Drain removal and aspiration to treat low output chylous fistula

Bilateral Chylothorax Following Total Thyroidectomy with Neck Dissection for Papillary Thyroid Cancer: Case report

Bilateral chylothorax is a rare condition that occurs after a thyroidectomy and neck dissection, which can lead to severe morbidity and, potentially, death, if not managed properly. We report a rare complication of neck surgery and subsequent bilateral pleural effusion in a 35-year-old female patient who presented at Sultan Qaboos University Hospital in 2018 with shortness of breath and respiratory distress. The bilateral pleural effusion and related symptoms occurred one week after a total thyroidectomy with central and left lateral neck dissection. The patient was managed conservatively and subsequently recovered.

Predictors for Postoperative Chyle Leak Following Neck Dissection, a Technique-Based Comparison

OBJECTIVE

Assess the impact of surgical technique used to address level IV on the rate of postoperative chyle leak.

STUDY DESIGN

Retrospective chart review.

SETTING

Academic tertiary care center.

METHODS

An analysis of 436 consecutive neck dissections (NDs) in 368 patients was performed by 3 head and neck surgeons between 2014 and 2017. Variation in technique reflects individual approaches to the management of level IV and included suture ligation (SL), monopolar electrocautery (MC), and harmonic scalpel transection (HS). Data points included patient demographics, surgical technique, intraoperative findings, postoperative chyle leaks, and leak management. Correlation between variables was analyzed through χ² test and Student t test with statistical α set at .05.

RESULTS

Overall, 12 patients (3.2%) developed chyle leaks postoperatively. Nine of 12 and 3 of 12 presented with left- and right-sided leaks, respectively. Five of 12 leaks occurred following bilateral ND, 5 of 12 following left ND, and 2 of 12 following right ND. Univariate analysis showed a statistically significant difference (P = .001) favoring SL (1.0%) and MC (1.2%) techniques over the HS technique (8.6%). A statistically significant increase existed in the rate of leak with endocrine vs nonendocrine pathology (P = .003). Average duration of leak was 13.3 ± 13.5 days. Management included diet modification (n = 11, 91.6%), pressure-dressing placement (n = 7, 58.3%), and octreotide (n = 5, 41.7%). No cases required reoperation, and no mortality or severe malnutrition was observed in this series.

CONCLUSIONS

SL and MC techniques demonstrated superiority over the HS technique in preventative management of chyle leak in level IV, with a significantly higher rate of chyle leak observed in endocrine-related pathology.

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.

Chyloma formation after anterior cervical disc fusion

Chyle leak from iatrogenic thoracic duct injury is a rare but serious complication of head and neck surgery. The chyloma in this case took months to recognize and required open thoracic ligation. He fully recovered.

Chyle Leakage after Esophageal Cancer Surgery

Surgeons recommend dissecting lymph nodes in the thorax, abdomen, and neck during surgery for esophageal cancer because of the possibility of metastasis to the lymph nodes in those areas through the lymphatic plexus of the esophageal submucosal layer. Extensive lymph node dissection is essential for accurate staging and is thought to improve survival. However, it can result in several complications, including chyle leakage, which refers to continuous lymphatic fluid leakage and can occur in the thorax, abdomen, and neck. Malnutrition, fluid imbalance, and immune compromise may result from chyle leakage, which can be potentially life-threatening if it persists. Therefore, various treatment methods, including conservative treatment, pharmacological treatment such as octreotide infusion, and interventions such as thoracic duct embolization and surgical thoracic duct ligation, have been applied. In this article, the risk factors, diagnosis, and treatment methods of chyle leakage after esophagectomy are reviewed.

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.

Negative Pressure Wound Therapy (Wound VAC) in the Treatment of Chylous Fistula After Neck Dissection

OBJECTIVES

Cervical chylous fistula is an uncommon but potentially severe occurrence associated with neck surgery. Methods for treating this problem have inconsistent efficacy and may result in lengthy hospital stays. Negative pressure wound therapy (NPWT) is a highly effective tool in the management of complex wounds. We report 3 cases where NPWT was successfully used to treat chylous fistulas following neck dissection.

METHODS

This is a retrospective chart review of 3 patients who developed chylous fistulas after neck dissection and were successfully treated with NPWT.

RESULTS

Chylous ouput ceased within 2 to 8 days of proper wound VAC placement. Hospital stays ranged from 6 to 47 days. Patients received altered diets, including TPN for 1 patient with high-flow output and nil-per-os (NPO) or clear liquids for the others. Patients received octreotide throughout their hospitalization.

CONCLUSION

NPWT shows potential as a treatment option for both high-volume and low-volume chylous fistulas following neck dissection.

Chylous-Related Complications Following Surgical Management of Clavicular Fractures: A Report of Two Cases

CASE

We treated 2 patients with chylous-related complications following open reduction and internal fixation (ORIF) of the clavicle. These complications were of unknown etiology; 1 was treated with percutaneous injection of a sclerosing agent, while the other was treated with ligation of the thoracic duct.

CONCLUSION

A chyle leak is more commonly seen with upper gastrointestinal, thoracic, and head and neck surgery. This complication potentially carries a substantial rate of morbidity. We report the successful management of 2 patients with difficult postoperative chylous-related complications following ORIF of the clavicle.

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.