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CASE REPORT
Year : 2007  |  Volume : 12  |  Issue : 2  |  Page : 96-98
 

Nontraumatic chylothorax: Revisited


Department of Pediatric Surgery, Orange City Hospital and Research Institute, Nagpur, India

Correspondence Address:
Debasish B Banerjee
2nd floor, Rajkamal Complex, Panchsheel Chowk, Dhantoli, Nagpur - 440 012, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9261.33234

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   Abstract 

A 2-month-old girl came with breathlessness of 5 days' duration. Clinical examination and plain chest radiograph showed it to be pleural effusion. On sonographically guided aspiration, the effusion fluid was found to be chyle.
Introduction of intercostal thoracic drainage tube and antibiotics helped the baby to recover. It is mainly the role of nutritional support in the form of using medium-chain-triglyceride-containing feed, which is discussed in details in the case report. There was no need of any surgery.


Keywords: Chyle, chylothorax, medium-chain-triglycerides


How to cite this article:
Banerjee DB. Nontraumatic chylothorax: Revisited. J Indian Assoc Pediatr Surg 2007;12:96-8

How to cite this URL:
Banerjee DB. Nontraumatic chylothorax: Revisited. J Indian Assoc Pediatr Surg [serial online] 2007 [cited 2019 Nov 21];12:96-8. Available from: http://www.jiaps.com/text.asp?2007/12/2/96/33234



   Introduction Top


Chylothorax is rare, more so if there is no history of thoracic surgery or trauma. Its successful management by conservative method, i.e., nutritional support using oral medium-chain-triglycerides (MCT) and chest tube drainage, is discussed by an illustrative case report of a 2-month-old baby. The article also comments upon the indications of surgical intervention.


   Case Report Top


A 2-month-old girl of weight 5 kg was referred to us for breathlessness of 5 days' duration. On clinical examination, the baby had dullness on percussion on right side of the chest and reduced air entry. Plain chest radiograph confirmed it to be right-sided pleural effusion.

With sonographic guidance, needle aspiration was done revealing milky-white odorless fluid. Fluid was examined and found to be sterile, with a cell count of 1,200 cells/µl with predominance (92%) of lymphocytes - all these being characteristic of chyle. Under local anesthesia, a no. 12 Portex intercostal thoracic drainage tube was introduced and anchored to the chest wall. About 100-125 ml/day of the fluid was drained through the tube for 7 days, gradually reducing down and stopping completely on the 11 th day. Plain chest radiograph did not show any residual fluid. This was confirmed by spiral computed tomography of the chest, which also showed features of pan-alveolo-bronchitis. The tube was removed on the 12 th day.

During this period, the baby was maintained on nasal oxygen support, intravenous fluids, antibiotics, plasma concentrates and multivitamin infusion. Breast feeding was completely stopped; top feeding prepared using SIMYL-MCT powder was given.

The baby recovered well and was off supplemented oxygen on the 26 th day. Repeat plain chest X-ray films did not reveal any fluid collection again and showed complete lung expansion. Baby was discharged home on feedings made with SIMYL-MCT and advised to keep regular follow-up.


   Discussion Top


Chylothorax can be managed conservatively, i.e., non-operatively, which if failed would require surgery.

Lampson [1] demonstrated the bacteriostatic quality of chyle that seems to account for the rarity of chylothorax complicated by empyema. However, the presence of chyle causes a gross pleural reaction which becomes greatly thickened and covered by exudates. [2] This can lead to loss of chest wall and lung parenchymal function. [2] These factors make the patient prone to sepsis; hence there is need for antibiotics. [3],[4]

Non-operative approach

Chyle being rich in fat content, persistent chylothorax leads to progressive nutritional depletion. Hence, nutritional support forms a major part of the management of chylothorax. [5] Since the amount of chyle produced daily depends mainly on the fat content of the food, the rate of accumulation of chylothorax can be controlled by dietary measures. Hott [6] demonstrated that feedings restricted to MCT result in minimal lymph flow in the thoracic duct. This is because MCT travel directly to the liver via the portal vein and not through the lymphatic system. [7] The decrease in the lymph flow through the thoracic duct on using MCT diet may be as much as tenfold. [8] This was our rationale of using SIMYL-MCT for the feeds.

MCT provides 8.3 kcal per gm and 116 kcal per tablespoon. [7] The feeding regime in a given patient will depend upon the amount of prescribed calorie intake, which depends upon his/her body weight. The total calorie intake should be above the average requirement so as to promote positive anabolic response.

Feeding regime [7]

Precautions: MCT should be introduced slowly into the diet, i.e., at a slow rate, to avoid abdominal distension, pain, nausea, vomiting and/or diarrhea. To incorporate MCT into the diet, add 1 tsp MCT oil to 4 oz fat-free milk / fruit juices.

Total parental nutrition (TPN) was found to be more effective than oral MCT in the treatment of spontaneous / congenital chylothorax by Fernandez et al. [9] Jalili [10] suggests that if chylothorax persists even after initially being given an MCT-enriched formula feed, TPN should be started. Similar step-by-step approach has been advocated by Le Coultre et al. [11]

Role of surgery

In view of repeated refilling and compression of the lung, thoracotomy tube drainage is better than repeated thoracentesis. [12]

With these conservative measures, chylothorax usually ceases. The time taken may be a few days to a few weeks - 10 days in our case. Conservative management has been found to fail in patients with high central venous pressures, as in cases of thrombosis of the superior vena cava. Milson et al. [13] were required to perform a surgical procedure in most of their patients - 19 of 20. Persistence of chyle flow for more than 4 weeks [5],[11],[14],[15] associated especially with difficulty to maintain lung inflation and pulmonary function merits surgical intervention.

