Professor Kokila Lakhoo joins us from Oxford to discuss issues around paediatric patients with Chylothorax.
[00:00:00] Andrew: Welcome to Discover Paediatric Surgery. My name is Andrew Grieve and I look forward to being your host today on this exciting episode. All right, so I'd just like to welcome Professor Kokila Lakhoo who's with us today from Oxford in the UK. Kokila is a clinical head of pediatric surgery in Oxford. Although Kokila works in the UK she's got very strong ties with Africa including South Africa, Tanzania and Malawi and she's got quite a passion for promoting care for children worldwide. So Kokila welcome and thank you for taking the time to join us. Kokila Lakhoo: You're most welcome. Andrew: Kokila today, we're going to chat about [00:01:00] Chylothorax or Chylothracies. Maybe you can just kick off by just defining for us what a chylothorax is? Kokila Lakhoo: Okay. So from a starting point it's a lymphatic fluid or a lymphatic effusion in the chest. And that's why chylo meaning lymphatic, thorax meaning the chest and when you really studying such a subject or when you have a patient of chylothorax the question you want to ask yourself is that is this congenital or is this aquired? Congenital chylothoracies have associated with a lot of syndromes and and if it's an acquired one, it's usually traumatic. Traumatic meaning iatrogenti injury during thoracic or cardiac surgery or during trauma and the recovery phase of the management of the two are very similar. But the [00:02:00] one has a very good and quick, better outcome, which is acquired one. Whereas the congenital ones can be quite trying due to the fact that they have other Associated abnormalities and sometimes you actually prognosticating whether this child's management should continue or not due to quality of life for these babies. Andrew: Yes. I suppose is one of the many problems. I suppose you have to tie it all together and decide what's the best way for the for the child and for the family? Kokila any sort of specific, you know, obviously the congenital ones as you say the symptoms are associated with but the aquired ones I mean, do we find any predisposing factors? I mean apart from sort of cardiac surgery in those things. Are there any patients that are more prone to that others? Kokila Lakhoo: No, I think it's mainly you know for during cardiac surgery more [00:03:00] so than when we doing our tracheoesophageal fistula repairs. And I haven't found inclination for a group of patients except that they need in cardiac surgery. Andrew: Okay. Now see some papers say that males are more predisposed and females, but you guys haven't really seen that in your experience. Kokila Lakhoo: Again, you are absolutely right, you know in the in the literature they said there's a gender preference towards male. But if you look at it generally in our figures, you know, we haven't found that difference. Andrew: Yeah, and then and in terms of the side that they develop the chylothorax, I mean it's a generally depend upon the side of the surgery or is it really depending on where the injury occurs. Kokila Lakhoo: So most of the time you have like a right-sided surgery, so we've been seeing them a lot on the right side and [00:04:00] it's surgery dependence so cardiac surgery could be you know, it's mainly median sternotomy is yeah, so it could be on the side. So, you know for cardiac surgery, there's no preferences when we look at pediatric surgical thoracic lesions many tend to be on the right side. And that's where we found. But if I have to give you an answer I would say chylothorax does not prefer a side. It has no site preferences. Andrew: Yeah. Okay. All right. So what are some of the side effects? What are some of the complications of having a Chyle leak? Kokila Lakhoo: So first when you do have the diagnostic method is that the child's having respiratory distress? All the ventilator requirements are going up chest x-rays done. And there's a white-out on one side. And the question is; what is this? Is this a severe pneumonia? Is this due to a [00:05:00] leak? From what you've done? Is it chyle and the diagnostic methodology is your pleural tap, and then you send it for diagnosis? And once the pleural tap comes back, it usually will have lymphatic cells in it and that makes your diagnosis. Andrew: So so you say just to go into that. So I mean you are mainly using the presence of high lymphocytes in the fluid as opposed to triglycerides and those things in the fluid have you because most people have moved away from that biochemical analysis rather than looking at the cell analysis. Kokila Lakhoo: Yeah, we still been a bit traditional you look for you know, and the other one the other way of distinguishing which is which is that if the baby is nil by mouth it should be kind of a clear tap but if the baby is fed it is milky . So if it's milky, it's quite clear that [00:06:00] this is a Chyle. In a less acute baby unless your oeophageal anastomosis has leaked and you put milk in the chest, you know, I have to take that into account as well. So then you're looking at is a milk or is this chyle? So again, you'll send it off for a test. Yeah. What do you using at your end for diagnositic taps? Andrew: Well, we've been many using biochemistry and but you know after doing some more reading I mean the trick is to try and convince our labs to do unusual tests on a abnormal sort of fluid types. So for example, we struggled to get into the bilirubin on ascitic techniques. The same where we struggle to get cell counts on thoracic taps, but I so we mainly have been using biochemistry. But I you know, I think we'll probably try and push them for lymphocyte guns now because it's probably more accurate more of an accurate picture because their triglycerides [00:07:00] everything; you right to are often more dependent upon what the child's been feeding in those things and it's a little bit harder to make the diagnosis, you know, depending upon what's going into the child's versus what comes out where as the lymphocytes are always high ; the predominant cell type. Kokila Lakhoo: You don't get specificity with your biochemical tests wheras