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Inhoud geleverd door Discover Paediatric Surgery. Alle podcastinhoud, inclusief afleveringen, afbeeldingen en podcastbeschrijvingen, wordt rechtstreeks geüpload en geleverd door Discover Paediatric Surgery of hun podcastplatformpartner. Als u denkt dat iemand uw auteursrechtelijk beschermde werk zonder uw toestemming gebruikt, kunt u het hier beschreven proces https://nl.player.fm/legal volgen.
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Discover Biliary Atresia Part I
Manage episode 205722629 series 2149221
Inhoud geleverd door Discover Paediatric Surgery. Alle podcastinhoud, inclusief afleveringen, afbeeldingen en podcastbeschrijvingen, wordt rechtstreeks geüpload en geleverd door Discover Paediatric Surgery of hun podcastplatformpartner. Als u denkt dat iemand uw auteursrechtelijk beschermde werk zonder uw toestemming gebruikt, kunt u het hier beschreven proces https://nl.player.fm/legal volgen.
Professor Mark Davenport has been studying and treating Biliary atresia for over 20 years.
Join us in discovering his insights into this fascinating complex condition!
19 afleveringen
Manage episode 205722629 series 2149221
Inhoud geleverd door Discover Paediatric Surgery. Alle podcastinhoud, inclusief afleveringen, afbeeldingen en podcastbeschrijvingen, wordt rechtstreeks geüpload en geleverd door Discover Paediatric Surgery of hun podcastplatformpartner. Als u denkt dat iemand uw auteursrechtelijk beschermde werk zonder uw toestemming gebruikt, kunt u het hier beschreven proces https://nl.player.fm/legal volgen.
Professor Mark Davenport has been studying and treating Biliary atresia for over 20 years.
Join us in discovering his insights into this fascinating complex condition!
19 afleveringen
Alle afleveringen
×The “True Spastic Colon”. Join Dr Chris Westgarth-Taylor in our discovery of Hirschsprung’s disease in this exiting episode!
Vomiting in neonates is a frequent occurence. Do you know when to be concerned? Join Dr Theshni Govender in discovering.
Chatting to Professor Henning Olsen, a Urologist with decades of experience in managing this renal condition. Read Full Transcript DPS PUJ obstruction [00:00:00] Welcome to Discover Paediatric Surgery. Andrew: My name is Andrew Grieve and I look forward to being your host today on this exciting episode. We are lucky to have Professor Henning Olsen today with us is a pediatric urologist from Denmark. And I can never pronounce his Hospital properly Aarhus, aahurs, but Aarhus, I definitely haven't got it. Henning: No one gets it right. Andrew: So Professor Olsen has two interests in life. The one is Urology and the other is sailing. But sadly today, we're going to talk a little bit about Urology and maybe next time it's about sailing. Thank you for [00:01:00] joining us. We appreciate your time. Sayo Henning. I mean, we'll just jump in we're going to talk about pelvic ureteric Junction obstructions and obviously in children. I mean in the first world there's obviously a lot of antenatal diagnosis of hydronephrosis does your unit get referred all the patients with this antenatal diagnosis for review or do you only see those that's end up having a problem later in life. Henning: Well it depends on and if they came from the local area, that means something like 500,000 we will see them and then they come from from outside of the country, which or referral area is something like three and a half million. They are seen in local hospitals and the prenatal diagnosis made there. And in case of a bilateral hydronephrosis, they come up [00:02:00] the questions and and often with bilateral hydronephrosis they are born in our Hospital. Unilateral hydronephrosis are born very normally and and get the follow-up after a schedule which we have in Danish Pediatric Society in the Danish Urological Society. It's very clear schedule how to handle these kind of of patients. So it's just in case in case of off bilateral hydronephrosis, then then they have to be referred to us. Andrew: So they're very early. Okay, do you ever get involved in antental counseling for these these parents? Henning: Well, if we talk about infra-vesicle obstruction means urethal valves. We are involved. Yes, because this is in some cases involve some some questions about continuing [00:03:00] the pregnancy and then the prognosis and what kind of surgery has to be done. And what's the prognosis after surgery? And what did what in general the parents have a very little understanding of course what the problem is and then they need some some discussion. Andrew: Just to give us an idea. I mean how many kids with hydronephrois that's noted antenatally, how many of those kids eventually come to surgery? Is it the majority of them or is it quite infrequent? Henning: No, it's is very infrequent, well not very but it's in the around 25 to 30 percent. We are very conservative in especially unilateral hydronephrosis. Andrew: And and I mean, you know, obviously there's a massive differential diagnosis for hydronephrosis. Do you know what portion in your unit eventually end up actually having a pelvouretheric junction obstruction out of all the antenatal hydronephrosis patients. [00:04:00] Henning: The majority the vast majority is UPJO (ureteric pelvic junction obstruction) . Of course it is, okay. You