Thoracoscopic management of chylous fistulae

Postoperative Chyle Leak Rate Following Neck Dissection for Squamous Cell Carcinoma Versus Papillary Thyroid Cancer

OBJECTIVES

Compare the rates of post-operative chyle leak following therapeutic lateral neck dissection during treatment of papillary thyroid carcinoma (PTC) versus squamous cell carcinoma (SCC) of the head and neck.

METHODS

A retrospective analysis of 226 consecutive neck dissections in 201 patients who underwent therapeutic neck dissection involving at least levels II-IV with a final pathologic diagnosis of mucosal SCC of the head and neck or PTC from 2010 to 2020. Specific cases of chyle leak were reviewed. Surgical factors associated with chyle leak were analyzed using logistic regression analysis. Duration of chyle leak was assessed by the Kaplan-Meier curve, and time-to-resolution was analyzed by Cox proportional hazard analysis.

RESULTS

Postoperative chyle leak was encountered in 15 (6.6%) neck dissections, eight (12.3%) in PTC, and seven (4.3%) in SCC. High-volume chyle leak and chyle leak requiring operative intervention were only encountered in neck dissections performed for PTC. Chyle leak was significantly associated with PTC on univariable analysis (OR 3.08, p = 0.037), but not on multivariable analysis (OR 1.35, p = 0.711). High-volume chyle leak and the need for operative intervention were associated only with PTC patients (OR 23.6, p = 0.006; OR 18.09, p = 0.023 respectively). Median duration of chyle leak was 12.1 days among patients with SCC, and 20.5 days among patients with PTC (p = 0.089).

CONCLUSIONS

Among 201 patients undergoing therapeutic neck dissection, chyle leak was associated with PTC pathology on univariable but not multivariable analysis. However, high-volume leaks and leaks requiring operative intervention only occurred among patients with PTC.

LEVEL OF EVIDENCE

level III Laryngoscope, 133:2959-2964, 2023.

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.

Novel thoracoscopic navigation surgery for neonatal chylothorax using indocyanine-green fluorescent lymphography

BACKGROUND

Postoperative chylothorax after surgery for esophageal atresia/tracheoesophageal fistula (TEF) is a rare but serious complication, especially in neonates. This study aimed to identify the thoracic duct and ligate chylous leakage sites, using thoracoscopic navigation of an indocyanine-green (ICG)-based near-infrared (NIR) fluorescence imaging system.

METHODS

From November 2014 to April 2017, thoracoscopic intraoperative ICG-NIR imaging was performed in 10 newborns (11 surgeries) with first TEF operation or with persistent postoperative chylothorax after TEF operation. NIR imaging was performed 1h after an inter-toe injection of ICG. Thoracoscopic ligations against the NIR-detected leakage sites were performed with sutures.

RESULTS

The thoracic duct or lymphatic leakage was directly visualized in each patient. In 8 surgeries with first thoracoscopic TEF operation, one case had suspected minor chylous leakage without postoperative chylothorax. Another case with no chylous leakage at the first operation resulted in chylothorax at postoperative day 11. In three neonates with postoperative chylothorax, leakage points were detected near the ablation site of the azygos vein during the first operation. These points were properly ligated, and postoperative chylous leakage ceased with no adverse events.

CONCLUSIONS

Thoracoscopic ICG-NIR imaging encourages the repair of refractory chylothorax and seems reliable.

LEVEL OF EVIDENCE

IV.

Thoracic Duct Injury Following Cervical Spine Surgery: A Multicenter Retrospective Review

STUDY DESIGN

Multicenter retrospective case series.

OBJECTIVE

To determine the rate of thoracic duct injury during cervical spine operations.

METHODS

A retrospective case series study was conducted among 21 high-volume surgical centers to identify instances of thoracic duct injury during anterior cervical spine surgery. Staff at each center abstracted data for each identified case into case report forms. All case report forms were collected by the AOSpine North America Clinical Research Network Methodological Core for data processing, cleaning, and analysis.

RESULTS

Of a total of 9591 patients reviewed that underwent cervical spine surgery, 2 (0.02%) incurred iatrogenic injury to the thoracic duct. Both patients underwent a left-sided anterior cervical discectomy and fusion. The interruption of the thoracic duct was addressed intraoperatively in one patient with no residual postoperative effects. The second individual developed a chylous fluid collection approximately 2 months after the operation that required drainage via needle aspiration.

CONCLUSIONS

Damage to the thoracic duct during cervical spine surgery is a relatively rare occurrence. Rapid identification of the disruption of this lymphatic vessel is critical to minimize deleterious effects of this complication.

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.

