Chylothorax & Chylous Ascites Rapid Fire: Update Course 2015

Ready to be here. We're gonna start off with Kylothorax and Kyle societies. I don't know about you guys, but this is a topic that causes a lot of consternation to me whenever I get these consults. So anyway, we'll start off with the first case. You have a one month old ex-term infant who is found to have progressive abdominal distention. Kyle societies is noted. Uh, this, uh, all the nutritional and pharmacological and radiological approaches have failed in management. Which of the following is not an adjunct to successful identification of the duct? I think it's a pretty easy question. Yeah, vans for me. A lymph leak is noted over when you give the cream. When do you give it and how much do you give? I give about 20 ccs per kilo, and I give it about 30 minutes before, 30 minutes before they put the kid to sleep. Yes, OK, so as we're moving the kid from the NICU, let's say, have them drink it. Yes, and your anesthesiologists are OK with that. Yes, OK. I thought there was a moratorium on using methylene blue. I don't know. I've not used it. Yeah, I haven't, I don't use methylene blue at all anymore, but I was just thinking that in general these are accepted areas. We, so you, so what we did is we wait till they're asleep, put an NG tube down, give it then, and by the time I get the case going, put the ports in and everything like that, by that time it's the right time. So because our anesthesiologist didn't love the idea of us giving it preoperatively, even though I'm sure it's probably fine. That's the way we deal with, OK, all right. So a lymph leak is noted over the bare area of the liver. What's your preferred way of addressing this leak? Over the bare area of the liver. Uh I don't know. Fibrant absorbable cellulose with fibrin glue, that's, uh, there are some case reports about that actually. So yeah, so that was kind of interesting to, to see that that it's just a general that this, this seems to be a lot of people using or some people using this absorbable cellulose with fibrin glue, whether it be in the chest or um in the belly. Um So, however, if you do see a discrete source of the leak, then sure, endo loop, vessel sealing device, sutures, ligature, but if you're not able to see a discrete duct, then just putting on some in a sheet of the cellulose and fibrinogen glue. So, um, despite, I want to add one more thing, there's a guy, Jeff Runge, who's a veterinarian who just described using fluoresce to identify the duct and he uses a black light scope in animals, uh, and I'm sure the same thing would work, um, in humans, so, and the pictures would be prettier. The problem with those things is that it can stain the tissues and you may see an ongoing leak and stuff, but you may not, and that's why I think the heavy, the heavy cream or milk is just a much better idea. There are also studies now going on from lymph, the vascular malformation teams in Philadelphia where they're doing lymph lymph angiograms to try to identify this preoperatively, where they can actually inject in different spots to identify the specific site even before you get to the OR and some of those times when they do the lymphangiograms that serves as an embolization process becomes a therapeutic, right? So this fluorescine, that's what I was talking about, you inject it as like a lymphangio. But you inject it now. I was always taught, I'm curious because I was always taught like the toe web spaces or something, but they actually inject in the groin now, I think, right, right, just into a lymph node. OK, yeah, well, I mean if you've ever done, um, node labeling for tumors, it's incredible how fast that stuff gets absorbed and transported up the lymphatics. So sentinel node has taught me that you inject some lymphosur and blue and you better hurry because it's there quickly. So you have your scope in and then inject type of thing, not like a preoperatively. Well, for sentinel lymph node we do it as we're prepping and then I see we go to look for it in the extremity. Now whether that then carries into the abdomen, um, is not something that we necessarily have thought about or looked, OK. So in this patient now you had, despite nutritional, pharmacological and surgical literature, the college societies continues to persist. What would your next step in management be? Yeah. One thing I don't see there is relook again. Thoracoscopically, this is a chylothorax. Well, this is chilocystis ascites go back in laparoscopically again, OK. And then what would you do when you do that? See if you can identify, give cream and try again, and if you can't. I've never done any of the others, so. I was going to say it depends on how clinically significant it is. You might just do nothing and wait right post transplant we deal with this not infrequently and so, um, challenge first of all is medical management and just supportive care and usually it'll settle, but on occasion we've actually. On peritiovenous, I mean actually peritoneal to thoracic shunts. We don't actually do necessarily the Denver shunt because that doesn't always stay patent. It actually has a thrombo thrombosis rate, but you actually can go peritoneal to thoracic cavity and absorption because then you add the extra space of the thoracic cavity for for absorption. So the idea of a Denver shunt, the last time we did the Denver shunt was probably 10 years ago, but we have done a couple of peritoneal to thoracic cavity shunts. So when you do that, do you use a, uh, a little prosthetic device? Yeah, there's actually, there is a device and actually that you, you, you lay it right on the ribs and you actually