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Smith R, Higginson J, Breik O, Praveen P, Parmar S. Nutritional management of chyle leak after head and neck surgery: a systematic review and proposed protocol for management. Oral Maxillofac Surg 2024; 28:51-62. [PMID: 37014458 DOI: 10.1007/s10006-023-01152-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/26/2023] [Indexed: 04/05/2023]
Abstract
PURPOSE Chyle leaks are a rare complication of neck surgery causing local damage, impairing healing and compromising free flaps. High output leaks can result in electrolyte imbalances and malnutrition. Nutritional management such as restricting the absorption of triglycerides is believed to reduce chyle, allowing spontaneous resolution of a leak. Dietary preparations and management can aid in reducing chyle production. There are no clear guidelines to aid nutritional decision-making in this complex scenario. METHODS A systematic review of the literature was carried out to identify studies evaluating nutritional management of chyle leaks in patients after neck dissections. RESULTS Ten studies were identified evaluating the role of nutritional therapy in the management of patients with chyle leaks after neck dissections. The level of evidence was low. Several studies identified that low volume leaks (defined as < 1000 mls per day) often resolved by dietary management and other conservative measures. High volume leaks rarely resolved with conservative measures alone. Parenteral nutrition had an established role in this context. CONCLUSIONS There is limited evidence to guide dietary restriction and introduction of oral diet in patients with chyle leak after major head and neck surgery. Based on available evidence, local guidelines for the nutritional management of patients identified with a chyle leak were produced and adopted by the Trust and the head and neck MDT. A national database for voluntary contribution of prospective data would help to generate better quality management protocols.
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Affiliation(s)
- Rebekah Smith
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
| | - James Higginson
- Faculty of Medicine, Imperial College London, and the International Centre for Recurrent Head & Neck Cancer, Royal Marsden Hospital, London, UK
| | - Omar Breik
- Royal Brisbane and Womens Hospital, Brisbane, Australia
| | - Prav Praveen
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Sat Parmar
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Closed-suction compared with Penrose drainage after free flap reconstruction in the head and neck. Br J Oral Maxillofac Surg 2019; 57:1098-1101. [PMID: 31635760 DOI: 10.1016/j.bjoms.2019.10.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 10/01/2019] [Indexed: 11/21/2022]
Abstract
Microsurgical free flaps are common in head and neck reconstruction, and their techniques and outcomes have continuously improved during the past decades. However, there are variations in practice among surgeons between the use of closed-suction drainage systems and Penrose drains. The proponents of Penrose drains propose that the negative pressure generated by the closed-suction drainage system may harm the microvascular anastomosis. We know of no previous studies that have compared the two drains for microvascular free flap reconstruction, so our aim was to compare them in a single-centre, retrospective review of all patients who had microvascular free flap reconstruction of the head and neck region in our department between 1 November 2010 and 1 September 2017. During this period 84 patients had 87 free flap reconstructions in the head and neck, 43 of which had Penrose, and 44 closed-suction, drainage. We compared the number of complications between the groups including haematomas, seromas, wound infections, anastomostic thrombosis, anastomotic revision, and need for re-exploration. There were no significant differences between the groups, despite a trend toward fewer negative explorations in the closed-suction group. There were no differences in complications between suction and passive drainage systems after microvascular free flaps, which suggests that closed suction drainage could be safely used after free flap reconstruction in the head and neck.
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Worrall DM, Tanella A, DeMaria S, Miles BA. Anesthesia and Enhanced Recovery After Head and Neck Surgery. Otolaryngol Clin North Am 2019; 52:1095-1114. [PMID: 31551127 DOI: 10.1016/j.otc.2019.08.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Enhanced recovery protocols have been developed from gastrointestinal, colorectal, and thoracic surgery populations. The basic tenets of head and neck enhanced recovery are: a multidisciplinary team working around the patient, preoperative carbohydrate loading, multimodal analgesia, early mobilization and oral feeding, and frequent reassessment and auditing of protocols to improve patient outcomes. The implementation of enhanced recovery protocols across surgical populations appear to decrease length of stay, reduce cost, and improve patient satisfaction without sacrificing patient quality of care or changing readmission rates. This article examines evidence-based enhanced recovery interventions and tailors them to a major head and neck surgery population.
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Affiliation(s)
- Douglas M Worrall
- Department of Otolaryngology, Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place Box 1189, New York, NY 10029, USA
| | - Anthony Tanella
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place Box 1010, New York, NY 10029, USA
| | - Samuel DeMaria
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place Box 1010, New York, NY 10029, USA
| | - Brett A Miles
- Department of Otolaryngology, Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place Box 1189, New York, NY 10029, USA.
