Chylous leakage after circumferential thoracolumbar fusion for correction of kyphosis resulting from fracture. Report of three cases

Lymphocele after anterior lumbar interbody fusion: a review of 1322 patients

OBJECTIVE

Anterior lumbar interbody fusion (ALIF) is an effective surgical modality for many lumbar degenerative pathologies, but a rare and infrequently reported complication is postoperative lymphocele. The goals of the present study were to review a large consecutive series of patients who underwent ALIF at a high-volume institution, estimate the rate of lymphocele occurrence after ALIF, and investigate the outcomes of patients who developed lymphocele after ALIF.

METHODS

A retrospective review of the electronic medical record was completed, identifying all patients (≥ 18 years old) who underwent at a minimum a single-level ALIF from 2012 through 2019. Postoperative spinal and abdominal images, as well as radiologist reports, were reviewed for mention of lymphocele. Clinical data were collected and reported.

RESULTS

A total of 1322 patients underwent a minimum 1-level ALIF. Of these patients, 937 (70.9%) had either postoperative abdominal or lumbar spine images, and the resulting lymphocele incidence was 2.1% (20/937 patients). The mean ± SD age was 67 ± 10.9 years, and the male/female ratio was 1:1. Patients with lymphocele were significantly older than those without lymphocele (66.9 vs 58.9 years, p = 0.006). In addition, patients with lymphocele had a greater number of mean levels fused (2.5 vs 1.8, p < 0.001) and were more likely to have undergone ALIF at L2-4 (95.0% vs 66.4%, p = 0.007) than patients without lymphocele. On subsequent multivariate analysis, age (OR 1.07, 95% CI 1.01-1.12, p = 0.013), BMI (OR 1.10, 95% CI 1.01-1.18, p = 0.021), and number of levels fused (OR 1.82, 95% CI 1.05-3.14, p = 0.032) were independent prognosticators of postoperative lymphocele development. Patients with symptomatic lymphocele were successfully treated with either interventional radiology (IR) drainage and/or sclerosis therapy and achieved radiographic resolution. The mean ± SD length of hospital stay was 9.1 ± 5.2 days. Ten patients (50%) were postoperatively discharged to a rehabilitation center: 8 patients (40%) were discharged to home, 1 (5%) to a skilled nursing facility, and 1 (5%) to a long-term acute care facility.

CONCLUSIONS

After ALIF, 2.1% of patients were diagnosed with radiographically identified postoperative lymphocele and had risk factors such as increased age, BMI, and number of levels fused. Most patients presented within 1 month postoperatively, and their clinical presentations included abdominal pain, abdominal distension, and/or wound complications. Of note, 25% of identified lymphoceles were discovered incidentally. Patients with symptomatic lymphocele were successfully treated with either IR drainage and/or sclerosis therapy and achieved radiographic resolution.

Lymphatic Injury After Vertebral Column Resection from a Posterior Approach for Spinal Deformity Correction: A Case Report

CASE

We describe a case of lymphatic injury that occurred during a 2-level vertebral column resection for spinal deformity correction from a posterior-only approach. Large surgical drain volume output with laboratory findings of high levels of triglycerides and lymphocytes prompted conservative treatment with an elastic wrap bandage and a "no fat" diet. The patient responded to the treatment with no sequelae noted.

CONCLUSION

Lymphatic complications are rare in spine surgery. All reported cases are associated with anterior approaches. The lymphatic injury presented here demonstrates the potential for this complication to occur during posterior-only approaches as well.

Chylous retroperitoneum following 720 degree anteroposterior-combined corrective surgery for adult spinal deformity with split vertebral fracture subluxation: a case report

STUDY DESIGN

Clinical case report.

PURPOSE

To report the rare case with post-operative chylous retroperitoneum after corrective surgery for adult spinal deformity.

