A prospective study on the role of Octreotide in management of chyle fistula neck

The Silent Spill: A Case Report on Navigating the Challenges of a Chyle Leak

A chyle leak occurs due to a discontinuity in the thoracic duct. It is a very rare condition that occurs as a result of injuries or surgical procedures. Chyle is rich in antibodies. Its functions are to maintain the equilibrium of the human fluid system, draw in fatty acids, and maintain the natural immunity of humans. It is identified by the increased quantity of drains, which show a milky white color and clinically palpable supraclavicular collection. It is a condition that has to be managed as soon as possible as it leads to serious nutritional debridement, electrolyte imbalance, and complications such as chylothorax and chylomediastinum. It is managed by various surgical and conservative approaches, such as ligating the thoracic duct, using sclerosing agents, giving total parenteral nutrition, and restricting physical activities, as discussed in this article.

Usefulness of preoperative ice cream consumption and novel postoperative drainage management in patients undergoing left-sided neck dissection for thyroid cancer: a nonrandomized prospective study

PURPOSE

This study investigated the effects of ice cream consumption on chyle leakage after left lateral neck dissection in patients with thyroid cancer.

METHODS

A total of 491 patients with thyroid cancer underwent left lateral neck dissection with identification of the thoracic duct following ice cream consumption. Before closing the wound, the anesthesiologist increased the intrathoracic pressure to observe chyle leakage. If chyle leakage occurred postoperatively, the drain was removed using the drain negative pressure release test.

RESULTS

Postoperative chyle leakage was observed in 18 of the 491 patients who underwent left lateral neck dissection. We treated 17 patients conservatively and 1 patient surgically. Drains were removed within five days in all patients. After the drain negative pressure release test had been performed in eight patients, the drainage volume significantly decreased from an average of 175 ml to 31 ml per day. The average number of days until the removal of the drainage tube was 3.2 days. No perioperative complications were associated with ice cream consumption.

CONCLUSIONS

In left lateral neck dissection for thyroid cancer, performing surgery following ice cream consumption does not completely prevent chyle leakage; however, early drain removal is possible because there is only mild leakage.

The application of a medium-chain fatty diet and enteral nutrition in post-operative chylous leakage: analysis of 63 patients

Background

Post-operative chylous leakage (CL) is the pathologic leakage of chylomicron fluid after surgery. This retrospective study was performed to evaluate a uniform oral nutrition management strategy on the post-operative CL.

Methods

We retrospectively reviewed patients who developed post-operative CL and received consultation from a clinical nutritionist in seven departments of the Second Affiliated Hospital of Dalian Medical University from May 2020 to April 2022. We designed the oral nutrition intervention program which mainly standardized the type and amount of foods contained in the medium-chain triglyceride (MCT) diet. The influencing factors of curative efficacy were analyzed. Finally, binary logistic regression analysis was conducted to observe the relationship between curative efficacy and potentially predictive variables, including post-operative albumin, post-operative hemoglobin, surgical procedure, and drainage volume at consultation.

Results

Sixty-three patients with post-operative CL were included in this analysis. Of this number, 58 patients were cured successfully without other treatments. Three patients had a significantly prolonged recovery period, and the remaining two cases were treated by reoperation therapy. The leakage volume at the initiation of enteral intervention had no statistically significant difference in seven surgical departments and surgical sites (left, right, median, and bilateral). The length of stay (LOS) of patients with CL after the intervention was not significantly increased in cardiac, hepatobiliary, gastrointestinal, and urological surgeries. Patients with CL had longer LOS than those without CL in gynecology (P=0.044) and thyroid surgery departments (P=0.008). Each unit increase in post-operative hemoglobin would increase the probability of an effective outcome by 8%, which was statistically significant (P = 0.037).

Conclusion

In treating patients with post-operative CL, we recommend the MCT diet and EN as the first option, rather than fasting, parenteral nutrition (PN), or octreotide.