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Li S, Huang Z, Chen W, Pan C, Huang Z. Risk factors for postoperative hemorrhage in patients with oral squamous cell carcinoma: A retrospective study. Head Neck 2019; 41:2093-2099. [PMID: 30706556 DOI: 10.1002/hed.25659] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 12/22/2018] [Accepted: 01/04/2019] [Indexed: 12/26/2022] Open
Affiliation(s)
- Shihao Li
- Department of Oral and Maxillofacial SurgerySun Yat‐sen Memorial Hospital, Sun Yat‐sen University Guangzhou Guangdong China
| | - Zixian Huang
- Department of Oral and Maxillofacial SurgerySun Yat‐sen Memorial Hospital, Sun Yat‐sen University Guangzhou Guangdong China
| | - Weiliang Chen
- Department of Oral and Maxillofacial SurgerySun Yat‐sen Memorial Hospital, Sun Yat‐sen University Guangzhou Guangdong China
| | - Chaobin Pan
- Department of Oral and Maxillofacial SurgerySun Yat‐sen Memorial Hospital, Sun Yat‐sen University Guangzhou Guangdong China
| | - Zhiquan Huang
- Department of Oral and Maxillofacial SurgerySun Yat‐sen Memorial Hospital, Sun Yat‐sen University Guangzhou Guangdong China
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Lin PY, Liou TL, Lin KC, Hsieh MH, Chien CY, Hsieh CH. Immediate Negative Pressure Wound Therapy After Free Flap Transfer for Head and Neck Cancer Surgery. Laryngoscope 2018; 128:2478-2482. [PMID: 30247762 DOI: 10.1002/lary.27169] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Revised: 02/01/2018] [Accepted: 02/13/2018] [Indexed: 12/29/2022]
Affiliation(s)
- Pao-Yuan Lin
- Department of Plastic and Reconstructive Surgery; Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine; Kaohsiung Republic of China
| | - Tz-Luen Liou
- Department of Plastic and Reconstructive Surgery; Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine; Kaohsiung Republic of China
| | - Ko-Chien Lin
- Department of Plastic and Reconstructive Surgery; Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine; Kaohsiung Republic of China
| | - Mu-Han Hsieh
- Department of Plastic and Reconstructive Surgery; Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine; Kaohsiung Republic of China
| | - Chih-Yen Chien
- Department of Otolaryngology; Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine; Kaohsiung Republic of China
| | - Ching-Hua Hsieh
- Department of Plastic and Reconstructive Surgery; Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine; Kaohsiung Republic of China
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Ikeshima R, Mizushima T, Takahashi H, Haraguchi N, Nishimura J, Hata T, Matsuda C, Ikenaga M, Nakajima K, Yamamoto H, Murata K, Doki Y, Mori M. The efficacy of active drainage for preventing postoperative organ/space surgical site infections in patients with Crohn's disease. Surg Today 2017; 48:25-32. [PMID: 28608250 DOI: 10.1007/s00595-017-1549-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 05/11/2017] [Indexed: 11/11/2022]
Abstract
PURPOSE Patients with Crohn's disease (CD) show a higher incidence of surgical site infections (SSIs) after bowel resection in comparison to other patient populations because CD patients commonly suffer from anemia, malnutrition, and immunosuppression. In comparison to conventional passive drainage, active drainage using a closed-suction drain reportedly reduces postoperative wound-related complications in several diseases. In the present study, we aimed to investigate the incidence of SSI and to identify the risk factors for SSI in patients with CD. METHODS We retrospectively analyzed the patient characteristics and perioperative data of 106 CD patients who underwent bowel resection at our institution between January 2000 and June 2016. We statistically analyzed the incidence of different types of SSI (overall, incisional, and organ/space) in relation to patient-related and surgery-related risk factors. RESULTS Overall postoperative SSIs were diagnosed in 19 patients (17.9%), including incisional SSI (n = 16; 15.1%), organ/space SSI (n = 7; 6.6%), and both (n = 4; 3.8%). A long operative time (p = 0.036) and colonic involvement (p = 0.011) were significantly associated with the overall risk of developing an SSI. Active drainage significantly reduced the incidence of organ/space SSI (p = 0.037). CONCLUSION Intraabdominal active drainage was more useful than passive drainage for preventing organ/space SSI development.
