Management of chylous fistula as a complication of neck dissection: a 10-year retrospective review

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.

Neck swelling 19 days after thyroidectomy: A case report of a rare chyle leak patient

The occurrence of chyle leak after neck dissection for thyroid carcinoma is uncommon, but it usually occurs within 1-10 days after surgery. We encountered a 30-year-old patient with chyle leak 19 days after the operation for thyroid carcinoma. The initial symptom was swelling of the neck, which was quickly diagnosed as chyle leak by puncture. This report describes the patient's presentation and discusses the conservative management of this complication. We highlight that more attention should be given to chyle leak in high-risk patients, and stricter dietary management for these patients after surgery may avoid this complication. In addition, timely diagnosis and rapid implementation of various conservative treatment measures play an important role in patient recovery.

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.

68Ga-NEB PET/CT can be a new method for diagnosing chylous fistula: Case reports of a rare complication after breast cancer surgery

RATIONALE

We hypothesize that with the determination of lymph fistula location 3-dimensionally, application of appropriate pressure would promote fistula healing, and a secondary surgery may be avoided. Ga-labeled 1,4,7-triazacyclononane-N, N', N"-triacetic acid (NOTA) conjugated with truncated Evan blue (NEB) forms a complex with serum albumin in the interstitial fluid after it is locally injected and allows rapid visualization of the lymphatic system.

PATIENT CONCERNS

A 44-year-old woman had a chief complaint of left nipple discharge. A 38-year-old woman came to the hospital after sensing a right breast mass.

DIAGNOSES

The 2 patients were diagnosed with chylous fistula after breast cancer surgery based on the findings of a novel method, Ga-NOTA-Evans Blue (NEB) positron emission tomography/computed tomography.

INTERVENTIONS

We successfully obtained clear images to locate the fistula using Ga-NEB positron emission tomography/computed tomography (PET/CT) for both patients. The lymphatic vessels and lymph nodes could be clearly visualized owing to the Ga-NEB activity during PET/CT.

OUTCOMES

Three-dimensional positioning to locate the fistula could direct the application of the pressure dressing and reduce drainage markedly.

LESSONS

Ga-NEB PET/CT may be a new method for diagnosing chylous fistula and providing guidance for treatment.

Chylous fistula: management of a rare complication following right anterior cervical spine approach

PURPOSE

Chylorrhea resulting from injury of the lymphatic system during neck dissection is a well-known complication. It is an uncommon occurrence in spinal surgery, and only one case after right anterior cervical spine surgery has been described so far. Despite its rarity, chylous leakage deserves a particular attention since it may become a serious and occasionally fatal complication if not detected early and managed appropriately.

METHODS

We report the case of a 42-year-old man who underwent a standard anterior cervical discectomy and fusion according to Cloward approach for a C6-C7 disk herniation. The patient developed a delayed prevertebral chyle collection on postoperative day 5, presenting with mild breathing and swallowing difficulties.

RESULTS

He was managed with conservative care, including bed rest, low-fat diet and drainage pouch positioning, which led to the complete resolution of the fluid collection.

CONCLUSIONS

Knowledge of the normal anatomy of the lymphatic system and of its variations is essential when planning an anterior spinal procedure, and represents the first measure to be adopted in order to avoid such complication. The prompt identification of a postoperative chylous fistula and the applicability of an individually based management's protocol may help in the majority of the cases to reduce the potential morbidity, without significant long-term effects.

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.

Conservative management of postoperative chylous fistula with octreotide and peripheral total parenteral nutrition

Postoperative chylous fistula after neck dissection is an uncommon complication associated with significant patient morbidity. Octreotide acetate is a somatostatin analogue established in the treatment of chylothorax; however, its utility in the management of cervical chylous fistulae has not been fully evaluated. The investigators hypothesized that chylous fistula can be managed by a combination of octreotide and peripheral total parenteral nutrition (TPN). A retrospective review of cases compiled at our institution from 2009 to 2015 was conducted. Ten patients, all men, were identified as having a postoperative chylous fistula after a neck dissection. All patients were treated with peripheral TPN and intravenous octreotide. Mean age of the patients was 63.0 years (range 49 to 82). Five (50.0%) had a neck dissection for the management of metastatic nasopharyngeal carcinoma and had previous neck irradiation. In 8 (80%) patients, chylous fistula occurred in the left neck. Seven (70.0%) of the leaks occurred within the first 2 postoperative days. Eight (80%) leaks were controlled using TPN and octreotide, with 2 (20%) patients requiring surgical intervention. No factors were significant in the successful conservative management of chylous fistulae. One patient with a chylous fistula of 1,800 ml/day was managed successfully without surgical intervention. The results of this case series suggest that chylous fistulae may be managed conservatively with octreotide and TPN. However, long-term evaluation is needed to define if and when surgical intervention is required for control.

