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Owusu-Brackett N, Chakedis JM, Dedhia P, Gilliam C, Agrawal A, Kang SY, Old M, Miller BS, Phay JE. Efficacy and safety of near-infrared fluorescence identification of the thoracic duct during left lateral neck dissection. Surgery 2024; 175:134-138. [PMID: 38057229 DOI: 10.1016/j.surg.2023.08.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 07/20/2023] [Accepted: 08/17/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND Thoracic duct leaks occur in up to 5% of left lateral neck dissections. No one imaging modality is routinely used to identify the thoracic duct intraoperatively. The goal of our study was to evaluate the efficacy and safety of indocyanine green lymphangiography for intraoperative identification of the thoracic duct compared to traditional methods using ambient and evaluate the optimal timing of indocyanine green administration. METHODS We enrolled all patients who underwent left lateral neck dissection at our institution from 2018 to 2022 in this prospective clinical trial. After indocyanine green injection into the dorsum of the foot, we performed intraoperative imaging was performed with a near-infrared fluorescence camera. We reported the data using descriptive statistics. RESULTS Of the 42 patients we enrolled, 14 had prior neck surgery, and 3 had prior external beam radiation. We visualized the thoracic duct with ambient light in 48% of patients and with near-infrared fluorescence visualization in 64%. In 17% of patients, we could identify the thoracic duct only using near-infrared fluorescence visualization, which occurred within 3 minutes of injection, and were required to re-dose 5 patients. We visualized the thoracic duct with near-infrared fluorescence in all patients with prior neck radiation and 77% of patients with prior neck surgery. One adverse reaction occurred (hypotension), and 5 intraoperative thoracic duct injuries occurred that were ligated. There with no chylous fistulas postoperatively. CONCLUSION This trial demonstrates that near-infrared fluorescence identification of the thoracic duct is feasible and safe with indocyanine green lymphangiography, even in patients with prior neck surgery or radiation.
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Affiliation(s)
- Nicci Owusu-Brackett
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital, Columbus, OH
| | - Jeffery M Chakedis
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital, Columbus, OH; Department of General Surgery, The Permanente Medical Group, Walnut Creek, CA
| | - Priya Dedhia
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital, Columbus, OH
| | - Christopher Gilliam
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Amit Agrawal
- Department of Otolaryngology-Head and Neck Surgery, Division of Head and Neck Oncology, Ohio State University, James Cancer Centre and Solove Research Institute, Columbus, OH
| | - Stephan Y Kang
- Department of Otolaryngology-Head and Neck Surgery, Division of Head and Neck Oncology, Ohio State University, James Cancer Centre and Solove Research Institute, Columbus, OH
| | - Matthew Old
- Department of Otolaryngology-Head and Neck Surgery, Division of Head and Neck Oncology, Ohio State University, James Cancer Centre and Solove Research Institute, Columbus, OH
| | - Barbra S Miller
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital, Columbus, OH
| | - John E Phay
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital, Columbus, OH.
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Gupta V, Dwivedi G, Chugh R, Sahu PK, Gupta DK, Basu A, Upadhyay K, Patnaik U, Bhatia R. Role of Octreotide in Conservative Management of Chyle Leak Post Neck Dissection in Cases of Head Neck Cancer: A Retrospective Analysis. Indian J Otolaryngol Head Neck Surg 2022; 74:6078-6086. [PMID: 36742480 PMCID: PMC9895617 DOI: 10.1007/s12070-021-02746-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 06/27/2021] [Indexed: 02/07/2023] Open
Abstract
Chyle leak is a dreadful complication in patients undergoing neck dissections. Octreotide has been used in the management of chyle leak post neck dissections in head and neck cancer patients. Currently there is no consensus and practice guidelines on the same. (1) To study the role of octreotide in early cessation of post neck dissection chyle leak. (2) To study incidence of intra-operative and post-operative CL, its relation to the extent of nodal disease and neck dissection, prior radiotherapy. Retrospective analysis of 16 patients out of 529 neck dissection over a period of 03 years between Jan 2016 and Dec 2019 who developed post-operative chyle leak. All patients who had post-operative chyle leak were administered octreotide. Time taken for chyle leak to stop was primary outcome. Secondary outcomes were duration of hospitalization post-operatively, incidence of intra-operative and post-operative chyle leak, its relation to the extent of nodal disease, prior radiotherapy and type of neck dissection. 59 of 529 neck dissections (11.15%) were noted to have intra-operative chyle leak. 16 of 529 neck dissections (3.02%) developed post-operative chyle leak. On applying chi square test, prior multimodality and N plus neck were found to be significant risk factors in developing postoperative chyle leak. Considering only RT versus no RT in prior multimodality treated group, the difference was insignificant. Onset of chyle leak varied from 1 to 5 post-op day (mean 2.68 days). 15 (93.75%) patients responded to octreotide. Chyle leak resolved between 3 and 10 days (mean 5.18 days) and octreotide was given for 5-12 days (mean-7.18 days). Overall duration of hospitalization ranged from 09 to 18 days (mean 12.18 days). 01 patient (6.25%) had to be re-explored due to high volume leak despite using octreotide. Adverse effects of octreotide were minimal and tolerable. Octreotide is effective in reducing the duration of chyle leak, hospital stay and need for surgical intervention. It may be considered as suitable adjunct to conservative measures in the management for post-operative chyle leak.