pump it and it actually does the shunting for you. All right, I'll be calling you next time I have, so it doesn't happen too commonly. What about the peritoneal thesis? I, I never even heard of that. Yeah, that's nothing we would ever explore, and I saw one case report about that, about just abrading the entire plural that sounds like a bad, that's not something I would go down that right route for population of patients that we care for. So now we'll go to the thorax. You have a 2 month old female status post bidirectional gland 14 days ago and now has this large left sided pleural effusion. There's decreased breath sounds on the left. This is your x-ray. Um, a pigtail is placed and milky fluid is noted. Um, the triglycerides are high. There's chylomicrons. The child's given MCTs and the output is still 50 ccs per kilogram per day. Can I stop you? I have a question that I've never understood. Isn't NPO better than MCT? MCT is not therapeutic. It's just a way to feed them. So you do NPO for a while before you could do that first, and then if they're doing OK, then go to MCT, right? Or am I misunderstanding? Is there some benefit of MCT? I don't think there is any benefit for MCT other than trying to continue feeding. Is that, but from a stages of. Of intervention, I agree with you. NPO would be the better way. And then if they're doing OK, then you try feeding them with medium chain triglycerides. And also we don't have a formula that's pure medium chain triglycerides. They are, they're about 80% or something like that. So still, even with that, you're gonna have some fats, right, OK. So with 50 cc per kilogram per day, um. Um You started octreotide. How many days of octreotide and for argument's sake, let's say even NPO would you give before you escalate your therapeutic approach? I'm, I'm not, I'm gonna stop being the first one guessing. What do you guys want? I would say 14 or 30. We would wait a while and again, it's a function of symptoms. You got to track their lymph, their lymph counts. If they start to have infectious complications from that process, then you're driven to actually get more active, um, but, and we, we try octreotide. It's not particularly effective, um, but that's. Certainly a route that will go, which is a course. And if that fails, then you're going to start thinking about exploring the chest and dealing with other considerations. A month, a month, some, some reasonable period of time. I think the problem is you end up getting pushed by things like their lymphocyte count or something ends up pushing you to do something sooner. But even if you try that, if I did a whatever approach you particularly want to take and it didn't work, I would just wait more, OK, I think. Would you change your approach knowing that this is, uh, possibly an iatrogenic issue after the open heart surgery versus a congenital chylothorax? The answer is yes, because if it's an acquired process, there's a better chance it will seal off on its own. Again, that's anecdotal experience. It's not based off anything, you know, study wise. I don't think it usually is, it actually creates a pretty high pressure system and most of the kylethorasis after these cardiac operations, uh, like a bidirectional glen, it's high, very high pressured system, and when you look at that thoracic duct, it's like almost pumping, so um. The higher, more likely chance, I think, on the, this is a left side though, yes, OK. You'll be there either way. That would be a great indication if you had the technical expertise to embolize it because it's probably a single cut in a major duct. So that's what I used to do is I used to wait for as long as I could until um we say, OK, we've we've got to go ahead and ligate this duct and then just um. Recently a paper came out of Michigan in which, well, first of all, we'll just talk about octreotide if we can bring the slides up again here octreotide, the bottom line is that it just, uh, it, there's no, there's maybe a marginal benefit from octreotide, so it doesn't whether or not it it really, uh, should be used or not is debatable, and the neonatologists are very. At least where I am, they're very concerned about giving it because of a solitary case report about necrotizing enterocolitis from a period of time. So, um. Um, so, however, the, the paper I was referring to earlier, the Michigan, uh, group, uh, um, reported on, uh, I believe it was close to 100 patients with, uh, catotthorax post cardiac surgery, and they've initiated a much more rapid clinical practice guideline in which they, if the outputs are high. They go ahead with surgical ligature within 2 weeks rather than waiting for 30 days because one of the downsides of waiting for 30 days is that these, these children need very expert fluid management. They lose so much when it's a high output klothorax, and plus they're a cardiac patient, plus they're losing, they're becoming progressively hypoalbuminemic that they've uh in their study they found that um. The ICU length of stay was cut in half by early ligation. The overall hospital length of stay went down from 30 to 23 days, and the, so and the days on ventilation was cut in half as well. So they have a nice algorithm. I can forward to you guys the uh the citation if you would like. I think it depends, Samir, if you're making no progress or you're making progress. If they're pouring out and it starts decreasing every day, I might wait longer than if I see no change in 2 weeks, right? So, but what they're saying is by 2 weeks, fish will cut bait. Wow. OK, so Um, sorry, so that's college of societies and colleges are awesome. All right, next. Inflammatory bowel disease.