Management of refractory chylothorax in the neonatal intensive care unit: A 22‐year experience

Abstract

Background The aim was to assess the therapeutic strategy of patients with chylothorax in a neonatal intensive care unit. Methods Twenty‐eight infants with chylothorax were included in this study. Their clinical characteristics and outcomes were reviewed retrospectively. Results The male‐to‐female ratio was 1:1. The mean gestational age and birthweight were 35.1 ± 3.5 weeks and 2,692 ± 791 g, respectively. Eighteen patients were diagnosed with congenital chylothorax; chylothorax occurred postoperatively in 10 patients. Chromosomal anomalies were diagnosed in 8 patients. Six patients received surgical therapy, such as pleurodesis, thoracic duct ligation, or lymphaticovenous anastomosis. Two patients required surgery due to resistance to pleurodesis. In surgically managed patients, the daily maximum amount of pleural effusion (mL)/bodyweight (kg) ratio was significantly larger than in non‐surgically managed patients: 229.0 ± 180.5 versus 59.7 ± 49.2 mL/kg. In the receiver operating characteristic analysis of the daily maximum amount of pleural effusion/bodyweight ratio, the area under the curve was 0.889 when the cut‐off value was 101 mL/kg, and the sensitivity was 0.8333 and the specificity was 0.8095 (P = 0.0059). Conclusions Pleurodesis using OK432 could become a surgical first‐line therapy for chylothorax even for neonates. It was important to initiate pleurodesis for refractory chylothorax at an earlier stage. A daily chylous effusion/bodyweight ratio of >101 mL/kg was a good predictor and seemed to be a useful parameter for prompt surgical intervention.

The usefulness of OK-432 for the treatment of postoperative chylothorax in a low-birth-weight infant with trisomy 18

“…However, there are no definite guidelines about which treatment is the most useful for persistent chylothorax. Some authors have suggested that surgical intervention may be necessary in cases with massive or persistent pleural drainage 6,7) . However, surgery such as pleuroperitoneal shunting, thoracic duct ligation, and lymphaticovenous anastomosis, should be performed only when conservative treatments fail, as such approaches are highly invasive in children.…”

“…It causes pleurodesis by inducing a strong cellular and cytokine-mediated inflammatory response and has been widely used to treat macrocystic lymphatic malformations in children 10) . Although the successful treatment of neonatal and prenatal chylothorax by intrapleural instillation of OK-432 has been reported 3,5,7) , there are only a few reports in neonates with chylothorax, with reports concerning such patients with chromosomal abnormalities being even rarer. Furthermore, there have been no reports concerning the efficacy of pleurodesis using OK-432 for high-risk patients, such as a low-birth-weight infant with 18 trisomy.…”

The usefulness of OK‐432 for the treatment of postoperative chylothorax in a low‐birth‐weight infant with trisomy 18

“…9 It causes pleurodesis by inducing a strong cellular and cytokinemediated inflammatory response and has been widely used to treat macrocystic lymphatic malformations in children. 10 Although the successful treatment of neonatal and prenatal chylothorax by intrapleural instillation of OK-432 has been reported, 3,5,7 there are only a few reports in neonates with chylothorax, with reports concerning such patients with chromosomal abnormalities being even rarer. Furthermore, there have been no reports concerning the efficacy of pleurodesis using OK-432 for high-risk patients, such as a low-birth-weight infant with 18 trisomy.…”

“…However, there are no definite guidelines about which treatment is the most useful for persistent chylothorax. Some authors have suggested that surgical intervention may be necessary in cases with massive or persistent pleural drainage 6,7 . However, surgery such as pleuroperitoneal shunting, thoracic duct ligation, and lymphaticovenous anastomosis, should be performed only when conservative treatments fail, as such approaches are highly invasive in children.…”

“…Some authors have suggested that surgical intervention may be necessary in cases with massive or persistent pleural drainage. 6,7 However, surgery such as pleuroperitoneal shunting, thoracic duct ligation, and lymphaticovenous anastomosis, should be performed only when conservative treatments fail, as such approaches are highly invasive in children. Pharmacologic or chemical pleurodesis has also been suggested as a possible alternative step before surgery in pediatric patients, with instillation of various agents (OK-432, bleomycin, tetracycline, and povidoneiodine) in the pleural space.…”