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Affiliation(s)
- Vikas Gupta
- Department of ORL-HNS, Command Hospital, Lucknow, Uttar Pradesh India
| | - Gunjan Dwivedi
- Department of ORL-HNS, Command Hospital, Pune, Maharashtra India
| | - Rajeev Chugh
- Department of ORL-HNS, Army Hospital (Research and Referral), New Delhi, India
| | | | | | - Abhijit Basu
- Department of ORL-HNS, Command Hospital, Lucknow, Uttar Pradesh India
| | - Kiran Upadhyay
- Department of ORL-HNS, Command Hospital, Lucknow, Uttar Pradesh India
| | - Uma Patnaik
- Department of ORL-HNS, Command Hospital, Pune, Maharashtra India
| | - Ritika Bhatia
- Department of ORL-HNS, Command Hospital, Lucknow, Uttar Pradesh India
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Surgical Skills and Technological Advancements to Avoid Complications in Lateral Neck Dissection for Differentiated Thyroid Cancer. Cancers (Basel) 2021; 13:cancers13143379. [PMID: 34298595 PMCID: PMC8304842 DOI: 10.3390/cancers13143379] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 06/27/2021] [Accepted: 07/01/2021] [Indexed: 11/16/2022] Open
Abstract
Neck dissection is a surgical procedure reserved for thyroid cancer cases with clinically evident lymphatic invasion. Although neck dissection is a reliable and safe procedure, it can determine a significant morbidity involving a variety of structures of nervous, vascular and endocrine typology. A careful pre-operative study is therefore essential to better plan surgery. Surgical experience, combined with accurate surgical preparation and merged with adequate and specific techniques, can certainly help reduce the percentage of complications. In recent years, however, technology has also proved to be useful. Its crucial role was already recognized in the safeguard of the integrity of the laryngeal nerve through neuro-monitoring, but new technologies are emerging to help the preservation also of the parathyroid glands and other structures, such as the thoracic duct. These surgical skills combined with the latest technological advancements, that allow us to reduce the incidence of complications after neck dissection for thyroid cancer, will be reported in the present article. This topic is of significant interest for the endocrine and metabolic surgeons' community.
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Pabst A, Thiem DGE, Goetze E, Bartella AK, Neuhaus MT, Hoffmann J, Zeller AN. How is neck dissection performed in Oral and Maxillofacial Surgery? Results of a representative nationwide survey among university and non-university hospitals in Germany. Clin Oral Investig 2021; 25:3007-3019. [PMID: 33779814 PMCID: PMC8113132 DOI: 10.1007/s00784-020-03622-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 10/01/2020] [Indexed: 11/30/2022]
Abstract
Introduction Neck dissection (ND) is a surgical procedure addressing cervical lymph nodes and metastases in patients with oral squamous cell carcinoma (OSCC). The aim of this study was to analyze clinical decisions regarding indications and variations of ND in Oral and Maxillofacial Surgery (OMFS) in Germany. Material and methods A nationwide survey of the German Association of Oral and Maxillofacial Surgery was performed using dynamic online questionnaires including 38 questions. Data about oncological centers, case numbers, and staging procedures were collected. Relevant aspects, such as inclusion of level IIb and levels IV and V to ND, uni- vs. bilateral ND, and the influence of extra-nodal extension (ENE) of metastases on extension of ND were evaluated. Results Eighty-four OMFS of university and non-university hospitals participated in the study (responding rate 21.4%). Sixty-six (78.57%) stated to work at certified cancer centers and 53.57% of the hospitals treated between 50 and 100 OSCC cases per year. CT and/or MRI of the head and neck was performed in most of the staging procedures. Level IIb was included by 71 (93.42%) of the participants in selective ND. Levels IV and V were included by 53 (69.74%) in node-positive neck. In solitary ipsilateral metastases (ENE−), 49 participants (62.82%) stated to perform exclusively an ipsilateral ND and 40 (51.95%) stated to perform only an ipsilateral ND in ENE+. Conclusion This study demonstrated a high rate of certified cancer centers in Germany showing differences regarding staging procedures, indications, and extension of ND, especially in increasingly complex cases. Clinical relevance Clinical decisions regarding ND are dependent on case-individual aspects and must be decided individually.