see reflex is is the next common cause of a kind of hydronephrosis but it's not so pronounced but in if you get trained in a way of looking at ultrasound their many, you know the AP diameter and they have calluses and then anything else but if you look at the ultrasound of a kidney in many cases you have in your mind. Well, this is real hydronephrosis. This is some guy we are going to operate on and this is a guy there's probably kind of reflex or something like that. And this is very subjective and it's not objective at all, but it's based on you know experience and you cannot describe it. Hmm. You see [00:05:00] if you see a patient with an appendicitis you make up your mind in the first very first moment when you see the patient; this is appendicitis have going to I'm going to operate right? Is it true? Andrew: Yes, you get a feel for it. Henning: Then you start out making all you know the evaluation and then in check and and so on but at the end; you will operate because you have seen it just in the very very first moment when you just open the door look at the child and then you know it okay, that's it. It's never right? Andrew: yes you are right it's almost like an art you get a feel for it. Henning: a clinical view. You cannot describe as you cannot use it for however studies. It's not it's not something you can use for anything. Just your personal your personal, you know experience. Andrew: Yeah. Any what exactly is a pelvoureteriec junction obstruction. How does it develop [00:06:00] what sort of the physics behind it? What's happening? Henning: Well, personally, I do not know what it is and I do no less while time is going and I but in principle of distortion of normal architectures and it's it's fibrosis dysplasia something in between and it's rather hyperplasia than an atrophy and in it, It's a growth failure. And that's why because it's a growth failure. That's why only 30% needs an operation because the child is growing and in many many many cases. This condition will resolved spontaneously by Nature. Andrew: Okay. And then how often do you see extrinsic causes of of puj [00:07:00] obstructions? Henning: What what's an extrinsic you mean? Andrew: Something like a lower from the vessel? Henning: Is this extrinsic? My my question is? How many normal children have an aberrant Crossing accessory vessel to the lower kidney pole and be logical think yeah, the is sending the pelvic region and upwards and end in the ascending process. For all children lose some of the vessels and get some new vessels upstairs. Hmm. I have some always thought it's it's it's a developer knows personal [00:08:00] question. And there's a reason why we see the crossing vessels accessory vessel, whatever you want to call is yeah. See this later in life. And it's very rare than you are operating on a very young child you were you see a Crossing vessel? You see this what you would call an intrinsic obstruction are high insertion of the pelvis or whatever. It's I think it's a bit different. Andrew: Yeah, yeah. Henning: Accessory vessel. Andrew: Okay, so it's not necessarily causing the problem. It's more that it's you know an Association. Henning: Of yeah, it's some point of time. It's the cause for the symptoms. Yeah. Okay. If you have that they have here they Crossing vessel and you have a hydronephrosis [00:09:00] and they drink a lot of whatsoever. They do. The ureter will Kink over the the accessory vessel and then they get symptoms and vomiting and pain and the symptoms which are caused by this Crossing vessel. Of course, they are. Okay. Otherwise on these guys. You see a lot of fibrosis. Hmm. a lot of fibrosis around the the upjo and you can release this fibrosis. But essentially we will be back on this and when we come to the to operation, How to operate these think when you operate on a hydronephrosis you should always do and dismembered pyeloplasty, but we can get and go back to this later. Andrew: Yeah, we'll discuss a bit more in detail later. I mean you mentioned a little bit about some of the symptoms that these [00:10:00] children present with. I mean, obviously those are to diagnosed antenatally have regular routine follow-up, but those that aren't diagnosised antenatally, and we obviously see more of those than you do. You mentioned some of the typical symptoms, but maybe we can just go through those again and what are some of the things that they present with? Henning: Well, one thing an older nurse in our department is observed is that they start to thrive after release the hydronephrosis the newborns again their bowel movements changing and something is happening because when you're born with a hydronephrosis, you don't know what pain is because you are born with your just developed with this pain. It is pain. What is pain? Pain pain is something you; you find [00:11:00] out when you are born and perhaps it is before you are born, and it's something which is intermittent. But if your constant pain it's not a pain. It's just a condition just life is these poor children? They just they live that this condition and that's it. They think life is like this. Okay, we have to find out and later in life they get the symptoms such as to the crossing vessel. As, as I mentioned they did they vomiting and and the pain and this lasts for some of them