Novel Management of Intractable Cervical Chylous Fistula with Local Application of Pseudomonas aeruginosa Injection

Objective

Cervical chylous fistula is an uncommon complication after neck dissection, but it might lead to some serious clinical outcomes. Although most cervical chylous fistulas can heal in a few days with standard treatments, some can be intractable. In this study, we describe a new method with local application of Pseudomonas aeruginosa injection for intractable cervical chylous fistula.

Study Design

Case series with chart review.

Setting

West China Hospital, Sichuan University, Chengdu, China.

Subjects and Methods

The charts of 18 patients who were treated with P aeruginosa injection (PAI) for intractable cervical chylous fistula were retrospectively reviewed.

Results

All patients were successfully treated with PAI. Mild fever (temperature, <38°C) occurred in 9 patients, moderate fever (38°C-39°C) in 4 patients, and severe fever (>39°C) in 5 patients. All patients had mild to severe neck pain.

Conclusions

Local application of PAI is an effective method for the treatment of intractable cervical chylous fistula, of which the most common side effects are transient fever and local pain.

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.

Chylothorax after esophagectomy for cancer: impact of the surgical approach and neoadjuvant treatment: systematic review and institutional analysis

BACKGROUND

Esophagectomy is a challenging operation with considerable potential for postoperative complications, including chylothorax.

METHODS

Because no randomized controlled trial or metaanalysis is available to clarify the incidence of chylothorax in esophageal cancer surgery, the authors analyzed their own institutional data for 1,856 patients and performed a systematic review using the MEDLINE database (9,794 patients) to identify risk factors, compare success rates of therapeutic approaches, and investigate long-term outcomes.

RESULTS

The overall institutional chylothorax rate was 2 % (n = 39). Reoperation was performed for 69 % of the patients. No significant difference was noted between the transthoracic and transhiatal approaches. Regression analysis showed neoadjuvant treatment (odds ratio [OR], 0.302; p = 0.001) and tumor type (OR, 0.304; p = 0.002) to be independent risk factors. The systematic review included 12 studies. Chylothorax occurred for 2.6 % of the patients. Treatment favored reoperation in five studies (70-100 %) and a conservative approach in four studies (58-72 %), with equal mortality rates. No significant difference was found between the transthoracic and transhiatal approaches.

CONCLUSION

Chylothorax rates are low in high-volume centers (2-3 %). No significant difference was noted between the transthoracic and transhiatal approaches. Neoadjuvant treatment and tumor type were shown to be independent risk factors. Treatment concept (reoperation vs conservative treatment) did not affect long-term survival.

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.

Near-infrared fluorescence imaging of thoracic duct anatomy and function in open surgery and video-assisted thoracic surgery

OBJECTIVE

Chylothorax resulting from thoracic duct damage is often difficult to identify and repair. We hypothesized that near-infrared fluorescent light could provide sensitive, real-time, high-resolution intraoperative imaging of thoracic duct anatomy and function.

METHODS

In 16 rats, 4 potential near-infrared fluorescent lymphatic tracers were compared in terms of signal strength and imaging time: indocyanine green, the carboxylic acid of IRDye 800CW (LI-COR, Lincoln, Neb), indocyanine green adsorbed to human serum albumin, and IRDye 800CW conjugated covalently to human serum albumin. Optimal agent was validated in 8 pigs approaching human size (n = 6 by open surgery with FLARE imaging system [Beth Israel Deaconess Medical Center, Boston, Mass] and n = 2 by video-assisted thoracoscopic surgery minimally invasive [m-FLARE] imaging system [Beth Israel Deaconess Medical Center]). Lymphatic tracer injection site, dose, and timing were optimized.

RESULTS

For signal strength, sustained imaging time, and clinical translatability, the best lymphatic tracer was indocyanine green, which is already Food and Drug Administration approved for other indications. In pigs, a simple subcutaneous injection of indocyanine green into lower leg (≥ 36 μg/kg), provided thoracic duct imaging with onset of about 5 minutes after injection, sustained imaging for at least 60 minutes after injection, and signal-to-background ratio of at least 2. With this technology, normal thoracic duct flow, collateral flow, injury models, and repair models could all be observed under direct visualization.

CONCLUSIONS

Near-infrared fluorescent light could provide sensitive, sustained, real-time imaging of thoracic duct anatomy and function during both open and video-assisted thoracoscopic surgery in animal models.