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Affiliation(s)
- Andreas Pabst
- Department of Oral and Maxillofacial Surgery, Federal Armed Forces Hospital, Rübenacherstr. 170, 56072, Koblenz, Germany.
| | - Daniel G E Thiem
- Department of Oral and Maxillofacial Surgery, University Medical Center Mainz, Augustusplatz 2, 55131, Mainz, Germany
| | - Elisabeth Goetze
- Department of Oral and Maxillofacial Surgery, University Hospital Erlangen, Glückstr. 11, 91054, Erlangen, Germany
| | - Alexander K Bartella
- Department of Oral- and Maxillofacial Surgery, University Hospital Leipzig, Liebigstr. 12, 04103, Leipzig, Germany
| | - Michael T Neuhaus
- Department of Oral and Maxillofacial Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Jürgen Hoffmann
- Department of Oral and Maxillofacial Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Alexander-N Zeller
- Department of Oral and Maxillofacial Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
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Management of High-Output Chyle Leak after Harvesting of Vascularized Supraclavicular Lymph Nodes. Plast Reconstr Surg 2019; 143:1251-1256. [PMID: 30676510 DOI: 10.1097/prs.0000000000005433] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Vascularized lymph node transfer is a physiologic microsurgical technique used for the treatment of lymphedema. As vascularized lymph node transfer is becoming more common, it is essential that one is aware of all potential complications associated with vascularized lymph node transfer and know how to avoid and manage them when they do occur. The authors recently encountered a complication after supraclavicular vascularized lymph node transfer that has not been previously reported. A patient developed a recalcitrant high-output (>500 ml/day) chyle leak in the neck donor site after supraclavicular vascularized lymph node transfer harvest. In this article, the authors share their experience with massive chyle leak and review the management strategies of how to effectively avoid and treat this potentially dangerous complication. This review of a previously unreported complication of supraclavicular vascularized lymph node transfer is timely and important, as this procedure is increasingly being offered to patients, and surgeons performing these procedures should be familiar with effectively managing this potentially dangerous complication. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, V.
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Chakedis J, Shirley LA, Terando AM, Skoracki R, Phay JE. Identification of the Thoracic Duct Using Indocyanine Green During Cervical Lymphadenectomy. Ann Surg Oncol 2018; 25:3711-3717. [PMID: 30076554 DOI: 10.1245/s10434-018-6690-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Injury to the thoracic duct (TD) is the most common complication after a left lateral neck dissection, and it carries a high degree of morbidity. Currently, no routine diagnostic imaging is used to assist with TD identification intraoperatively. This report describes the first clinical experience with lymphangiography using indocyanine green (ICG) during lateral neck dissections. METHODS In six patients undergoing left lateral neck dissection (levels 2-4) for either thyroid cancer or melanoma, 2.5-5 mg of ICG was injected in the dorsum of the left foot 15 min before imaging. Intraoperative imaging was performed with a hand-held near infrared (NIR) camera (Hamamatsu, PDE-Neo, Hamamatsu City, Japan). RESULTS In five patients, the TD was visualized using NIR fluorescence, with a time of 15-90 min from injection to identification. Imaging was optimized by positioning the camera at the angle of the mandible and pointing into the space below the clavicle. No adverse reactions from the ICG injection occurred, and the time required for imaging was 5-10 min. No intraoperative TD injury was identified, and no chyle leak occurred postoperatively. For the one patient in whom the TD was not identified, it is unclear whether this was related to the timing of the injection or to duct obliteration from a prior dissection. CONCLUSION This is the first described application of ICG lymphangiography to identify the thoracic duct during left lateral neck dissection. Identification of TD with ICG is technically feasible, simple to perform with NIR imaging, and safe, making it a potential important adjunct for the surgeon.
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Affiliation(s)
- Jeffery Chakedis
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH, USA
| | - Lawrence A Shirley
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH, USA
| | - Alicia M Terando
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH, USA
| | - Roman Skoracki
- Division of Oncologic Plastic Surgery, Department of Plastic Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH, USA
| | - John E Phay
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH, USA.
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Delaney SW, Shi H, Shokrani A, Sinha UK. Management of Chyle Leak after Head and Neck Surgery: Review of Current Treatment Strategies. Int J Otolaryngol 2017; 2017:8362874. [PMID: 28203252 PMCID: PMC5288539 DOI: 10.1155/2017/8362874] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 12/07/2016] [Indexed: 11/17/2022] Open
Abstract
Chyle leak formation is an uncommon but serious sequela of head and neck surgery when the thoracic duct is inadvertently injured, particularly with the resection of malignancy low in the neck. The thoracic duct is the primary structure that returns lymph and chyle from the entire left and right lower half of the body. Chyle extravasation can result in delayed wound healing, dehydration, malnutrition, electrolyte disturbances, and immunosuppression. Prompt identification and treatment of a chyle leak are essential for optimal surgical outcome. In this article we will review the current treatment options for iatrogenic cervical chyle leaks.