half an hour others of them two days. Some of them were avoiding vomiting and when the vomiting the loser lot of fluid and losing lot of fluid means reducing urine [00:12:00] production, reducing urine production resolves the problem with the kidney and then then then then the the symptoms disappear. Andrew: Okay. Henning: The essential difference between these two kinds of children is that that many of the children with Crossing vessels and intermittent symptoms have nearly normal differential function of the kidney, but the young ones they might from the beginning have a decreased differential function in their kidney. Andrew: Okay, thats an interesting facts. Yeah. Do you see a lot of urinary tract infections in these this group of patients? Henning: no, no, once in a while? The same as haematuria, the same is true for stones. We see more and more I think. [00:13:00] okay, the older ones all the patients are but rarely in the young ones. But but you have to ask people about them from from the from Turkey or from the Eastern Asia they have much more Stones there in even in hydronephrosis children. Andrew: Yeah. Okay. Yeah, I think it's um, there might be some genetic predisposition as well. Henning: Yes genetic or environment the you can speculate about what what's the reason is? Andrew: Hmm. Do we see these more common in males versus females left versus right or most then bilateral? What's your experience in your cohort of patients? Henning: Bilateral is about 15%. 10- 15% not more. In small [00:14:00] children It's more on the left side. Both groups can say and then both male and females. Okay, whether there are more males in the end the accessory vessels. All right, let's look where we are. We have a database about these these guys and it's obvious that the more males 55% males and females in the older group Andrew: Okay, so, All right. So you mentioned that your kids with antenatal diagnosis of hydronephrosis obviously have a regular screening program and then they get referred to you only if there are problems. What some of your investigations of kids with suspected pelvoureteric Junction obstructions? What's things you guys look at? Henning: Well, if you have a unilateral hydronephrosis as you know, we do [00:15:00] it about 7 to 10 days after birth because they kidney function is not fully developed. It's better after six weeks. We do it after 7 to 10 days to get some kidney function and when when when they start drinking and voiding, okay, if we have a case of bilateral we do the ultrasound already. Prenatal diagnosed children, we do the ultrasound the day of birth just to to avoid that we are overlooking cases of infravesical obstruction. Okay means it's the walls but we will always repeat this study day 7 and then we will do depending a bit on what we find out about the four weeks old. And then again at it three months. The nuclear studies are postponed always to four [00:16:00] to six weeks due to the development of the nephrons that takes at least four weeks to get some some proper answer from the nucleus studies. And so we wait for this time and it depends of course, how much is this very rare that you think that you need to operate or do some relief just after birth in that upjo. It's very haven't seen this. Yes. I don't think so. Yeah. Andrew: Okay. Can I can I ask I mean there's you know initially when you know people started talking about doing antenatal ultrasounds in their neonates for this condition they used to always to talk about the size of the pelvis. And you know, did it have some baring on surgery and outcomes in those things and my impression is has been a bit of a move away from that. Do you [00:17:00] still find it important to see the size of the pelvis in these kids in these neonates? Henning: Well, we look mostly because of what communication courses we look most of all of the intra-renal. anterior-posterior diameter of the pelvis the external part of the pelvis is so far not of Interest (right) does this is just Nature's Way of defending the kidney against the against the possible obstruction while the intra renal APD diameter has been shown that it has some significance on the on the prognosis and we use AP diameter of 12 millimeters when the we call the case a hydronephrosis the radiologist the call hydronephrosis after AP [00:18:00] diameter of 10 millimeters. Both of us might be right, but but it has something to do with a follow-up. In most cases, you don't have this question. But if you have an AP diameter of seven millimeters, let's see seven millimeters. So we will make one ultrasound after four weeks and if this is true still true, we will not do anymore. We will redo not do a nuclear study we will just leave the child and that's it. Okay. So we will not make any further investigations. We will call this hydronephrosis. Andrew: I guess it's more of a screening tool then. Yeah. And we've been using MAG-3 as our nuclear study. Are you using the same? Yeah, Can you maybe just go through what some of the principles are behind the [00:19:00] MAG-3? What are we looking for? And what makes it useful in puj obstruction? Henning: The MAG-3. It's a renography. It's a it's it's both renography, and it's scintigraphy. For us the most important part of it is the the the scintigraphy part of the examination; that