METHODS

We present a case of a 73-year-old woman with Parkinson's disease. She sustained a severe split fracture subluxation of the L3 vertebra with AO Spine Thoracolumbar classification type CN2M2, resulting in severe kyphoscoliosis in global alignment. She underwent a two-stage 720-degree anteroposterior-combined corrective surgery with anterior vertebral column resection of L3 and posterior fusion from T4 to the pelvis. On post-operative day 1, milky fluid in the drainage tube was noted, which was diagnosed as post-operative chylous retroperitoneum.

RESULTS

Oral intake was discontinued immediately and peripheral parenteral nutrition was started. A low-fat, high-protein diet was started on post-operative day 4, and drainage was removed on day 6. A low-fat diet was continued until 3 months post-operatively, with dietary counselling by a nutritionist. The chylous retroperitoneum resolved without recurrence at the final follow-up evaluation at 3 years.

CONCLUSION

Surgeons should recognize this rare complication, which might be induced by direct damage to the lymphatic flow during an operative maneuver anterior to the lumbar vertebral body and indirect damage due to shearing force during correction of a subluxated vertebra, especially in cases with a severe deformity.

Management of Chyloretroperitoneum After Lumbar Surgery by Anterior Approach

BACKGROUND

Anterior lumbar approach, routinely used in spinal surgery, provides many advantages, specifically avoidance of manipulation and potential injury to nervous system structures; it also provides indirect central and foraminal decompression, with a complication rate of 1%-3%. Chyloretroperitoneum is a rare complication of spinal procedures using anterior lumbar approach. The aim of this study was to discuss diagnosis, treatment, and management of chyloretroperitoneum based on review of the international literature through 2017.

METHODS

The literature review was conducted using the terms "chyloretroperitoneum," "spinal surgery," and "lymphocele." Additionally, an illustrative case of chyloretroperitoneum following anterior retroperitoneal lumbar approach was presented.

RESULTS

In 33 cases, including the present case, clinical symptoms appeared after discharge in 75.8% (n = 25) and reflected direct mass effect. Abdominopelvic computed tomography permitted assessment of the fluid collection observed as a hypodense collection around the psoas muscle. In 24 cases, drainage of the chyloretroperitoneum was maintained for a mean duration of 2.9 days. Surgery was performed in 14 patients (42.4%) owing to lymphatic collection. In 5 cases, surgery was performed for direct lymphatic vessel treatment. Laparoscopic marsupialization of the collection and peritoneal fenestration were performed, especially after percutaneous drainage failure.

CONCLUSIONS

Computed tomography was the most useful imaging modality for diagnosis and assessment of associated complications. If puncture alone is not sufficient and should be avoided, percutaneous computed tomography-guided drainage with sclerosing agent administration appears to be a safe and efficient first-line treatment. Laparoscopic fenestration should be used in cases of complicated or recurrent lymphoceles.

Chylous ascites treated by traditional Chinese herbal medicine: a case report and discussion

Chylous ascites, which can lead to peritonitis, intestinal obstruction, metabolic disorder, and even death from pyemia, is a rare complication of abdominal surgery. Currently, first-line treatment involves conservative management, which includes oral diet and total parenteral nutrition (TPN). However, the efficacy of these treatments cannot be guaranteed. For example, single diet control can result in consecutive drainage for up to 1 month, and salvage surgery is required for some invalid cases. Here, we report 6 cases of chylous ascites after abdominal surgery. In addition to diet control, we delivered traditional Chinese herbal medicine (TCHM) twice daily orally. The drainage volume of the chylous fistula showed an obvious decrease 1 day after the TCHM administration and all 6 patients completely recovered within 4 to 8 days (median: 5.5 days). Although relevant data are limited, our cases would suggest that TCHM could play an important role in the management of chylous ascites. However, randomized controlled trials are still needed to confirm its efficacy in a larger population.

Chyloretroperitoneum following anterior spinal surgery

Injury to the lymphatic channels is a rare and relatively unknown complication of anterior approaches to the lumbar spine and can cause fluid to build up in the retroperitoneal space, resulting in a lymphocele. If they enlarge sufficiently, these collections of chyle in the abdomen can cause pain and bowel ischemia, and can compress nearby organs. The authors report 4 cases in which anterior approaches to the lumbar spine were complicated by a postoperative retroperitoneal chylous fluid collection. They describe the anatomy of the lymphatic system and pathophysiology of this disease entity, review the sparse literature on this subject, and recommend a treatment algorithm. Maintaining a high index of suspicion for this clinical entity in patients who have recently undergone an anterior approach to the thoracic or lumbar spine is vital to avoid delays in diagnosis and treatment.