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Affiliation(s)
- Ryo Ikeshima
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Tsunekazu Mizushima
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan. .,Department of Therapeutics for Inflammatory Bowel Diseases, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan.
| | - Hidekazu Takahashi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Naotsugu Haraguchi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Junichi Nishimura
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Taishi Hata
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Chu Matsuda
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Masakazu Ikenaga
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan.,Department of Gastroenterological Surgery, Higashiosaka City Medical Center, Osaka, Japan.,Japan Department of Surgery, Higashiosaka City General Hospital, Osaka, Japan
| | - Kiyokazu Nakajima
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Hirofumi Yamamoto
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Kohei Murata
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan.,Department of Surgery, Suita Municipal Hospital, Osaka, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
| | - Masaki Mori
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Yamadaoka 2-2, Suita, Osaka, 565-0871, Japan
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Čečka F, Loveček M, Jon B, Skalický P, Šubrt Z, Neoral Č, Ferko A. Intra-abdominal drainage following pancreatic resection: A systematic review. World J Gastroenterol 2015; 21:11458-68. [PMID: 26523110 PMCID: PMC4616221 DOI: 10.3748/wjg.v21.i40.11458] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 06/25/2015] [Accepted: 09/30/2015] [Indexed: 02/06/2023] Open
Abstract
AIM To study all the aspects of drain management in pancreatic surgery. METHODS We conducted a systematic review according to the PRISMA guidelines. We searched the Cochrane Central Registry of Controlled Trials, EMBASE, Web of Science, and PubMed (MEDLINE) for relevant articles on drain management in pancreatic surgery. The reference lists of relevant studies were screened to retrieve any further studies. We included all articles that reported clinical studies on human subjects with elective pancreatic resection and that compared various strategies of intra-abdominal drain management, such as drain vs no drain, selective drain use, early vs late drain extraction, and the use of different types of drains. RESULTS A total of 19 studies concerned with drain management in pancreatic surgery involving 4194 patients were selected for this systematic review. We included studies analyzing the outcomes of pancreatic resection with and without intra-abdominal drains, studies comparing early vs late drain removal and studies analyzing different types of drains. The majority of the studies reporting equal or superior results for pancreatic resection without drains were retrospective and observational with significant selection bias. One recent randomized trial reported higher postoperative morbidity and mortality with routine omission of intra-abdominal drains. With respect to the timing of drain removal, all of the included studies reported superior results with early drain removal. Regarding the various types of drains, there is insufficient evidence to determine which type of drain is more suitable following pancreatic resection. CONCLUSION The prophylactic use of drains remains controversial. When drains are used, early removal is recommended. Further trials comparing types of drains are ongoing.
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Wang Q, Jiang YJ, Li J, Yang F, Di Y, Yao L, Jin C, Fu DL. Is routine drainage necessary after pancreaticoduodenectomy? World J Gastroenterol 2014; 20:8110-8118. [PMID: 25009383 PMCID: PMC4081682 DOI: 10.3748/wjg.v20.i25.8110] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Revised: 02/13/2014] [Accepted: 03/06/2014] [Indexed: 02/06/2023] Open
Abstract
With the development of imaging technology and surgical techniques, pancreatic resections to treat pancreatic tumors, ampulla tumors, and other pancreatic diseases have increased. Pancreaticoduodenectomy, one type of pancreatic resection, is a complex surgery with the loss of pancreatic integrity and various anastomoses. Complications after pancreaticoduodenectomy such as pancreatic fistulas and anastomosis leakage are common and significantly associated with patient outcomes. Pancreatic fistula is one of the most important postoperative complications; this condition can cause intraperitoneal hemorrhage, septic shock, or even death. An effective way has not yet been found to avoid the occurrence of pancreatic fistula. In most medical centers, the frequency of pancreatic fistula has remained between 9% and 13%. The early detection and routine drainage of anastomotic fistulas, pancreatic fistulas, bleeding, or other intra-abdominal fluid collections after pancreatic resections are considered as important and effective ways to reduce postoperative complications and the mortality rate. However, many recent studies have argued that routine drainage after abdominal operations, including pancreaticoduodenectomies, does not affect the incidence of postoperative complications. Although inserting drains after pancreatic resections continues to be a routine procedure, its necessity remains controversial. This article reviews studies of the advantages and disadvantages of routine drainage after pancreaticoduodenectomy and discusses the necessity of this procedure.