means to find out the differential function and something which is very important. You have to look at the pictures these nuclear medicine guys are doing especially in a newborn child. If you have a right-sided quite large hydronephrosis, the liver is very close and the background in this examination can be quite active close to the liver and make it gives you some misinterpretation, especially [00:20:00] in large kidneys and enlarged kidneys. Andrew: Right. Henning: You have to be very careful on their interpretation of the differential function. And where they place; especially when the function is down to 20% or something of that the look carefully at this pictures not just at the curves and then tracing their but look at the pictures. Look what's going on there. And where have they drawn the lines. Because the lines in the MAG 3 they draw on the picture is subjective assessment of the nuclear medicine and not not the truth. Yeah, so be careful be careful there. With regards to the washout. Well In smaller children, we don't rely if you have a normal curve. Normal curve means [00:21:00] like a Gaussian distribution if you remember this from your statistics, this is a normal curve. Andrew: Okay, Henning: but but if you are at normal curve, you cannot interpret this as an obstruction, even if it goes up after half an hour or something like that. It depends on the size of, the size of the pelvis. If you have a bath tube on one side and just then one normal wash hand wash on the other side and you have the same amount of nuclear activity in both of them. No matter what if the if the drainage is the same; the activity will sustain in the large system for much longer than the other system. This does not mean that there's an [00:22:00] obstruction. Okay. So quickly the same the same drainage on both sides. Andrew: Right right Henning: Therefore the disease side needs to drain much more volume to get rid of the activity. Okay. Be careful interpretating large systems with the halftime or anything else? Andrew: Okay. Henning: Forusemide might might help you a bit. If you get a kick after furosemide you can be quite sure that there is not very much obstruction. Obstruction is not absolute. It's not a complete obstruction. It's a obstruction is a degree of obstruction if there is obstruction. Hmm. There Is no established washout time the literature regards to children in contrast to adults. In adults you have established [00:23:00] washout times you should rely on but but in children there's no literature about the the the real washout time. The preferred washout time. They're not good studies on their own pace. Andrew: Okay, so we just bear that in mind obviously when we interpret the MAG-3 tests. Have you been using or you're tempted to look at MR urography with gadolinium? Henning: We have been tempted a couple of years ago, especially because the the MRI urography was was kind of way of to estimate the differential function in the kidneys, but a few years ago in Denmark, we had Scandal about the gadolinium with some adult patients. And with insufficient kidney function they get a lot of fibrosis and symptoms after gadlolineium in a very [00:24:00] few patients, but you know how things are once you have this story in the newspapers, then it will hang on and since then it has been forbidden to do to any kind of these gadolinium, especially not in children. So this is not an option anymore. We use MRI for without gadolinium for some some reasons if you have unclear Anatomy for for any kind of dilation of the upper urinary tract, but not a routine. No, of course not. Andrew: Okay. Okay, so I mean obviously once you've made the diagnosis and then done the nucleur studies and those things obviously at some stage we need to decide whether we either going to watch the patients or we going to consider offering them surgery. When do you make that distinction? What kind of things are you looking at to make that decision? Henning: Well [00:25:00] you have some Nordic guidelines, which define when the kidney function is deteriorating and when we are suggested to to do surgery. We do operate when the differential function on follow-up decreases more than five percent. Andrew: Okay. Henning: If there is a huge progress on ultrasound and then you might recall the statistics from Great Ormond Street. If you have an AP diameter of more than 35mm to 50mm in the intra- renal pelvis. Then we find the indication we discuss the indication for surgery. [00:26:00] Andrew: And on your first MAG-3 if there's a big difference in differential function between the two kidneys. Would you consider it then or would you still watch them to see what's happening? Henning: This is an ongoing discussion. If you our limit for normal differential function is 40%. In Copenhagen it is 42% and somewhere else might be something else. This is yeah, there's not going to be really really clear where it should be done. We follow always the children. If you are born with a differential function you have a hydronephrosis , hydronephrosis. Significant...…
Professor Kokila Lakhoo joins us from Oxford to discuss issues around paediatric patients with Chylothorax. Read Full Transcript DPS 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]…
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