Incidence and management of chyle leaks following pancreatic resection: a high volume single-center institutional experience

BACKGROUND

No data on incidence, management, or natural history of chyle leaks following pancreatic resection have been published. We sought to identify possible risk factors associated with chyle leaks following pancreatic resection, as well as determine the natural history of this rare complication.

METHODS

Between 1993 and 2008, 3,532 patients underwent pancreatic resection at a single institution. Data on demographics, operative details, primary tumor status, and chyle leak were collected. To identify risk factors associated with chyle leak, a matched 3:1 paired analysis was performed.

RESULTS

Of 3,532 patients undergoing pancreatic resection, 47 (1.3%) developed a chyle leak (n = 34, contained chyle leak versus n = 13, diffuse chylous ascites). Chyle leak was identified at median 5 days following surgery. Median drain triglyceride levels were 592 ng/dl. After matching on tumor size, disease etiology, and resection type, the number of lymph nodes harvested and history of concomitant vascular resection predicted higher risk of chyle leak (both P < 0.05). Total parenteral nutrition (TPN) was required in more patients with chylous ascites (92.3%) than those with chyle leaks (44.1%) (P = 0.003). The median time to resolution was shorter for contained chyle leaks (13 days) versus chylous ascites (36 days) (P < 0.001). Patients with chylous ascites tended to have shorter overall survival (3-year, 18.8%) versus patients with no chyle leak (3-year, 46.9%) (P = 0.12). In contrast, patients with a contained chyle leak had a similar survival as patients with no chyle leak (3-year, 53.4% versus 46.9%, respectively) (P = 0.32).

CONCLUSION

Chyle leak was a rare (1.3%) complication following pancreatic resection that was associated with number of lymph nodes harvested and concomitant vascular resection. In general, chyle leaks were successfully managed with TPN with no adverse impact on outcome. Patients with chylous ascites, however, had a more protracted clinical course and tended to have a worse long-term survival.

Chyloretroperitoneum following anterior spinal deformity correction

✓ Chyloretroperitoneum is an uncommon complication following spinal surgery. The authors present the case of a patient in whom conservative treatment and initial surgical measures failed to relieve varied symptoms of postsurgical chyloretroperitoneum. Following attempts at conservative management, a peritoneal window was surgically created to divert lymphatic flow from the retroperitoneal space into the peritoneal space, where it was resorbed. This unique surgical technique provides yet another option in the treatment of refractory chyloretroperitoneum following anterior lumbar spinal surgery. The authors describe their technique and review retroperitoneal lymphatic anatomy along with similar case reports in the literature.

Spontaneous healing of retroperitoneal chylous leakage following anterior lumbar spinal surgery: a case report and literature review

Cisterna chyli is prone to injury in any retroperitoneal surgery. However, retroperitoneal chylous leakage is a rare complication after anterior spinal surgery. To the best of our knowledge, only ten cases have been reported in the English literature. We present a case of a 49-year-old man who had lumbar metastasis and associated radiculopathy. He had transient retroperitoneal chylous leakage after anterior tumor decompression, interbody bony fusion, and instrumental fixation from L2 to L4. The leakage stopped spontaneously after we temporarily clamped the drain tube. Intraperitoneal ascites accumulation developed thereafter due to nutritional loss and impaired hepatic reserves. We gathered ten reported cases of chylous leak after anterior thoracolumbar or lumbar spinal surgery, and categorized all these cases into two groups, depending on the integrity of diaphragm. Six patients received anterior spinal surgery without diaphragm splitting. Postoperative chylous leak stopped after conservative treatment. Another five cases received diaphragm splitting in the interim of anterior spinal surgery. Chylous leakage stopped spontaneously in four patients. The remaining one had a chylothorax secondary to postop chyloretroperitoneum. It was resolved only after surgical intervention. In view of these cases, all the chylous leakage could be spontaneously closed without complications, except for one who had a secondary chylothorax and required thoracic duct ligation and chemopleurodesis. We conclude that intraoperative diaphragm splitting or incision does not increase the risk of secondary chylothorax if it was closed tightly at the end of the surgery and the chest tube drainage properly done.