with the lymphocytes you get an accurate outcome that you have lymph in in your effusion. Andrew: Yeah, carry on. Kokila Lakhoo: Going back to the reading you know where we said, you know, as I said, we found it more on the right side, but there is literature out there that you know, there is equal amount on the left side as well. And again bring that subject up. It's very much depends on where you've done the surgery and which cavity you've accessed. Yeah, Andrew: I just have supposed in reality. It's you know, it's semantics. It's really a clinical picture and that's [00:08:00] what's important and obviously just to be aware that you can get it both sides as well. So don't be, don't be put off by the fact that you might have a bilateral effusion and think it can't be chylous thorax because obviously can be. Kokila Lakhoo: You asked me about what are the side effects of a Chyle leak? Andrew: Yes. Why are we worried about these patients? Kokila Lakhoo: So when this happens you've got a problem. So you need to tackle the problem. So firstly they will have respiratory insufficiency that will alert you to do your chest x-ray and then further investigate. And we lose Chyle you also use nutritional depletion. So the child becomes nutritionally depleted and you know, your intestinal factor and lymphocytes are lost so that again has a nutritional impact and then the child becomes dehydrated there is metabolic [00:09:00] changes and then immune deficiency takes place. So with an abnormality in the chest cavity, you've got to deal with it. Andrew: Yeah. One of the interesting things that I was reading about it is that you know, although these patient's become immunodeficient and they're prone to developing sepsis, there's almost no recorded incidents of local sepsis within the hemithorax. So they don't develop an empyema because of the higher lymphocyte count there but systemically they are very prone to infections. Kokila Lakhoo: You're absolutely right. It's a systemic sepsis rather than the specific localized sepsis, which is related to the immunodeficiency. Andrew: Yeah, so can I ask just I mean just broadly speaking. What's your general sort of treatment approach to these patients with a chylo thorax? Kokila Lakhoo: So what we do is once we've established that this [00:10:00] is Chylothorax the aim is conservative management and I would say conservative, conservative, conservative unless you have refractory leaks. So the conservative management would be to put in an intercostal drain to release the pressure from the chest. Keep the patient nil by mouth Start them on Parental nutrition so that you can dry the leak out and about 90% of the patients will be fine with that. In countries where you don't have tpn or after a week, we would change them to a medium chain triglyceride diet. And that's quite helpful. Hmm. And in a neonate it's about a month- three weeks to a month of conservative treatment, you know. In older infants Six weeks [00:11:00] to two months of conservative treatment and then failing that it becomes refractory but before that I do try somatostatin analogs. Okay, say of so once I start my treatment by keeping the patient starved, IC drainage, tpn or MCT diet and after two weeks. I don't notice a change or the change is very slow; then I would add a somatostatin analog. Which works in the way that it just dries up secretions? Okay. And that has been quite successful in most patients. Andrew: Mmm. I mean, I know it's obviously it works better in young neonates when compared to the older kids; what happens if the conservative treatment fails and fortunately, it's relatively rare, but what do you do after that if you still failing conservative management? [00:12:00] Kokila Lakhoo: So if the conservative management fails, then I would go with either thorocoscopy or thoracotomy and identify the leak. So if it's traumatic you might be able to identify the leak and one of the clues of helping identified is that give the patient like a cream diet few hours before the surgery. I mean a limited amount so they don't aspirate. Yeah, see if you give them a high fatty diet you be able to identify the leak. In my experience, you know in the traumatic ones the leaks can be identified and usually if it's a one area you can just put a stitch on there. Okay, some colleagues will use glue some will use and in the literature people have talked about success with glue a successful coagulation with a diathermic device. Yeah, if you find that the leak is unidentified at this you find [00:13:00] mainly in congenital where its like a water can and you just find that the medial aspect of the chest cavity is just leaking. Hmm. And in the neonate, it's quite it's not very difficult procedure but you consider doing a pleurodesis. So where you find high-volume leak you can apply some diathermy, but what I do is I remove the pleura cause like a pluralodesis, okay, and then inject bit of the patients blood because the blood itself is a pluraldeasing. So you put a needle into the intercostal vein and just take a little bit of blood and kind of spray it across we suspect the lymphatic channels are so using a pleurodesing technique and that has worked especially in neonates it's been very very successful and if that fails then there is consideration for a shunt, so in my experience, I've [00:14:00] managed I've had I was lucky I suppose that both using conservative or surgical approach has worked. But I've had a referral of a patient where both the techniques didn't work and then I considered putting in a shunt and it was only once in my career that I've used a shunt and you know, they're different shunts available on the market and if you are used to putting Central lines, you know either percutaneously or open through the internal jugular vein then shunts are not difficult to do or if you used to put in VP shunts. So basically the shunt is a one-way valve where you put one end into the chest like a chest drain and the other end into the internal jugular vein and to the Atrium and it works very very well when you have refectory chylothorax. Andrew: Okay. All right. Kokila I just want to go [00:15:00] back just to two