Role of Octreotide in Conservative Management of Chyle Leak Post Neck Dissection in Cases of Head Neck Cancer: A Retrospective Analysis

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.

Management of Chyle Leak After Head and Neck Surgery; Our Meritorious Experience in 52 Cases and Review of Literature

Iatrogenic chyle leak is commonly seen when dissection happens very low in neck. Management of chyle leak is conservative with compression dressing, fat restricted diet, somatostatin analogues. Surgery is required in extreme cases with failure of conservative treatment. This is a retrospective observational study carried out from a prospectively maintained database. A total of 6482 head and neck surgeries with neck dissections were carried out between January 2015 till July 2020 at our tertiary cancer center. Out of which there were 52 cases of chyle leak reported post neck dissection. All details regarding age, sex, primary tumor location, surgery performed, level of nodal dissection performed, details related to chyle leak from beginning day and its progression and management offered. The median age in the study group was 42 years (24-70 years). Chyle leak was most commonly seen on left side (88.5%). Low output leaks(n = 43) resolved within a median period of 9 days (5-13 days) period of conservative management. High output leak (n = 9) had leak resolution within a median period of 12 days (7-19 days). Patients who had received preoperative radiotherapy and who had extra nodal extension in lymph nodes had significantly higher incidence of high output leaks. Chyle leak is a rare but serious complication in head and neck surgery. Timely identification and management is crucial. Conservative management is mainstay. Surgical management is instituted in cases of failure of conservative management.

Effect of Octreotide in stopping post surgical chyle leak in neck Dissection-A systematic review

Objective

Neck dissection causes an unusual and challenging complication called Chyle Leak. Octreotide, a long-acting somatostatin analogue, is one way Chyle Leak can be managed faster and effectively. The objective of the review was to evaluate the efficiency of Octreotide in stopping post surgical Chyle Leak in neck dissection.

Methods

Three electronic database and manual search was undertaken to identify the literature. All the published articles, which included data about Octreotide used to stop post-surgical Chyle leak in neck dissection, published in the English language between January 1, 2010 to May 31, 2022 were included. Joanna Briggs critical assessment tool was used to assess the included studies.

Results

Preliminary screening of 206 studies from data sources and ten from additional sources was done. After necessary exclusion, ten studies were included for qualitative synthesis. The data included 65 patients with neck dissections followed by Chyle leak postoperatively. Chyle leak was presented from 0-8th POD (range of 150 ml-2500 ml). 100mcg-eight hourly subcutaneously was given in maximum studies for 2-14 days. A gradual reduction in chyle leak started 2-4 days after the administration. The chyle leak completely resolved within 2-11 days in the majority of cases with conservative treatment and Octreotide.

Conclusion

Octreotide Therapy with primary treatment is an effective way of stopping Chyle Leak in Neck Dissection. However, well-designed and robust randomized controlled studies are needed to confirm the results in the future.

An unusual complication of tumor surgery: chylous leakage

PURPOSE

This study was designed to evaluate the effectiveness of conservative treatment for chylous leak after tumor surgery and to propose a management algorithm.

METHODS

The data of patients with postoperative chylous leak after tumor surgery in our institution between 2010 and 2019 were retrospectively reviewed. In this study, 469 laparotomies, 89 thoracotomies, and 57 cervical excisions were performed for tumor surgery in our institution.

RESULTS

Twelve patients with a median age of 4 (IQR, 3-8) years had postoperative chylous leak. All patients received total parenteral nutrition for a median of 13 days. Five patients had intravenous somatostatin for a median of 14 days (IQR, 9-16) to decrease chyle production. Eventually, chylous leak ceased in all patients with conservative treatment and surgical drains were removed after no leak was observed with enteral feeding.

CONCLUSIONS

The incidence of chylous leak in childhood tumor surgery is approximately 2%. Extended tumor resection and lymph node dissection lead to the injury of the delicate structures that drain chyle. Conservative treatment with total parenteral nutrition and somatostatin seems to be effective. In particular, somatostatin may be used in resistant cases. Conservative treatment can take up to 1 month. The algorithm consists of how to manage postoperative chylous leak in childhood.

