlying etiology. The prognosis of chylothorax is generally good with appropriate treatment. Nonetheless, the severity of accompanying pulmonary hypoplasia, and presence of prematurity and hydrops have been reported to be among the factors increasing mortality rate

Keywords

Octreotide, Chylothorax, Newborn

References

• Dubin PJ, Kind IN, Gallagher PG. Congenital chylothorax. Curr Opin Pediatr 2000;12:505-9.
• Schmid G, Fahnenstich H, Redel D, Gembruch U, Niesen M, Kowalewski S. Nonimmunologic hydrops fetalis-a review of 31 cases. Klin Padiatr 1988; 200:287-93.
• Das A, Shah PS. Octreotide for the treatment of chylothorax in neonates. Cochrane Database Syst Rev 2010; 9:CD006388.
• Soto-Martinez M, Massie J. Chylothorax: Diagnosis and management in children. Paediatr Respir Rev 2009;10:199-207.
• Ozkan H, Ay N, Ozaksoy D, Ercal D, Erata Y, Durak H, et al. Congenital chylothorax. Turk J Pediatr 1996;38:113-7.
• Au M, Weber TR, Fleming RE. Successful use of somatostatin in a case of neonatal chylothorax. J Pediatr Surg 2003;38:1106-7.
• Tutor JD. Chylothorax in infants and children. Pediatrics 2014;133:722-33.
• Paget-Brown A, Kattwinkel J, Rodgers BM, Michalsky MP. The use of octreotide to treat congenital chylothorax. J Pediatr Surg 2006;41:845-7.
• Eddiernan KA, Levine AB, Chitkara U, Berkowitz RL. Reliability of pleural fluid lymphocyte counts in the antenatal diagnosis of congenital chylothorax. Obstet Gynecol 1991;178:530-2.
• Bellini C, Ergaz Z, Boccardo F, Bellini T, Campisi CC, Bonioli E, et al. Dynamics of pleural effusion and chylothorax in the fetus and newborn: Role of the lymphatic system. Lymphology 2013;46:75- 84.
• Van Aerde J, Campbell AN, Smyth JA. Spontaneous chylothorax in newborn. Am J Dis Child 1984;138:961-4.
• Caserío S, Gallego C, Martin P, Moral MT, Pallás CR, Galindo A. Congenital chylothorax: From foetal life to adolescence. Acta Paediatr 2010;99:1571-7.
• Rocha G. Pleural effusions in the neonate. Curr Opin Pulm Med 2007;13:305-11.
• Lee CJ, Tsao PN, Chen CY, Hsieh WS, Liou JY, Chou HC. Prenatal therapy improves the survival of premature infants with congenital chylothorax. Pediatr Neonatol 2015;15:113-8.
• Büttiker V, Fanconi S, Burger R. Chylothorax in children: Guidelines for diagnosis and management. Chest 1999;116:682-7.
• Beghetti M, La Scala G, Belli D, Bugmann P, Kalangos A, Le Coultre C. Etiology and management of pediatric chylothorax. J Pediatr 2000;136:653-8.
• Kim JE, Lee C, Park KI, Park MS, Namgung R, Park IK. Successful pleurodesis with OK-432 in preterm infants with persistent pleural effusion. Korean J Pediatr 2012;55:177-80.
• Tansel T, Sayin OA, Ugurlucan M, Dayioglu E, Onursal E. Successful bleomycin pleurodesis in a patient with prolonged pleural effusion after extracardiac fontan procedure. J Card Surg 2006;21:585-6.
• Mitanchez D, Walter-Nicolet E, Salomon R, Bavoux F, Hubert P. Congenital chylothorax: What is the best strategy? Arch Dis Child Fetal Neonatal Ed 2006;91:153-4.
• Cohan RH, Saeed M, Schwab SJ, Perlmutt LM, Dunnick NR. Povidone–iodine sclerosis of pelvic lymphoceles: A prospective study. Urol Radiol 1988;10:203-6.
• Wolff AB, Silen ML, Kokoska ER, Rodgers BM. Treatment of refractory chylothorax with externalized pleuroperitoneal shunts in children. Ann Thorac Surg 1999;68:1053-7.
• Murphy MC, Newman BM, Rogers BM. Pleuroperitoneal shunts in the management of persistent chylothorax. Ann Thorac Surg 1989;48:195-200.
• Nath DS, Savla J, Khemani RG, Nussbaum DP, Greene CL, Wells WJ. Thoracic duct ligation for persistent chylothorax after pediatric cardiothoracic surgery. Ann Thorac Surg 2009;88:246-51.
• Pego-Fernandes PM, Nascimbem MB, Ranzani OT, Shimoda 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.
• Engum SA, Rescorla FJ, West KW, Scherer LR 3, Grosfeld JL. The use of pleuroperitoneal shunts in the management of persistent chylothorax in infants. J Pediatr Surg 1999;34: 286 -90.
• Allen EM, van Heeckeren DW, Spector ML, Blumer JL. Manage- ment of nutritional and infectious complications of postoperative chylothorax in children. J Pediatr Surg 1991; 26:1169-74.
• Bond SJ, Guzzetta PC, Snyder ML, Randolph JG. Manage- ment of pediatric postoperative chylothorax. Ann Thorac Surg 1993;56:469-72.
• Bulbul A, Okan F, Nuhoglu A. Idiopathic congenital chylothorax presented with severe hydrops and treated with octreotide in term newborn. J Matern Fetal Neonatal Med 2009;22:1197-200.