things just for a bit of expansion. So I mean you were talking about somatostatin analogs and we obviously use them relatively frequently, but there are some important side effects that we need to be aware of in terms of somatostatin. Maybe you can just elaborate on what some of these are and what we should look out for when we treat these patients. Kokila Lakhoo: So if you take somatostatin is a drug hyperglycemia hypothyroidism liver, kidney damage pulmonary hypertension bloating and then this there's a concept of necrotizing enterocolitis. So if I go through all of them. If you using them short-term, then it's not a very dangerous drug because side effects are far and few between but after use them for a month or sometimes longer than a month, then you need to keep an eye on the two main things which is [00:16:00] hyperglycemia and hypothyroidism. So you check those biochemically. And it's important to keep a weekly eye on the liver function test and you're u&e's just to make sure that your kidneys and your liver is not failing. A month treatment; I haven't seen the side effects because I have not used them for longer than a month. But having been describing the literature there was an issue of a pulmonary hypertension and my view is the was that the primary hypertension due to the drug or was it due to the effect of the chylothorax? Yeah, and I think in my mind necrotizing enterocolitis I think is a red herring. Because it might have been just a very ill child with needing input from a hemodynamic instability and you know when NEC happens; [00:17:00] it happens when the babies are very vulnerable. They need blood that needs to rush to the brain the heart the kidneys and the bowel suffers. Yeah. So I think it's that phenomena rather than the drug. Andrew: And I suppose also them being immunosuppressed as well predisposes them to NEC. Yeah. Kokila Lakhoo: Yeah, absolutely. Andrew: The other thing I want to ask you about is a you mentioned using blood for pleurodesis. Are there any other agents that people are using routinely apart from blood? Kokila Lakhoo: Yes. So our adult surgeons use talcum powder. Tank works very well. I think there's a resistance in children because of reaction. Okay. But it is a very good product to use. The only problem is if you're going to use it percutaneously or through the drain it blocks. So if you have an open chest, the talcum powder works really well because you can just kind of sprayed in the area that you want to. [00:18:00] Hypertonic saline, Betadine, you know erythromycin solution, tetracycline is the other one. Those can also be injected through a drain if you want to create a Chemical pleurodysis percutaneously. Andrew: I suppose some of the agents are better to be done open and some obviously better percutaneously and I suppose as you say something is also easily available on the table, like the patient's blood for example, whereas others you may need to make some earlier preparations to make sure that there are are there for your surgery. Kokila Lakhoo: I mean better than is a very good adhesive and that's why I don't like, you know, bowel washouts with betadine than because they cause adhesions, so if you use in the chest you can but you need to be careful that you don't use a large amount otherwise you get iodine toxicity. So the safest and the most available is right in front of you. You've opened the chest. [00:19:00] You've got the intercostal veins or you've got your azygous veins, you know, take a bit of blood from there and just sprinkle it around the area that you want pleurodysed and tell you it works fantastic. Andrew: Okay that is good to keep in mind. Kokila Can I ask you you haven't mentioned the potential concept of sort of periaortic ligation of tissue at the diaphragmatic hiatus. I know some people have mentioned doing that for resistant leaks where they can't find the location; sort of one step before doing a shunt. Have you ever done that or had any experience with that or do you tend to just do a pleurodysis and then move on to shunt as you're next step? Kokila Lakhoo: No, I have done it and thanks for bringing it up. What happens is you know, where the thoracic duct is running. As a surgeon, you're familiar with the anatomy. So if you put a running stitch in that [00:20:00] area, you know, you catch it sometimes catch it and you know sort of surgeon so as us pediatric surgeons are familiar with the chest and sometimes you just see a blob in an area. So if you just put in a blind running Stitch making sure you don't Stitch the aorta or make a hole you'd be fine. Yeah, it does work. That's another method as well. Andrew: Okay? Okay, that's good too just to bare in mind as an alternative option now, yeah. Kokila Lakhoo: It's a nice area to talk about because it's specific and you can do something about it. Andrew: And I think it's something we don't see particularly often, but it's good to have an approach to treating these patients. And there's you say they can get really sick and actually become real problems if you don't try and get on top of it sooner rather than later. Kokila, did you have any take home messages? You want to leave with the guys? Kokila Lakhoo: Yeah, I think the take-home message is be like prompt with your diagnosis. Is [00:21:00] that early? The diagnosis the more successful your conservative treatment? And if conservative treatment fails if you're doing Surgical, you know try the minimalistic approaches such as you know, the tying of the duct, pleurodysis; because those work. I mean shunts are very very rare and shunts can be problematic. So I would leave the shunt as the last resort in a try all the other tricks that we've talked about and then you know, if you're not winning then then you do have something to use which is the shunt. Andrew: Yeah. No, perfect. Thank you so much. That's that's very helpful. I'm sure the guys will learn a lot from that. Thank you so much for your time. I really appreciate it. Kokila Lakhoo: And just take you to we'll see you soon. Andrew: Thank you for joining us on Discover Paediatric Surgery. Let your friends and colleagues know so we can all learn together? [00:22:00]