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Alhayek N, Alwani A, Pio L, Abdelhafeez AH. Management of Chyle Leak in Pediatric Surgical Oncology: A Systematic Review. J Pediatr Hematol Oncol 2024:00043426-990000000-00470. [PMID: 39088315 DOI: 10.1097/mph.0000000000002933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 07/11/2024] [Indexed: 08/03/2024]
Abstract
INTRODUCTION Chyle leak, a rare complication, arises from damage to primary lymphatic vessels due to congenital factors or medical interventions, leading to conditions such as chylothorax and chylous ascites. Managing chyle leaks is challenging, especially in pediatric surgical oncology, often arising as postoperative complications. Treatment options range from conservative dietary adjustments to surgical interventions, depending on leak severity and patient condition. This systematic review examines the management of chyle leaks in pediatric surgical oncology, emphasizing both conservative and surgical approaches. METHODS This systematic review involved extensive database searches (EMBASE, Web of Science, and PubMed) to identify relevant studies on chyle leak management in the pediatric population. The review included studies from 1982 to 2023 and focused on pediatric and adolescent patients, assessing various treatment approaches and outcomes. Nine articles composed of 163 patients (study population size ranging from 2 to 82 patients). Independent reviewers evaluated the selected studies for inclusion. RESULTS Among 9 articles analyzed, 98.8% of pediatric patients initially received conservative management for chyle leaks, with 11.7% eventually requiring surgical intervention due to persistent leaks (8, 10, and 16 to 22). Neuroblastoma resection is associated with 20% to 40% rate of chyle leak, and the extent of lymphadenectomy has been identified as a risk factor for chyle leak. The study highlighted variability in clinical success rates based on conservative management approaches. DISCUSSION Chyle leak, while rare, presents a complex challenge, especially in pediatric surgical oncology. Various causes and treatment options exist, with a preference for conservative management initially and surgical intervention in specific circumstances. Factors such as leak severity and patient condition guide the choice between approaches. However, the scarcity of comparative data and randomized trials in the pediatric population necessitates further research to establish optimal management strategies for chyle leaks. CONCLUSIONS Conservative management of chyle leaks has proven to be the preferred approach in early stages of treatment, whereas surgical management could be the preferred choice in certain situations. Larger prospective studies are needed to further evaluate these results.
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Affiliation(s)
- Nabil Alhayek
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | | | - Luca Pio
- Departments of Surgery, St. Jude Children's Research Hospital, Memphis, TN
- Paediatric Surgery Unit, Université Paris-Saclay, Assistance Publique-Hôpitaux de Paris, Bicêtre Hospital, Le Kremlin-Bicêtre, France
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Purwono G, Lee YT, Chua JH, Loh AH. Systematic Lymphatic Repair for Reduction of Postoperative Lymphatic Leak Following Neuroblastoma Resection. J Pediatr Surg 2024; 59:1591-1599. [PMID: 38493026 DOI: 10.1016/j.jpedsurg.2024.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 02/12/2024] [Indexed: 03/18/2024]
Abstract
BACKGROUND Gross total resection of neuroblastoma is associated with lymphatic leaks that can delay postoperative resumption of treatment. To prevent postoperative lymphatic leak, we introduced systematic lymphatic repair (SLR), which involved oversewing the entire edge of the disrupted lymphatic plane after neuroblastoma resection. We sought to study the impact of SLR on postoperative lymphatic leak and time to return to treatment. METHODS We reviewed 60 neuroblastoma patients who underwent gross total resection at KK Women's and Children's Hospital. Patient, disease, and operative factors were correlated with surgical drainage, treatment delay and length of stay (LOS). Among patients with sufficient records, the interaction between variables associated with drainage, delay and LOS outcomes were compared in 14 patients who had SLR versus 35 historical controls who had targeted lymphatic repair (TLR). RESULTS Postoperative drain duration and volume were significantly higher in tumors with ≥2 image-derived risk factors (IDRFs, P = 0.005 and P = 0.013, respectively) or vessel encasement (P = 0.031 and P = 0.024, respectively). Longer LOS was significantly associated with ≥2 IDRFs (P = 0.006). All forms of suture repair of lymphatics and use of Tachosil™ were associated with significantly longer postoperative drain duration (P < 0.05); the former was also associated with significantly higher total drain volume (P < 0.05) - indicating appropriate use of these adjuncts in patients at risk of chyle leak. In patients who had suture repair of lymphatics, SLR was significantly associated with reduced postoperative interval to chemotherapy resumption (P = 0.014, two-way ANOVA). CONCLUSION A systematic approach to repair of lymphatic channels following neuroblastoma resection can significantly reduce time to postoperative resumption of treatment. TYPE OF STUDY Clinical Research. LEVEL OF EVIDENCE III.