Management of chyle leak post neck dissection: a case report and literature review

Chyle leakage post head-and-neck resection is a rare but potentially life-threatening complication. Management may be problematic and prolonged. Recently, thoracoscopic ligation of the thoracic duct has emerged as a promising technique to definitively treat this difficult problem. We present a recent case of a hemimandibulectomy, radical modified neck dissection and osseocutaneous fibular-free-flap complicated by a chyle leakage. The chyle leak was successfully treated with thoracoscopic ligation of the thoracic duct. In the light of our clinical experience and following a thorough literature review, we have proposed that complicated or high-output chyle leaks (>1000 ml day(-1)) should be treated with early thoracoscopic thoracic duct ligation.

Reliability of Poirier's triangle in localizing the thoracic duct in the thorax

PURPOSE

Preemptive ligation of the thoracic duct (TD) is occasionally performed during cardiothoracic procedures to prevent chylothorax. Landmarks for localizing this structure are thus important to the surgeon during such procedures. One historically used area for identifying this structure in the thorax is Poirier's triangle. The present paper aimed to investigate the relationship of the TD to Poirier's triangle.

METHODS

We evaluated the use of this geometric area in localizing the TD in 35 adult cadavers.

RESULTS

Poirier's triangle was found in all specimens, but the TD was found within the confines of Poirier's triangle in only 17 specimens (45.7%). When not identified in Poirier's triangle, the regional TD was often (28.6%) seen in the interval between the proximal left subclavian and left common carotid arteries.

CONCLUSIONS

These data may be of use to the surgeon when identifying the proximal TD within the thorax.

Introduction of lymphangiography and percutaneous embolization of the thoracic duct in a stepwise approach to the management of chylous fistulas

BACKGROUND

Chylous fistula occurring after head and neck or thoracic surgery is an uncommon but well-described complication, with a reported incidence of 1% to 2.5%. Conservative management can be successful and consists of dietary measures combined with suction drainage. This article reports on percutaneous embolization of the thoracic duct through catheterization of the retroperitoneal lymph vessels.

METHODS

Two patients, in whom conservative management for cervical chylous fistula failed, underwent lymphangiography with opacification of the thoracic duct, followed by radioguided catheterization and embolization.

RESULTS

Embolization was successful in both patients. In 1 patient the procedure had to be repeated once to stop the chylous drainage.

CONCLUSIONS

Radioguided percutaneous catheterization and embolization of the retroperitoneal lymph vessels offers an excellent treatment option for patients with persistent chylous fistulas after failure of conservative management. We revised our stepwise management protocol (de Gier, Head Neck 1996; 18:347-351) and now consider this procedure as the secondary intervention step.

Management of Chyle Fistula Utilizing Thoracoscopic Ligation of the Thoracic Duct

OBJECTIVES

To document the treatment of refractory chyle leaks using thoracoscopic thoracic duct ligation and provide systematic guidelines to manage chyle leaks.

METHODS

The medical records of 2 patients with chyle leaks are reviewed, followed by a review of the literature on chyle leaks and their thoracoscopic management.

CONCLUSIONS

Initial treatment of chyle fistula is aimed at conservative medical management. Persistent high-output fistulas (>500 cm(3)) should be considered for neck reexploration as conservative management is likely to fail. Thoracoscopic thoracic duct ligation provides a safe and efficient means of treating chyle leaks refractory to repeated surgical and medical intervention. It should also be considered as a primary surgical intervention for patients with: (1) chyle output exceeding 500 cm(3)/day where prior intraoperative attempts at ligation have failed, (2) severe metabolic and nutritional complications, (3) coexisting chylothorax with respiratory compromise, and (4) low-output fistulas (<500 cm(3)/day) of long duration (>14 days).

The versatile contact Nd:YAG laser in head and neck surgery: an in vivo and clinical analysis

OBJECTIVE

Lasers have been used in otolaryngology as a surgical instrument for more than 25 years, and the CO2 laser has emerged as the most widely employed surgical laser in use today. However, recent technological advances have made the Nd:YAG laser a challenger as an effective photothermal surgical tool.

STUDY DESIGN AND METHODS

This is a two-part study. Tissue injury and healing profiles after application of both the CO2 and Nd:YAG lasers are compared using an in vivo rat tongue model. A prospective clinical review based on the experience of 327 operative cases spanning a 7-year interval using the Nd:YAG laser, highlighting its various applications and associated complications, is detailed.

RESULTS

Comparable tissue and healing effects were noted with both lasers in the in vivo rat tongue model with no statistical differences. The clinical application of the laser showed wide versatility in the head and neck with a complication rate of 3%.

CONCLUSION

The Nd:YAG laser has proved equivalent in tissue damage and healing to the CO2 laser. The Nd:YAG laser has proved itself to be an excellent and perhaps superior laser for use in head and neck surgery.