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Affiliation(s)
- Sean W. Delaney
- Department of Otolaryngology Head and Neck Surgery, Keck School of Medicine, University of Southern California, 1540 Alcazar St, Suite 204Q, Los Angeles, CA 90033, USA
| | - Haoran Shi
- Department of Biochemistry and Molecular Biology, University of Southern California, Los Angeles, CA, USA
| | - Alireza Shokrani
- Department of Otolaryngology Head and Neck Surgery, Keck School of Medicine, University of Southern California, 1540 Alcazar St, Suite 204Q, Los Angeles, CA 90033, USA
| | - Uttam K. Sinha
- Department of Otolaryngology Head and Neck Surgery, Keck School of Medicine, University of Southern California, 1540 Alcazar St, Suite 204Q, Los Angeles, CA 90033, USA
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Chen CY, Chen YH, Shiau EL, Liang HL, Chang HS, Chen HC. Therapeutic role of ultrasound-guided intranodal lymphangiography in refractory cervical chylous leakage after neck dissection: Report of a case and review of the literature. Head Neck 2015; 38:E54-60. [DOI: 10.1002/hed.24134] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2015] [Indexed: 12/14/2022] Open
Affiliation(s)
- Chia-Yu Chen
- Department of Oromaxillofacial Surgery; Kaohsiung Veterans General Hospital; Kaohsiung Taiwan
- Department of Stomatology; Kaohsiung Veterans General Hospital; Kaohsiung Taiwan
| | - Yu-Hung Chen
- Department of Oromaxillofacial Surgery; Kaohsiung Veterans General Hospital; Kaohsiung Taiwan
- Department of Stomatology; Kaohsiung Veterans General Hospital; Kaohsiung Taiwan
| | - En-Li Shiau
- Department of Radiology; Kaohsiung Veterans General Hospital; Kaohsiung Taiwan
| | - Hui-Lung Liang
- Department of Radiology; Kaohsiung Veterans General Hospital; Kaohsiung Taiwan
| | - Hao-Sheng Chang
- Department of Stomatology; Kaohsiung Veterans General Hospital; Kaohsiung Taiwan
- Dental Laboratory Technology; Shu Zen College of Medicine and Management; Kaohsiung Taiwan
| | - Hung-Chih Chen
- Department of Oromaxillofacial Surgery; Kaohsiung Veterans General Hospital; Kaohsiung Taiwan
- Dental Laboratory Technology; Shu Zen College of Medicine and Management; Kaohsiung Taiwan
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Biometric measurements involving the terminal portion of the thoracic duct on left cervical level IV: an anatomic study. Anat Sci Int 2015; 91:274-9. [DOI: 10.1007/s12565-015-0295-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 07/31/2015] [Indexed: 10/23/2022]
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Abstract
PURPOSE OF REVIEW The present review is focused on the management of lymphatic, chylous, and thoracic duct lesions following head and neck surgery, with particular attention to these complications after neck dissection. Postoperative scenarios may include chylous fistula, chylothorax, chylomediastinum, chylopericardium, lymphocele, persistent lymphorrhea, and secondary lymphedema. RECENT FINDINGS There is a paucity of literature on the treatment of lymphatic, chylous, and thoracic duct injuries following head and neck surgery; however, this review suggests that the most appropriate treatment should include both conservative and surgical approaches. Nonsurgical options consist of low-fat diet with medium-chain triglycerides, total parenteral nutrition, careful monitoring of fluid and electrolytes, drainage of the leakage, somatostatin analogs such as octreotide, and negative-pressure wound therapy. On the other hand, surgical management includes therapeutic percutaneous lymphography-guided thoracic duct cannulation and embolization, thoracic duct ligation, excision and imbrication of leaking lymphatics, chylous fistula surgical/microsurgical repair, fistula closure by locoregional flaps, video-assisted thoracoscopic surgery, thoracotomy, pleurodesis and decortication, pericardial 'window', and pleura-venous/pleura-peritoneal shunts. In addition, single or, preferably, multiple lymphovenous anastomoses may be taken into account. SUMMARY The various possible clinical presentations of such challenging lymphatic, chylous, and thoracic duct injuries require an appropriate multidisciplinary approach by experienced teams. Primary prevention of these complications can be achieved through adequate surgical planning to minimize lesions, including structured and thorough patient assessment, and centralization of resources and teams.
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Current World Literature. Curr Opin Oncol 2013; 25:325-30. [DOI: 10.1097/cco.0b013e328360f591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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