Administration of Octreotide for Management of Postoperative High-Flow Chylothorax

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.

Octreotide Dosing in the Medical Management of Chyle Leak Following Otolaryngologic, Thoracic, and Trauma Surgery: A 9-Year Evaluation

Background: Chyle leak is a rare complication following otolaryngologic, thoracic, and trauma surgery wherein the thoracic duct is transected. Case reports and small case series describe octreotide for the medical management of chyle leak, but limited data exist to determine the ideal dose. Objective: To evaluate octreotide dosing in patients with acute chyle leak. Methods: This retrospective, single center, cohort study evaluated adult patients admitted to the otolaryngology, cardiothoracic, and trauma surgery teams over a 9-year period. Patients diagnosed with a chyle leak who received octreotide were eligible for inclusion. Groups were defined as successful medical management or failure requiring definitive surgery. The primary endpoint was daily octreotide dose between groups. Results: Forty-seven patients were included with 29 (61.7%) admitted to the otolaryngology service and 44 (93.6%) with surgical complication as the chyle leak cause. Thirty-two (68.1%) patients had successful medical management while 15 (31.9%) patients failed and required surgical intervention. There was no difference in median daily octreotide dose (250 [IQR, 170-288] µg vs 253 [IQR, 200-282] µg, P = .9). Octreotide weight-based dose, treatment duration, and route of administration were similar between groups. Daily drain output and complete bowel rest were significantly higher in the failure group. Daily drain output was identified as an independent risk factor for failure. Conclusion: Octreotide dose was similar in patients with and without successful medical management of chyle leak. Future studies are needed to determine optimal octreotide dosing and elucidate the relationship between octreotide, drain output, and surgical intervention need.

Use of Octreotide in association with talc poudrage for the management of a severe chylothorax: A case report

INTRODUCTION AND IMPORTANCE

Chylothorax is an uncommon form of pleural effusion characterized by the presence of chylomicrons, triglycerides and cholesterol in the physical and chemical examination of the pleural fluid. It may have poor prognosis if not properly treated. Currently, conservative measures are the first line of treatment for managing chylothorax. The aim of our study is to show and suggest the use of octreotide in association with talc poudrage as good option to manage post-operative a severe chylothorax.

CASE PRESENTATION

A 59-year-old male patient who underwent a replacement of the ascending aorta, aortic hemiarch and surgery of the aortic valve for aortic dissection showed a severe pleural effusion three months after surgery. Because the physical and chemical examination of the pleural fluid revealed high levels of triglycerides and cholesterol, a conservative treatment with pleural drainage, TPN and nihil per os was attempted, with the introduction of 0.3 mg/die of octreotide on day thirty-four. With the application of talc poudrage, the chylothorax completely resolved.

CLINICAL DISCUSSION

Octreotide has been shown to significantly decrease chylous effusion in many studies, but the dose and duration of therapy have not yet been defined. Our patient responded partially to octreotide after two days of treatment, with the drainage leak reduced to less than 100 mL/day.

CONCLUSION

After octreotide treatment associated with talc poudrage, the drainage leak was drastically reduced, suggesting that this could be a useful approach in the management of severe chylous leaks.

Lymphovenous Anastomosis for the Treatment of Thoracic Duct Lesion: A Case Report and Systematic Review of Literature

BACKGROUND

Chylous leak is an uncommon complication after head and neck surgery and typically results from a lesion of the thoracic duct (TD). Beside conservative treatment, different minimally invasive and surgical procedures exist, of which almost all lead to a total closure of the TD.

METHODS

We report on a rare case of microsurgical lymphovenous anastomosis to treat a TD lesion. An additional systematic review on surgical procedures to treat TD lesions with special attention to lymphovenous anastomoses was performed according to the PRISMA guidelines.

