In the past decade chylothorax after heart surgery in children has gained more attention because of a real or perceived rise in its incidence and the emergence of octreotide, the synthetic analogue of somatostatin, as a therapy. Whether postoperative chylothorax is recognized more remains unclear, because as Chan and colleagues [1Chan S.Y. Lau W. Wong W.H.S. Cheng L.C. Chau A.K.T. Cheung Y.F. Chylothorax in children after congenital heart surgery.Ann Thorac Surg. 2006; 82: 1650-1657Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar] suggest, the complexity of congenital heart operations has increased and recovery with the reintroduction of enteral nutrition is expedited. However, this complication can produce significant morbidity from fluid and electrolyte imbalances, protein losses, and immunosuppression, all of which can lead to long hospitalizations and mortality. In several case reports and a small retrospective series including the current study, octreotide use has only been reported in a total of 51 patients with chylous effusions after cardiovascular operations in children. In many reports the results are mixed, but the authors of this study observed resolution of chylothorax in 83% of 18 patients with chylous pleural drainage refractory to dietary modification alone. Although these results are promising, the efficacy and safety of octreotide for treatment of postoperative chylothorax after congenital heart surgery demands a more rigorous evaluation. Several points are raised by the current study [1Chan S.Y. Lau W. Wong W.H.S. Cheng L.C. Chau A.K.T. Cheung Y.F. Chylothorax in children after congenital heart surgery.Ann Thorac Surg. 2006; 82: 1650-1657Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar]. First, those patients treated with octreotide who responded with resolution of the chylothorax required a mean of 15.3 days for the effect. This interval occurred after a median of 19.5 days from the onset of the chylous pleural effusion, during which time the treatment was a modified diet rich in medium chain triglycerides (MCT) and low in long chain triglycerides (LCT). By comparison, patients from other contemporary studies who were successfully treated exclusively with similar diets responded during a period of between 2 weeks and 2 months. The length of time in both instances is comparable. The question then becomes, did octreotide cause resolution of the chylothoraces in the 83% of patients in this study or did dietary modification alone eliminate the chylous pleural fluid despite the addition of octreotide? Second, the dose titration used by the authors began at 10 mcg/kg/day and increased to 40 mcg/kg/day administered subcutaneously for a period of between 9 and 12 days. Once the chylothorax resolved or dramatically improved, octreotide was weaned for 3 to 4 days, giving a total length of octreotide therapy between 12 and 16 days. This timeframe is consistent with the mean of 15.3 days reported here as the interval for chylothorax resolution in the 18 patients treated with octreotide. However, if octreotide did produce the observed resolution of the chylothoraces, what is the appropriate dosing of the medication and could a shorter dose adjustment period help reduce the length of hospitalization? Third, the 18 patients treated with octreotide in this study exhibited a statistically significant higher prevalence of septicemia and hypoalbuminemia. Those patients had a longer duration and higher volume of chyle drainage compared with the patients who did not receive octreotide. Although the excessive chyle losses could explain the more prevalent sepsis episodes and low albumin levels, the authors alternatively suggest that octreotide therapy itself may cause or contribute to these adverse outcomes. Whether octreotide contributes to higher infection rates or lower serum albumin levels in patients with chylothorax remains unanswered. These questions and others raised by Chan and colleagues [1Chan S.Y. Lau W. Wong W.H.S. Cheng L.C. Chau A.K.T. Cheung Y.F. Chylothorax in children after congenital heart surgery.Ann Thorac Surg. 2006; 82: 1650-1657Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar] can only be answered by a multicenter, prospective, randomized controlled trial. For a problem that carries significant morbidity and mortality and today seems more prevalent, a safe and effective treatment of chylothorax after repair of congenital heart defects is a priority. Chylothorax in Children After Congenital Heart SurgeryThe Annals of Thoracic SurgeryVol. 82Issue 5PreviewA definitive management strategy for postoperative chylothorax remains elusive. We reviewed our experience in the management of chylothorax in children after congenital heart surgery. Full-Text PDF