Thoracic duct variations may complicate the anterior spine procedures

The aim of this study is to localize and document the anatomic features of the thoracic duct and its tributaries with special emphasis on the spinal surgery point of view. The thoracic ducts were dissected from nine formaldehyde-preserved male cadavers. The drainage patterns, diameter of the thoracic duct in upper, middle and lower thoracic segments, localization of main tributaries and morphologic features of cisterna chyli were determined. The thoracic duct was detected in all cadavers. The main tributaries were concentrated at upper thoracic (between third and fifth thoracic vertebrae) and lower thoracic segments (below the level of ninth thoracic vertebra) at the right side. However, the main lymphatic tributaries were drained into the thoracic duct only in the lower thoracic area (below the level of the tenth thoracic vertebra) at the left side. Two major anatomic variations were detected in the thoracic duct. In the first case, there were two different lymphatic drainage systems. In the second case, the thoracic duct was found as bifid at two different levels. In formaldehyde preservation, the dimensions of the soft tissues may change. For that reason, the dimensions were not discussed and they may not be a guide in surgery. Additionally, our study group is quite small. Larger series may be needed to define the anatomic variations. As a conclusion, anatomic variations of the thoracic duct are numerous and must be considered to avoid complications when doing surgery.

[Surgery for chylothorax]

Chyle is lymph fluid of intestinal origin containing fat digestion products. Chylothorax is produced by leaks from the thoracic duct or from one of its collaterals subsequent to valve incompetence. These leaks may be due to trauma (post-surgical chylothorax, the most frequent) or to spontaneous rupture of a lymph vessel distended by chyle reflux, the thoracic duct itself being pathological. When the thoracic duct is interrupted (obstruction, agenesis), chylothorax may occur from leakage due to reflux within substitution collateral pathways diverting the flow of chyle into the venoux confluents of the neck. Medical treatment is always attempted first: evacuation of chylothorax by drainage and fat-free diet or parenteral nutrition. Recently, treatment with octreotide has been found to be beneficial. Surgery consists in thoracic duct ligation or suture of leaking collaterals. In difficult cases, when the chyle leakage cannot be identified, pleurodesis is the only option.

Chylous leakage after thoracolumbar fracture may cause paraplegia

STUDY DESIGN

Retrospective case report.

PURPOSE

This case demonstrates that paraplegia can develop due to chylous leakage into the spinal canal without obvious retroperitoneal or intrathoracic involvement.

BACKGROUND INFORMATION

This clinical presentation of chylous leakage has not been reported previously. RESULTS A 61-year-old female with osteoporosis suffered a pathologic fracture of the vertebral bodies T12 and L1 and developed partial paraplegia two weeks later. Imaging showed expansive pooling of intraspinal fluid without intrathoracic or retroperitoneal involvement. A blood-tinged fluid was aspirated from dorsal. Repeated surgery by a posterior approach with drainage of the fluid did not improve the patient's condition, so she was finally transferred to our hospital. Under the suspected diagnosis of lymphatic leakage a scintiscan with 123I-iodinephenylpentadekanacid-marked cream verified the presumption of a lymph fistula at the level of T12/L1, originating from the thoracic duct. By permanent draining of the posterior fistula without suction and strict intravenous alimentation the fluid production decreased continuously and finally ceased completely. Simultaneously, the neurologic state improved gradually without returning to normal completely.

CONCLUSIONS

This case demonstrates that paraplegia can develop due to chylous leakage into the spinal canal without obvious retroperitoneal or intrathoracic involvement. This differential diagnosis should be kept in mind when treating patients with abundant fluid drainage into or from the spinal canal.