The first successful intrathoracic ligation of thoracic duct was reported by Lampson [1] in 1946 in traumatic chylothorax, and Randoff and Gross [16] in 1957 in congenital chylothorax. Aziz Khan et al. [17] first used pleuroperitoneal shunt for persistent chylothorax, which was found to have 75% success rate by Murphy et al. [18] Use of talc, Kaolin, tetracycline or fibrin glue for pleurodesis has also been found to be successful. [19]

Marts et al. [20] strongly recommend conservative management over surgical therapy as they found lower complication rate with the former. However, others advise earlier surgical intervention, [15] especially by using video-assisted thoracoscopic surgery [21] for lesser morbidity and better results.


   Acknowledgment Top


I sincerely thank Dr. N. Dingankar and his team; FDC Limited, the manufacturers of SIMYL-MCT, for providing the necessary assistance.

 
   References Top

1.Lampson RS. Traumatic chylothorax. J Thorac Surg 1948;17:778.  Back to cited text no. 1    
2.Collis JL, et al . Part V chap 36 Thoracic injuries, d' Abreu's practice of cardiothoracic surgery. 4 th ed. Edward Arnold Publishers Ltd: 1976. p. 676-7.  Back to cited text no. 2    
3.Irving IM. Malformations and acquired lesions of the lungs, pleura and mediastinum in neonatal surgery. 3 rd ed. Lister J, Irving IM, editor. Butterworths and Co Publishers Ltd: 1990.  Back to cited text no. 3    
4.King TC, Smith CR. In : Chap 16 Chest wall, pleura, lung and mediastinum. Principles of Surgery. 6 th ed. Schwartz SJ, editor. McGraw-Hill Inc: USA; 1994. p. 701.  Back to cited text no. 4    
5.Reynolds M. In : Chap 58 Disorders of the thoracic cairty and pleura and infections of the lung, Pleura and mediastinum paediatric surgery. 5 th ed. O'Neil JA, et al , editors. Mosby Year Book Medical Publishers: Chicago; 1998. p. 912-4.  Back to cited text no. 5    
6.Holt PR. Studies of medium chain triglycerides in patients with differing mechanisms for fat mal-absorption. In : Senior JR, editor. Medium chain triglycerides. University of Pennsylvania Press: Philadelphia; 1968.  Back to cited text no. 6    
7.Medium Chain Triglycerides (MCT). In : Manual of clinical nutrition management copyright©, Morrison Management Specialists Inc: 2003.  Back to cited text no. 7    
8.Ibrahim AH. Pleural effusion an article in eMedicine.com Inc. Copyright© 2003.  Back to cited text no. 8    
9.Fernandez Alvarez JR, Kalache KD, Grauel EL. Management of spontaneous congenital chylothorax: Oral medium chain triglycerides versus total parentral nutrition. Am J Perinatol 1999;16:415-20.  Back to cited text no. 9    
10.Jalili F. Medium chain Triglycerides and total parentral nutrition in the management of infants with congenital chylothorax. South Med J 1987;80:1290-3.  Back to cited text no. 10    
11.Le Coultre C, Oberhansli I, Mossaz A, Bugmann P, Faidutti B, Belli DC. Post-operative chylothorax in children: Differences between vascular and traumatic origin. J Pediatr Surg 1991;26:519-23.  Back to cited text no. 11    
12.Kosloske AM, Martin LW, Schubert WK. Management of chylothorax in children by thoracocentesis and medium-chain trigelyceride feedings. J Pediatr Surg 1974;9:365-71.  Back to cited text no. 12    
13.Milson JW, Kron IL, Rheuban KS, Rodgers BM. Chylothorax: An assessment of current surgical management. J Thorac Cardiovasc Surg 1985;89:221-7.  Back to cited text no. 13    
14.Buttiker V, Fanconi S, Burger R. Chylothorax in children Guidelines for diagnosis and management. Chest 1999;116:682-7.  Back to cited text no. 14    
15.Lieu CS, Chin TW, Wei CF. Successful Surgical treatment of bilateral congenital chylothorax: A case report. Zhonghua Yi Xue Za Zhi (Taipei) 1997;59:190-3.  Back to cited text no. 15    
16.Randolph JG, Gross RE. Congenital chylothorax. Arch Surg 1957;74:405-18.  Back to cited text no. 16    
17.Aziz Khan RG, Canfield J, Alford BA, Rodgers BM. Pleuroperitoneal Shunts in the management of neonatal chylothorax. J Pediatr Surg 1983;18:842-50.  Back to cited text no. 17    
18.Murphy MC, Newman BM, Rodgers BM. Pleuroperitoneal Shunts in the management of persistent chylothorax. Ann Thorac Surg 1989;48:195-200.  Back to cited text no. 18    
19.Seaton anthony in diseases of the pleura in crofton and doughlas' respiratory disease. Seation A, Seaton D, editor. 5 th ed. vol. 2, Blackwell Science Ltd: UK; 2000.  Back to cited text no. 19    
20.Marts BC, Naunheim KS, Fiore AC, Pennington DG. Conservative versus surgical management of chylothorax. Am J Surg 1992;164:532-5.  Back to cited text no. 20    
21.Graham DD, McGahren ED, Tribble CG, Daniel TM, Rodgers BM. Use of video-assisted thoracic surgery in the treatment of chylotorax. Ann Thorac Surg 1994;57:1507-12.  Back to cited text no. 21    



This article has been cited by
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[Pubmed]



 

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    Abstract
    Introduction
    Case Report
    Discussion
    Acknowledgment
    References

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