RESULTS

A 52-year-old patient with a chylous fistula after modified radical neck dissection was successfully treated by a lymphovenous anastomosis of the TD and external jugular vein with additional coverage by sternocleidomastoid muscle flap. The patient showed a complete resolution of chylous leak with an uneventful postoperative course.The systematic search of literature yielded 684 articles with 4 case reports on lymphovenous anastomosis in chylous leak with a high success rate. Other surgical techniques include transcervical, thoracoscopic, or video-assisted thoracoscopic TD ligation, either alone or combined with a local muscle flap.

CONCLUSIONS

Lymphovenous anastomosis of the TD is a feasible and safe technique allowing for treatment of cervical TD lesions, especially if minimally invasive procedures fail. Compared with other techniques, lymphatic circulation can successfully be maintained.

Usefulness of lymphography and computed tomography for detecting the site of chyle leakage

Chylothorax is a rare but serious complication following aortic surgery. Our patient was a 68-year-old man who underwent descending aortic replacement for a chronic dissected aortic aneurysm and in whom chylothorax postoperatively developed due to a thoracic duct injury. Although adequate medical treatment was immediately initiated at diagnosis, chyle leakage persisted. Lipiodol lymphography followed by computed tomography showed the accurate site of the leakage. Surgical repair was performed via a repeat thoracotomy with smaller incision. We were able to detect the laceration of the thoracic duct. The patient recovered and was uneventfully discharged.

Delayed Chyle Leak Following Anterior Cervical Spinal Surgery: A Case Report and Management Algorithm

Injury to the thoracic duct during anterior cervical spine surgery is a rare occurrence. A delayed chyle leak following an elective anterior cervical spinal surgery has not been reported in the literature. We present a report of a 59-year-old female with multiple prior neck surgeries who underwent an anterior cervical corpectomy and fusion (ACCF). The patient developed a delayed thoracic duct injury on postoperative day (POD) one, as no injury was noted intraoperatively. She was managed with conservative care involving a low-fat diet along with octreotide which led to the resolution of her symptoms. We present this case report because of its unique presentation and to assist spine surgeons with initial management. Surgeons should have increased awareness when performing anterior cervical approaches to the lower cervical and upper thoracic levels from the left side.

Management of Aortic Replacement-Induced Chylothorax by Lipiodol Lymphography

Chylothorax is a rare but serious complication of thoracic aortic surgery, leading to malnutrition, respiratory insufficiency, and prolonged hospital stay. In this article, we describe the successful treatment of a case of intractable chylothorax by lipiodol lymphography. The patient was a 39-year-old man who underwent descending aortic replacement for a remaining dissected aneurysm after total arch replacement. Chylothorax developed postoperatively. After complete oral intake cessation, total parenteral nutrition, and plasmatic factor XIII administration, lipiodol lymphography detected the chyle leakage location and subsequently decreased pleural effusion. The patient recovered uneventfully and was discharged on postoperative day 30 without any complications.

Therapeutic effectiveness of diagnostic lymphangiography for refractory postoperative chylothorax and chylous ascites: correlation with radiologic findings and preceding medical treatment

OBJECTIVE

The purpose of this study was to assess the therapeutic effect of lymphangiography for refractory postoperative chylothorax and chylous ascites and analyze the relation between the clinical outcomes and radiologic findings or response to the preceding medical treatment.

MATERIALS AND METHODS

Between January 2004 and June 2012, 14 patients underwent lymphangiography. All patients had been unresponsive to at least two medical treatments for 3-62 days (median, 13.5 days) before lymphangiography. Leaks were classified as major, minor, and undetectable on the basis of radiologic findings including CT and conventional radiography after lymphangiography. The clinical outcomes were correlated with the radiologic findings or the changes of the daily chylous output after the preceding medical treatments.

RESULTS

The leaks were healed in nine of 14 patients (64.3%) by 3-29 days (median, 8 days) after lymphangiography. Healing was achieved for two of seven major leaks, and all of the minor leaks (n=4) and undetectable leaks (n=3) after lymphangiography. The remaining five major leaks were not healed after a median follow-up of 15 days. The daily output decreased more than half after medical treatment in seven of the 14 patients, and the leak was healed in six of these patients (85.7%) by 5-18 days (median, 10 days).