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A prospective randomized controlled trial of subcutaneous passive drainage for the prevention of superficial surgical site infections in open and laparoscopic colorectal surgery. Int J Colorectal Dis 2014; 29:353-8. [PMID: 24385026 DOI: 10.1007/s00384-013-1810-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/24/2013] [Indexed: 02/04/2023]
Abstract
INTRODUCTION A number of studies have evaluated the effects of subcutaneous drainage during digestive surgery. All of the previous studies assessed the usefulness of active-suctioning drain, including two randomized controlled studies which found no benefit for the placement of active-suctioning drains in digestive surgery. The utility of passive drainage has not been evaluated previously. The purpose of this study was to evaluate the efficacy of subcutaneous passive drainage system for preventing surgical site infections during major colorectal surgery. PATIENTS AND METHODS A total of 263 patients who underwent major colorectal surgery were enrolled in this study. Patients were randomly assigned to receive subcutaneous passive drainage or no drainage. The primary outcome measured was the incidence of superficial surgical site infections. The secondary outcomes measured were the development of hematomas, seromas, and wound dehiscence. RESULTS Finally, a total of 246 patients (124 underwent passive drainage, and 122 underwent no drainage) were included in the analysis after randomization. There was a significant difference in the incidence of superficial surgical site infections between patients assigned to the passive drainage and no drainage groups (3.2 % vs 9.8 %, respectively, P = 0.041). There were no cases that developed a hematoma, seroma, or wound dehiscence in either group. A subgroup analysis revealed that male gender, age ≥75 years, diabetes mellitus, American Society of Anesthesiologists (ASA) status ≥2, blood loss ≥100 ml, and open access were factors that were associated with a beneficial effect of subcutaneous passive drainage. CONCLUSIONS Subcutaneous passive drainage provides benefits over no drainage in patients undergoing major colorectal surgery.
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Ho M, Brown J, Magennis P, Bekiroglu F, Rogers S, Shaw R, Vaughan E. Salvage outcomes of free tissue transfer in Liverpool: trends over 18 years (1992–2009). Br J Oral Maxillofac Surg 2012; 50:13-8. [DOI: 10.1016/j.bjoms.2010.11.014] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2010] [Accepted: 11/22/2010] [Indexed: 10/18/2022]
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Outcomes following pharyngolaryngectomy reconstruction with the anterolateral thigh (ALT) free flap. Br J Oral Maxillofac Surg 2012; 50:19-24. [DOI: 10.1016/j.bjoms.2010.10.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2010] [Accepted: 10/08/2010] [Indexed: 11/18/2022]
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Active versus passive neck drainage in head and neck oncology surgery: completing the re-audit cycle: Re: Batstone MD, Lowe D, Shaw RJ, Brown JS, Vaughan ED, Rogers SN. Passive versus active drainage following neck dissection: a non-randomised prospective study. Br J Oral Maxillofac Surg 2011; 49:412-3. [PMID: 21353353 DOI: 10.1016/j.bjoms.2011.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2010] [Accepted: 01/10/2011] [Indexed: 11/24/2022]
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Analysis of risk factors for surgical-site infections in 276 oral cancer surgeries with microvascular free-flap reconstructions at a single university hospital. J Infect Chemother 2010; 16:334-9. [DOI: 10.1007/s10156-010-0108-y] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2010] [Accepted: 07/27/2010] [Indexed: 10/19/2022]
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Kerawala CJ, Heliotos M. Prevention of complications in neck dissection. HEAD & NECK ONCOLOGY 2009; 1:35. [PMID: 19822010 PMCID: PMC2768705 DOI: 10.1186/1758-3284-1-35] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/02/2009] [Accepted: 10/12/2009] [Indexed: 12/16/2022]
Abstract
BACKGROUND The neck dissection has remained a pivotal aspect of head and neck cancer management for over a century. During this time its role has expanded from a purely therapeutic option into an elective setting, in part promoted by efforts to reduce its morbidity. OBJECTIVES This review will consider the potential complications of neck dissection and on the basis of the available evidence describe both their management and prevention. CONCLUSION Although the neck dissection continues to provide clinicians with a method of addressing cervical disease, its reliability and safety can only be assured if surgeons remain cognisant of the potential complications and aim to minimise such morbidity by appropriate management in the peri-operative period.
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Affiliation(s)
- Cyrus J Kerawala
- Head and Neck Unit, The Royal Marsden NHS Foundation Trust, Fulham Road, London SW3 6JJ, UK
| | - Manolis Heliotos
- North West London Regional Maxillofacial Unit, Northwick Park Hospital, Watford Road, Harrow, Middlesex HA1 3UJ, UK
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