[Chylous effusions]

This paper presents 4 patients with chylothorax, and one patient with bilateral chylothorax and chyloperitoneum. The chylous effusions were of benign etiology, developed as a complication of miliary tuberculosis (1 patient), after L-2 vertebral body fracture (1 patient), and idiopathic (2 patients). The diagnosis was confirmed by the presence of chylomicrons and high content of triglycerides in the effusion, ranged 11.9-29.1 mmol/l. Lymphangiography showed multiple abnormalities of lymphatic system, the obstruction of ductus thoracicus, dilatation and convulsion of lymphatic channels, but the site of lymphatic leak was not detected. The treatment included an extended period of pleural and peritoneal drainage with total parenteral nutrition (1 patient), pleurodesis using Corynebacterium parvum (2 patients), and surgical partial parietal pleurectomy with continuous drainage (1 patient). The treatment was successful in all patients.

Management of thoracic duct injuries after oesophagectomy

BACKGROUND

Thoracic duct laceration is a rare but potentially life-threatening complication of oesophagectomy. The management of such an injury is uncertain in respect of the relative merits of conservative and surgical treatment.

METHODS

The literature was reviewed by searching Medline databases from 1966 to the present time. The majority of the evidence presented is level 3, as no randomized or controlled data are available.

RESULTS

Prolonged conservative treatment of thoracic duct injury is associated with a mortality rate of 50-82 per cent. The results of early surgical ligation of the duct are more encouraging, with a mortality rate of 10-16 per cent. Elective ligation of the duct reduces the incidence of postoperative chylothorax.

CONCLUSION

The thoracic duct should be ligated during oesophagectomy. A high index of suspicion for duct injury must be maintained in all patients after operation. A policy of very early thoracic duct ligation at 48 h from diagnosis is proposed for duct injury if aggressive conservative management fails.

Thoracic duct scintigraphy by orally administered I-123 BMIPP: normal findings and a case report

PURPOSE

To investigate the use of orally administered iodine-123-labeled 15-(4-iodophenyl)-3(R,S)-methyl-pentadecanoic acid (I-123 BMIPP) for thoracic duct imaging in normal and pathologic states and to study the tracer distribution and dynamics in healthy participants.

METHODS

The radiotracer was administered with solid (in three healthy persons and one patient) or liquid meals (in three other healthy persons). Solid meals contained relatively more fat content than did the liquid meal. Images were acquired to trace the passage of radiotracer from the intestine to the systemic venous circulation via the lymphatic route. Multiple static planar images were acquired in the anterior and posterior views. Blood samples were analyzed for radioactivity and serum triglyceride levels.

RESULTS

In the healthy participants, I-123 BMIPP was absorbed from the intestine and reached the venous circulation through the thoracic duct. The thoracic part of the duct was visualized successfully in all healthy persons within 80 minutes. The radiotracer dynamics varied according to the type of meal administered. The patient had chylomediastinum and right chylothorax and underwent thoracic duct ligation. In the patient, marked stasis in the collateral lymphatic channels was seen, as was chylous leakage into the mediastinal space and right pleural cavity. Passage of tracer to the general venous circulation was delayed. A normal thoracic duct was not seen in this patient.

CONCLUSIONS

Scintigraphy by orally administered I-123 BMIPP is a simple method to image the thoracic duct and to monitor its lesions. Meals with a higher fat content result in better BMIPP absorption and may be used as a standard method.

Chylous ascites after oncological abdominal surgery: incidence and treatment

AIMS

Chylous ascites can be a problem after oncological abdominal surgery. The aim of this study was to report the incidence and the management of the problem.

METHODS

A retrospective study over a 2-year period of all oncological patients undergoing abdominal surgical procedures was carried out. Patients with resections in the upper abdomen and retroperitoneum were studied in more detail.

RESULTS

Twelve (7.4%) of 163 patients with complex surgical procedures developed a chyloperitoneum. Chylous ascites stopped in time with conservative management in nine patients. Three patients had a peritoneovenous shunt inserted with success. No relaparotomies to ligate leaking intestinal lymph vessels were necessary.