CONCLUSION

Lymphangiography might be useful for the treatment of refractory postoperative chylothorax and chylous ascites.

Evolution of chylous fistula management after neck dissection

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.

Prospective randomized trial of high versus low negative pressure suction in management of chyle fistula after neck dissection for metastatic thyroid carcinoma

BACKGROUND

Negative pressure drainage has been shown to be an effective treatment of chyle fistula. However, the optimal level of negative pressure has not been determined. We therefore conducted a prospective randomized trial to address this issue.

METHODS

In all, 21 patients with chyle fistula were randomly assigned to a high negative pressure suction (HNPS) group (-600 mmHg, n = 10) or low negative pressure suction (LNPS) group (-125 mmHg, n = 11). The duration of drain leakage and hospital stay, and the incidence of complications were compared between the 2 groups.

RESULTS

All patients were successfully treated with conservative management without surgical intervention. The median durations of chyle leakage and hospital stay were significantly shorter in the HNPS group compared with the LNPS group: 4 versus 7 days (p = .0048) and 5 versus 11 days (p = .0107), respectively.

CONCLUSIONS

Negative suction was demonstrated to be highly effective in the management of chyle fistula, and HNPS appeared to be more efficient than LNPS.

A case of a traumatic chyle leak following an acute thoracic spine injury: successful resolution with strict dietary manipulation

Background

Chylothorax is a rare form of pleural effusion that can be associated with both traumatic and non-traumatic causes. Thoracic duct ligation is often the treatment of choice in postsurgical patients; however the optimal treatment of this disease process after traumatic injury remains unclear [1]. We present a rare case of a thoracic duct injury secondary to a blunt thoracic spine fracture and subluxation which was successfully treated non-operatively.

Case Presentation

A 51 year old male presented as a tier one trauma code due to an automobile versus bicycle collision. His examination and radiographic work-up revealed fractures and a subluxation at the third and fourth thoracic spine levels resulting in paraplegia. He also sustained bilateral hemothoraces secondary to multiple rib fractures. Drainage of the left hemothorax led to the diagnosis of a traumatic chylothorax. The thoracic spine fractures were addressed with surgical stabilization and the chylothorax was successfully treated with drainage and dietary manipulation.

Conclusions

This unusual and complex blunt thoracic duct injury required a multidisciplinary approach. Although the spine injury required surgical fixation, successful resolution of the chyle leak was achieved without surgical intervention.

Videotoracoscopia como uma opção no tratamento cirúrgico do quilotórax após cirurgia cardíaca pediátrica

OBJETIVO: Avaliar o uso de videotoracoscopia no tratamento cirúrgico do quilotórax após cirurgia para correção de cardiopatias congênitas em crianças. MÉTODOS: Revisamos os prontuários médicos de 3.092 crianças operadas para a correção de cardiopatias congênitas no Instituto do Coração/Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo (SP) entre fevereiro de 2002 e fevereiro de 2007. RESULTADOS: Das 3.092 crianças, 64 (2,2%) apresentaram quilotórax como complicação pós-operatória. Em 50 (78,1%) dessas, o tratamento clínico foi bem-sucedido, enquanto esse falhou em 14 (21,9%), as quais foram submetidas à ligação do ducto torácico por videotoracoscopia. A ligação do ducto torácico obteve sucesso em 12 pacientes (86%) e falhou em 2 casos, os quais foram resolvidos com medidas clínicas adicionais, como dieta pobre em gorduras e nutrição parenteral. Não houve morbidade ou mortalidade relacionada à operação. Dos 14 pacientes, 5 (35%) faleceram em decorrência de complicações cardíacas ou infecciosas. CONCLUSÕES: A ligadura videoassistida do ducto torácico pode ser realizada com segurança em pacientes gravemente enfermos e com doença cardíaca grave, com resultados favoráveis.