Asian Cardiovasc Thorac Ann 2005;13:222-224
© 2005 Asia Publishing EXchange Ltd
Conservative Management of Postsurgical Chylothorax with Octreotide
Abel A Gómez-Caro, MD,
Francisco J Moradiellos Diez, MD,
Carmen F Marrón, MD,
Emilio J Larrú Cabrero, PhD,
José L Martín de Nicolás, MD
Department of Thoracic Surgery. "12 de Octubre" University Hospital Madrid, Spain
For reprint information contact: Abel A Gómez-Caro, MD Tel: 34 6 2753 6654 Fax: 34 9 1390 8267 Email: abelitov{at}yahoo.es, Department of Thoracic Surgery, "12 de Octubre" University Hospital, Andalucía Ctra KM 5.400, Madrid 28004, Spain.
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ABSTRACT
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Postsurgical chylothorax after lung resection has an important associated rate of morbidity and mortality, and a large proportion of cases require re-exploration. The most desirable and least aggressive option is conservative treatment. The use of octreotide seems to be associated with a higher rate of resolution without the need for surgical intervention. We present 4 cases in which this drug showed excellent efficacy and minimal adverse effects in the resolution of postsurgical chylothorax.
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INTRODUCTION
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The incidence of chylothorax after surgical procedures is 0.5–2%,1 and is most frequently seen in corrective heart surgery for congenital malformations. Today, conservative management of this complication is the treatment of choice, at least in the first 1–2 weeks postoperatively. In addition, conservative measures are complemented by different drugs that reduce the debit of chyle production.
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CASE REPORTS
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CASE 1
A 73-year-old male was operated on for lung cancer of squamous cell type cT2N2M0 (Stage cIIIA), performing a left inferior lobectomy and standard sampling mediastinal lymphadenectomy. Over the following postoperative 24–48 hours, the drainage fluid became milky with biochemical values compatible with chylothorax. Owing to a persistent debit of > 2000 mL·day–1, oral nutrition was stopped and total parenteral nutrition (TPN) was instated. Whilst drainage over this period continued to be over 2000 mL, it became serous in appearance, and biochemical criteria of exudates and triglyceride (TG) and cholesterol (ChL) levels were within normal limits. After failure of conservative measures and the impossibility of removing chest tubes due to a high debit, octreotide, a somatostatin analog, was administered after postoperative day 5, at a dose of 0.1 mg q8h subcutaneously. From postoperative day 7, there was a significant reduction in drainage to less than 300 mL·day–1 (Figure 1
) that was maintained even after administering a specific diet for chylothorax followed by a normal diet. The thoracic drains were removed on postoperative days 8 and 9.
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Figure 1. Chest drainage during the postoperative course. The marks indicate initiation of treatment with octreotide.
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CASE 2
A 67-year-old male with aortic stenosis and ischemic heart disease underwent a left inferior lobectomy and mediastinal lymph node sampling for typical carcinoid pT2N0M0, stage pIA. On the 2nd postoperative day, 1800 mL of a milky liquid compatible with chylothorax was collected by chest tubes. Biochemical examination confirmed the diagnosis of chylothorax, (TG 465 mg·dL–1, ChL 135 mg·dL–1). TPN and subcutaneous octreotide were instated. On the 3rd postoperative day, drainage was reduced to 200 mL·day–1, the appearance of the liquid was serous and fluid (Figure 1
), and one chest tube was removed. Normal diet was instated and octreotide was stopped on the 7th postoperative day without incident.
CASE 3
A 74-year-old diabetic and hypertensive female was admitted to our department with pulmonary metastases of an endometrial carcinoma. Wedge upper left pulmonary resection was performed by video-assisted thoracic surgery (VATS). On the 2nd postoperative day right pleural effusion was detected on chest X-Ray. A milky liquid was evident on right thoracocentesis. Biochemical examination confirmed a chylothorax (TG 402 mg·dL–1, ChL 143 mg·dL–1). The only manipulation on this side had been the placing of a jugular venous line. This venous access was removed immediately and a 32F chest tube was inserted in the right side. Initially, 2300 mL of a milky liquid was evacuated. TPN and octreotide were started. Subsequently, the appearance of the drain liquid changed to serous with a debit of only 200 mL·day–1 (Figure 1). The chest tube was removed on the 6th postoperative day and a chest X-Ray revealed no evidence of pleural effusion.