Early diagnosis of chyle fistula with SD LipidoCare after neck dissection

OBJECTIVE

This study aimed to analyse the results of chyle fistula testing using the SD LipidoCare system in patients who had undergone neck dissections performed in our hospital in 2019.

METHOD

Sixty patients who underwent neck dissections from March 2019 to November 2019 were identified based on their medical records.

RESULTS

Post-operative chyle fistulas were observed in 3 of 60 patients (5 per cent). All patients who developed chyle fistulas had undergone left-sided neck dissections. Within 3 minutes, the SD LipidoCare test had produced triglyceride results of 49, 56 and 207 mg/dl in the three patients. The remaining 57 patients measured 'low' for triglycerides on the SD LipidoCare test system.

CONCLUSION

The SD LipidoCare test quickly and accurately diagnosed chyle fistulas in patients who had undergone neck dissections. All patients improved with conservative treatment following the early diagnosis of chyle fistulas.

Octreotide versus oral dietary modification for the treatment of chylous fistula following neck dissection: A systematic review and meta-analysis

AIMS

Chylous fistula following neck surgery is a rare, but significant complication. Currently, there is no standardised treatment, which may comprise pressure dressings, oral dietary modification (ODM), surgery or a combination of such measures. Octreotide is a somatostatin analogue that has gained popularity in the management of cervical chyle leaks. The effectiveness of octreotide compared with ODM is unclear. We provide a comprehensive, systematic review of the literature pertaining to the management of chylous fistulae, comparing both treatment strategies.

METHODS

The bibliographic databases MEDLINE, Cochrane, PubMed, EMBASE and Google Scholar were searched from inception to October 2019. Search terms included (chyle [title/abstract]) OR (chylous [title/abstract]) AND (fistula [title/abstract]) OR (fistulae [title/abstract]) OR (leak [title/abstract]) AND (neck [title/abstract]) OR (dissection [title/abstract]). The study was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Risk of bias was assessed using guidelines from the Joanna Briggs Institute. Outcome measures included the proportion of chylous fistulae that spontaneously resolved without the need for surgery and time taken until resolution, for both DM and octreotide, respectively.

RESULTS

The primary search identified 20 articles for review, comprising 313 patients. Two studies were suitable for pooled analysis. There was no statistically significant difference in the time taken for chylous fistula to resolve between groups (octreotide 10.0 days; ODM 12.0 days; P = .38). The overall rate of resolution was 89.6% and 81.5%, respectively (P = .25). Surgery was highly effective in cases failing to resolve following intervention with either method (96% [53/55] patients).

CONCLUSION

The use of octreotide for chylous fistula following neck dissection surgery is associated with a high rate of spontaneous resolution. However, significant heterogeneity, bias and concurrent use of ODM/TPN for patients in studies investigating octreotide precludes universal recommendation at this time. Further research in the form of randomised controlled trials is required to establish an independent treatment effect.

The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults

OBJECTIVE

To develop evidence-based recommendations for safe, effective, and appropriate thyroidectomy.

BACKGROUND

Surgical management of thyroid disease has evolved considerably over several decades leading to variability in rendered care. Over 100,000 thyroid operations are performed annually in the US.

METHODS

The medical literature from 1/1/1985 to 11/9/2018 was reviewed by a panel of 19 experts in thyroid disorders representing multiple disciplines. The authors used the best available evidence to construct surgical management recommendations. Levels of evidence were determined using the American College of Physicians grading system, and management recommendations were discussed to consensus. Members of the American Association of Endocrine Surgeons reviewed and commented on preliminary drafts of the content.