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Affiliation(s)
| | - York Tien Lee
- Duke-NUS Medical School, Singapore; Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore; VIVA-KKH Paediatric Brain and Solid Tumour Programme, KKH Children's Blood and Cancer Centre, KK Women's and Children's Hospital, Singapore
| | - Joyce Hy Chua
- Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore
| | - Amos Hp Loh
- Duke-NUS Medical School, Singapore; Department of Paediatric Surgery, KK Women's and Children's Hospital, Singapore; VIVA-KKH Paediatric Brain and Solid Tumour Programme, KKH Children's Blood and Cancer Centre, KK Women's and Children's Hospital, Singapore.
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Feng J, Mou J, Yang S, Ren Q, Chang S, Yang W, Cheng H, Chang X, Zhu Z, Han J, Qin H, Wang H, Ni X. Risk factors, impact and treatment of postoperative lymphatic leakage in children with abdominal neuroblastoma operated on by laparotomy. BMC Surg 2024; 24:168. [PMID: 38811926 PMCID: PMC11134958 DOI: 10.1186/s12893-024-02459-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 05/17/2024] [Indexed: 05/31/2024] Open
Abstract
BACKGROUND Lymphatic leakage is one of the postoperative complications of neuroblastoma. The purpose of this study is to summarize the clinical characteristics and risk factors of lymphatic leakage and try to find effective prevention and treatment measures. METHODS A retrospective study included 186 children with abdominal neuroblastoma, including 32 children of lymphatic leakage and 154 children of non-lymphatic leakage. The clinical information, surgical data, postoperative abdominal drainage, treatment of lymphatic leakage and prognosis of the two groups were collected and analyzed. RESULTS The incidence of lymphatic leakage in this cohort was 14% (32 children). Through univariate analysis of lymphatic leakage group and non-lymphatic leakage group, we found that lymphatic leakage increased the complications, prolonged the time of abdominal drainage and hospitalization, and delayed postoperative chemotherapy (p < 0.05). In this cohort, the median follow-up time was 46 (95% CI: 44-48) months. The follow-up data of 7 children were partially missing. 147 children survived, of which 23 had tumor recurrence (5 children recurred in the surgical area). 37 children died, of which 32 had tumor recurrence (9 children recurred in the operation area). In univariate analysis, there was no statistical difference in overall survival (p = 0.21) and event-free survival (p = 0.057) between lymphatic leakage group and non-lymphatic leakage group, while 3-year cumulative incidence of local progression was higher in lymphatic leakage group (p = 0.015). However, through multivariate analysis, we found that lymphatic leakage did not affect event-free survival, overall survival and cumulative incidence of local progression in children with neuroblastoma. Resection of 5 or more lymphatic regions was an independent risk factor for lymphatic leakage after neuroblastoma surgery. All 32 children with lymphatic leakage were cured by conservative treatment without surgery. Of these, 75% (24/32) children were cured by fat-free diet or observation, 25% (8/32) children were cured by total parenteral nutrition. The median drain output at diagnosis in total parenteral nutrition group was higher than that in non-total parenteral nutrition group (p < 0.001). The cut-off value was 17.2 ml/kg/day. CONCLUSIONS Lymphatic leakage does not affect the prognosis of children with neuroblastoma, but long-term drain output caused by lymphatic leakage will still adversely affect postoperative complications and follow-up treatment, which requires attention and active treatment measures. More attention should be paid to the children with 5 or more lymphatic regions resection, and the injured lymphatic vessels should be actively found and ligated after tumor resection to reduce the postoperative lymphatic leakage. Early application of total parenteral nutrition is recommended for those who have drain output at diagnosis of greater than 17.2 ml/kg/day. LEVEL OF EVIDENCE Level III, Treatment study (Retrospective comparative study).
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Affiliation(s)
- Jun Feng
- Department of Surgical Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Jianing Mou
- Children's Hospital, Capital Institute of Pediatrics, 2# Yabao Road, Chaoyang District, Beijing, 100020, China
| | - Shen Yang
- Department of Surgical Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Qinghua Ren
- Department of Surgical Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Saishuo Chang
- Department of Surgical Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Wei Yang
- Department of Surgical Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Haiyan Cheng
- Department of Surgical Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Xiaofeng Chang
- Department of Surgical Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Zhiyun Zhu
- Department of Surgical Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Jianyu Han
- Department of Surgical Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Hong Qin
- Department of Surgical Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China.
| | - Huanmin Wang
- Department of Surgical Oncology, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China.
| | - Xin Ni
- Beijing Children's Hospital, National Center for Pediatric Cancer Surveillance, Capital Medical University, National Center for Children's Health, Beijing, 100045, China.