CASE 4
A 21-year-old female underwent exploratory thoracotomy for desmoids tumor of the superior left outlet. During surgery, thoracic duct injury was detected and repaired. However, on the 2nd postoperative day a thick and milky liquid was drained (1300 mL) by chest tubes. TPN and octreotide were started. Progressively, the liquid became serous and fluid (Figure 1), and the debit was reduced to 150 mL·day–1 on the 5th postoperative day. Chest tubes were removed on the 6th and 7th postoperative days and X-Ray investigations were unremarkable.
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DISCUSSION
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Conservative treatment of chylothorax is well documented in the literature.1–2 Postsurgical chylothorax is common in cardiovascular surgery and specifically when the left mammary artery is used for cardiac revascularization surgery.3 In pulmonary resections for lung cancer, there is a lower incidence (around 1%) of this complication, however it is more frequent in patients with pneumonectomy and neo-adjuvant therapy.4 It is accepted that conservative treatment for chylothorax corresponds to a set of measures that must be progressive and stepped. Conservative management is usually implemented for 1–2 weeks after which surgery is indicated as the procedure of choice, regardless of the route or approach used.1 Treatment is initially pleural drainage and an HMCFA diet (a specific diet rich in medium-chain fatty acids) followed by TPN. However, TG and chylomicron levels can rise after a HMCFA diet and water alone can increase drainage by 20% in some patients. This could explain the poor resolution of chylothorax treated exclusively with an HMCFA diet.5 TPN resolves 77% of chylothorax but can cause problems associated with increased infections, thrombosis or cholestasis in the medium and long-term.2 When surgical treatment is a difficult option and the previously mentioned conservative measures have been applied without success, different drugs such as somatostatin and its analogs, have been tried.
Octreotide has a similar activity, greater selectivity and a longer half-life than somatostatin, inhibiting several hypophyseal and gastrointestinal hormones. Inhibition of serotonin and other intestinal peptides causes increased water absorption, a reduction in pancreatic-duodenal secretion and increased intestinal transit. More importantly, there is an increased resistance to splenic flow and reduced intestinal arteriolar flow that reduces lymphatic debit. Possible mechanisms of action of octreotide in the improvement of chylothorax are postulated to be decreased chyle production by reducing the intestinal absorption of fats, mainly triglycerides, and increasing fecal fat excretion. This drug is indicated in endocrine tumors, bleeding of esophageal varices in portal hypertension, and to reduce lymphatic flow in chylose ascites.5 The initial infused dose of octreotide is 0.1 mg q8h subcutaneously, the minimum recommended dose for the treatment of pancreatic fistulas, which can be increased to 0.4 mg q8h. Initially, the drug is stopped in the five days following treatment although there are no contraindications for a more prolonged treatment.
The use of both internal and external pleuroperitoneal shunts is widely accepted in the palliative treatment of resistant chylothorax.6 However, if conservative measures are unsuccessful, the definitive treatment consists of a surgical approach by thoracotomy4 or ultimately VATS.1 Any of these approaches are usually combined with pleurodesis.1,4 Use of octreotide has proven to be an effective and non-invasive approach, with a low incidence of reported adverse side effects. Treatment goals include the cessation of chyle production so as to allow enteral feeding, and the avoidance of further surgical intervention, which in cases of postpneumonectomy chylothorax can present a mortality of almost 10%.4 The combination of TPN and octreotide increases the resolution rate of chylothorax7 thereby avoiding further surgical intervention.
However, further randomized retrospective or prospective trials are required comparing standard conservative therapy versus conservative therapy with octreotide, in order to verify the real role of octreotide in the conservative treatment of chylothorax after thoracic surgery.
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REFERENCES
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- 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.[Medline]
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ABSTRACT
INTRODUCTION