RESULTS

These clinical guidelines analyze the indications for thyroidectomy as well as its definitions, technique, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Fine Needle Aspiration Biopsy Diagnosis, Molecular Testing, Indications, Extent and Outcomes of Surgery, Preoperative Care, Initial Thyroidectomy, Perioperative Tissue Diagnosis, Nodal Dissection, Concurrent Parathyroidectomy, Hyperthyroid Conditions, Goiter, Adjuncts and Approaches to Thyroidectomy, Laryngology, Familial Thyroid Cancer, Postoperative Care and Complications, Cancer Management, and Reoperation.

CONCLUSIONS

Evidence-based guidelines were created to assist clinicians in the optimal surgical management of thyroid disease.

Critical Care and Postoperative Management of the Head and Neck Patient

Head and neck surgical patients, at times, can represent a challenging population to manage in the intensive care unit postoperatively. Close interaction between the critical care and surgical teams, awareness of potential surgery-specific complications, and utilization of protocol-driven care can reduce risk of morbidity significantly in this population and enhance outcomes. Given the relative complexity of otolaryngologic surgery and the unique risk that head and neck pathologies can pose to patient airway, breathing, and circulation, these collective circumstances warrant detailed discussion in the interest of minimizing patient morbidity and mortality.

A systematic review of chyle leaks and their management following axillary surgery

INTRODUCTION

Chyle leaks following surgery to the axilla are seldom encountered with an incidence <0.7%. Management varies with no consensus in the literature. Injury to branching tributaries of the thoracic duct may require lengthy management at significant cost to patient and clinical team. This paper aims to provide an up-to-date review to support clinical management.

METHODS

The term 'chyle' was combined with 'breast' or 'axilla.' EMBASE, Medline and PubMed database searches were conducted. All papers published in English were included with no exclusion date limits.

RESULTS

51 cases from 31 papers. All were female (mean age = 53.3yrs). 47/51 leaks were left-sided. 5/51 underwent sentinel node biopsy, 19/51 level II axillary node clearance (ANC), 23/51 level III ANC, 5/51 not specified. 59% (30/51) of leaks were identified within 2 postoperative days (mean = 3.3days). 96% initially managed conservatively: Drain = 38/51; low-fat diet = 34/51; compression bandaging = 20/51; Aspiration = 6/51. 40/51 (78%) were successfully managed conservatively, 11 patients returned to theater for secondary management. 7/11 recorded volumes >500mls/24 hrs before secondary surgery. Mean resolution time from initial surgery was 17.3days (range = 4-64days). No statistically significant difference (p = 0.72) in time to resolution between conservatively and surgically managed patients.

CONCLUSIONS

Chyle leaks are rarely seen following axillary surgery. Aberrant thoracic duct anatomy represents the likeliest aetiology. We advocate early recognition and tailored individual management. Conservative management with non-suction drainage, low-fat diet and axillary compression bandaging appear effective where output <500ml/24 hrs. Secondary surgical management should be considered in high chylous output (<500mls/24 hrs) patients unresponsive to conservative measures. We propose a management algorithm to aide clinicians.

Diagnosis and management of chyle leak following axillary dissection

Chyle leak following oncological breast and axillary surgery is a rare complication with small number of reported cases in the literature and little formal guidance regarding management. We present a review of the current literature and further related guidance from other specialties, along with suggested strategies for identification, diagnosis and management of this uncommon but potentially significant complication.

Ultrasound-guided percutaneous injection of Pseudomonas aeruginosa-mannose sensitive hemagglutinin for treatment of chyle fistula following neck dissection: Two case reports

RATIONALE

Chyle fistula is a rare but troublesome complication of neck dissection. Topical application of Pseudomonas aeruginosa-mannose sensitive hemagglutinin (PA-MSHA) injection has been reported as a novel, viable, and effective approach in the treatment of chyle fistula following neck dissection. However, there have been no reports regarding the treatment of chyle fistula using ultrasound (US)-guided percutaneous injection of PA-MSHA.

PATIENT CONCERNS

We describe 2 patients with thyroid cancer who developed chyle fistula following neck dissection, which remained unresolved despite the use of conservative treatment.