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Koester TM, Chewning RH, Weldon CB, Shaikh R, Weil BR. Lymphatic Embolization for the Management of Post-operative Chyle Leaks Following Solid Tumor Resection in Pediatric Patients. J Pediatr Surg 2023; 58:2141-2148. [PMID: 37336682 DOI: 10.1016/j.jpedsurg.2023.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/16/2023] [Accepted: 05/22/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND Chyle leaks are a common post-operative complication following solid-tumor resection in pediatric patients. Current treatments for persistent chyle leaks are limited, leading many patients to experience prolonged hospitalization, nutritional deficits and/or delays in cancer therapies. Lymphatic embolization is an emerging treatment option for chyle leaks, however, limited reports exist of its use in pediatric populations. METHODS We conducted a retrospective review of pediatric patients (<18) who underwent lymphangiogram with intent for lymphatic embolization for the management of chyle leaks following solid-tumor resection between 2017 and 2022. RESULTS Seven patients underwent a total of 11 attempted lymphatic embolization procedures after current standard of care treatments failed to resolve the leak. Lymphangiograms identified a chyle leak in 6 of 7 patients and embolization had a technical success rate of 73%. The complication rate was 9% and complications were limited to one episode of inadvertent gastric wall perforation that did not result in a gastric leak. Lymphatic embolization was ultimately associated with chyle leak resolution in 100% of patients within a median of 24 days, however, repeat embolization was required in 5 of 7 patients (83%). CONCLUSION Lymphatic embolization appears to be a safe and effective treatment for persistent chyle leaks in pediatric patients, leads to a direction reduction in chyle output, and has high rates of technical and clinical success. Complete resolution of the chyle leak may require multiple embolization procedures. Further work is needed to determine whether earlier intervention may offer benefit for the management of pediatric chyle leaks. LEVEL OF EVIDENCE IV.
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Affiliation(s)
| | - Rush H Chewning
- Harvard Medical School, 25 Shattuck Street, Boston, MA, USA; Division of Interventional Radiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, USA
| | - Christopher B Weldon
- Harvard Medical School, 25 Shattuck Street, Boston, MA, USA; Department of Pediatric Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, USA; Department of Pediatric Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, USA
| | - Raja Shaikh
- Harvard Medical School, 25 Shattuck Street, Boston, MA, USA; Division of Interventional Radiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, USA
| | - Brent R Weil
- Harvard Medical School, 25 Shattuck Street, Boston, MA, USA; Department of Pediatric Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, USA; Department of Pediatric Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, USA
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Moussa AM, Maybody M, Santos E, Gonzalez-Aguirre AJ. Intranodal Lymphangiography and Lymphatic Embolization for Management of Iatrogenic Chylous Ascites in Children. Lymphat Res Biol 2021; 19:531-538. [PMID: 33481666 DOI: 10.1089/lrb.2020.0101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background: To demonstrate the value of intranodal lymphangiography (INL) and lymphatic embolization (LE) in management of iatrogenic chylous ascites in children who fail conservative management. Methods and Results: Retrospective review of medical records revealed six patients (four males and two females; age range 11-39 months) who underwent eight INLs and three LEs between 2017 and 2019. In one patient, the leak was visualized and embolized. In three patients, the leak was not visualized and no embolization was done, but drain output decreased and INL was not repeated. In two patients, the leak was not visualized and no embolization was done, but drain output did not decrease and INL was repeated. Repeat INL identified a leak in one patient and targeted LE was done. Repeat INL did not identify a leak in the other patient, but empirical LE was performed at the sites suspicious for leakage after multidisciplinary discussion. INL was able to identify the site of lymphatic leak in two patients (33%). In the three patients who underwent LE (two targeted at the site of identified leak and one empirical at sites suspicious for leak), one (33%) was clinically successful and the other two required surgery to address the lymphatic leak. In three patients, chylous ascites resolved after INL alone with no additional interventions. Three patients developed complications after the procedure, but only one appears to be related to the procedure itself. Follow-up for 13.8 months (13-26 months) revealed no long-term complications or mortality. Conclusion: INL with or without LE is a safe treatment for iatrogenic pediatric chylous ascites. Early utilization before more invasive surgical intervention should be considered in light of the response to INL.
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Affiliation(s)
- Amgad M Moussa
- Interventional Radiology Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Majid Maybody
- Interventional Radiology Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ernesto Santos
- Interventional Radiology Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Adrian J Gonzalez-Aguirre
- Interventional Radiology Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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