DIAGNOSES

Both the patients were diagnosed with chyle fistula by laboratory testing, which showed that drainage fluid triglyceride concentration was >100 mg/dL.

INTERVENTIONS

When conservative treatment failed, a 2 mL undiluted PA-MSHA preparation was percutaneously injected at the effusion site of the left supraclavicular area under US guidance with aseptic technique. Concomitantly, the drainage tube was clamped for at least 30 minutes.

OUTCOMES

Chyle fistula in both patients were successfully resolved with this technique within 2 or 4 days, without notable side effects.

LESSONS

US-guided percutaneous injection of PA-MSHA is a simple and effective method to treat chyle fistula following neck dissection, which may serve as a useful addition to the medical treatment for cervical chyle fistula.

Pseudomonas aeruginosa-mannose sensitive hemagglutinin injection therapy for the treatment of chyle fistula following neck dissection

BACKGROUND

The efficacy of Pseudomonas aeruginosa-mannose sensitive hemagglutinin (PA-MSHA) injection therapy in the treatment of chyle fistula following neck dissection is unclear.

METHODS

This prospective study enrolled 26 patients who developed chyle fistula after neck dissection. Patients were divided into high-output (>500 mL) and low-output groups (≤500 mL) and were initially treated conservatively for 5 days in the high-output group or 7 days in the low-output group. When conservative treatment failed, topical PA-MSHA therapy was applied.

RESULTS

Twelve of 26 patients were cured with conservative treatment, and the remaining 14 patients were all successfully resolved by PA-MSHA therapy. Chyle fistula got resolved in the low-output and high-output groups after the initiation of therapy were at a median 1 days and 6 days, respectively. Among them, 12 (85.7%) patients experienced fever and 11 (78.6%) patients experienced neck pain.

CONCLUSIONS

Topical PA-MSHA injection therapy could effectively manage chyle fistula following neck dissection.

High Output Chylous Fistula Post First Rib Resection

We present a patient who developed high output chyle leak post left first-rib resection for neurogenic thoracic outlet syndrome. The persistent high output chylorrhea was refractory to 3 surgical reexplorations attempting to ligate leaking branches, bed rest, nonfat diet, parenteral nutrition, octreotide administration, and vacuum-assisted closure (VAC) therapy. In addition, she developed hypovolemia, hyponatremia, and hypoalbuminemia. Control of the chylous fistula was achieved by reattaching the sternocleidomastoid muscle laterally to protect the phrenic nerve and brachial plexus in order to redirect chyle to the medial portion of the neck incision site. This was supported by the application of fibrin sealants in combination with VAC therapy. The patient was discharged after a 27-day hospital stay with complete resolution of her chylous fistula prior to discharge.

Management of High-Output Chyle Leak after Harvesting of Vascularized Supraclavicular Lymph Nodes

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.

Chyle fistula in advanced and metastatic thyroid cancer

Background

Chyle fistula (CF) is a rare but challenging condition for the surgeon and the patient's health.

Methods

A retrospective review of single surgeon's case load in a 12-year period is presented, reviewing the case of those patients presenting with a CF.

Results

Three patients were found during this study period from more than 1,050 surgeries performed due to thyroid cancer. Patients underwent extensive lymph node dissection for advanced, metastatic and infiltrative disease. In all patients, a long hospital stay and surgical re-interventions were required.

Conclusions

A description of the management of CF is presented along with a review of current Literature.

Management of Chyle Leak after Head and Neck Surgery: Review of Current Treatment Strategies

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.

Chylous Fistula following Axillary Lymphadenectomy: Benefit of Octreotide Treatment

Chyle leak following axillary lymph node clearance is a rare yet important complication. The treatment of postoperative chyle fistula still remains unclear. Conservative management is the first line of treatment. It includes axillary drains on continuous suction, pressure dressings, bed rest, and nutritional modifications. The use of somatostatin analogue is well documented as a treatment for chylous fistulas after neck surgery. We present a case of chylous fistula after axillary surgery resolved with the use of octreotide.