Bilateral Chylothorax Following Neck Dissection: Case Report & Review of Literature

Bilateral Chylothorax following neck dissection is an extremely rare complication. We report a case of bilateral chylothorax detected after neck dissection for carcinoma of lower alveolus. A 61 year Indian female underwent wide excision with segmental mandibulectomy with comprehensive neck dissection for carcinoma of left lower alveolus clinically staged T4N0. Evaluated for dyspnea in post operative period, she was found to have bilateral chylothorax that was managed conservatively. This case report presents potentially life threatening complication following neck dissection that often responds to non surgical management.

Neck swelling after thyroidectomy: not always a haematoma

We present a case of a patient who returned with a neck swelling 6 days following thyroidectomy and central neck compartment lymphadenectomy for suspected thyroid carcinoma. The initial clinical suspicion pointed to a haematoma, but a needle aspiration showed chyle. Chyle leak is a rare complication of thyroid surgery. In the described case, this was successfully managed conservatively with repeated aspirations and a low-fat diet. We discuss the aetiology, presentation and management of this complication.

Malpractice claims and unintentional outcome of tonsil surgery and other standard procedures in otorhinolaryngology

BACKGROUND

Septoplasty, tonsillectomy (with and without adenoidectomy) and cervical lymph node excision are amongst the most common 50 inpatient operations in Germany. Intracapsular tonsillectomies (i.e. tonsillotomies) are increasingly performed. The aim of this study was to evaluate technical traps and pitfalls as well as alleged medical malpractice associated with tonsillectomy (TE), adenoidectomy (AE), tonsillotomy (TT), septoplasty (SP) and cervical lymph node excision (LN).

METHODS

A questionnaire was sent to the Regional Medical Conciliation Boards, Medical Services of the Health Insurance Companies (MDK) and Regional Institutes of Forensic Medicine in Germany to collect anonymized cases of complications following TE, TT, AE, LN and SP. The results were discussed in the light of the contemporary medical literature and published trials and verdicts in Germany.

RESULTS

The response rate of our survey was 55.9%. The Institutes of Forensic Medicine contributed nine cases, 49 cases were submitted by the Regional Conciliation Boards and none by MDK. All forensic cases were associated with exsanguinations following tonsillectomy including two children (5 and 8 years of age) and seven adults (aged 20 to 69 years). The fatal post-tonsillectomy hemorrhage (PTH) had occurred 8.7 days on average; four patients experienced the bleeding episode at home (day 5, 8, 9 and 17, respectively). Repeated episodes of bleeding requiring surgical intervention had occurred in 6 patients. Three Conciliation Boards submitted decicions associated with TT (1), AE (4), LN (3), SP (16) and TE (25). Cases with lethal outcome were not registered. Only three of the 49 cases were assessed as surgical malpractice (6.1%) including lesion of the spinal accessory nerve, wrong indication for TE and dental lesion after insertion of the mouth gag. The review of the medico legal literature yielded 71 published verdicts after AE and TE (29), LN (28) and SP (14) of which 37 resulted in compensation of malpractice after LN (16; 57%), TE (10; 37%), SP (8; 57%) and AE (2; 100%). There were 16 cases of PTH amongst 27 trials after TE resulting either in death (5) or apallic syndrome (5). Bleeding complications had occurred on the day of surgery in only 2 patients. 16 trials were based on malpractice claims following SP encompassing lack of informed consent (6), anosmia (4), septal perforation (2), frontobasal injury (2) and dry nose (2). Trials after LN procedures were associated exclusively with a lesion of the spinal accessory nerve (28), including lack of informed consent in 19 cases. 49 cases (69%) were decided for the defendant, 22 (31%) were decided for the plaintiff with monetary compensation in 7 of 29 AE/TE-trials, 9 of 28 LN-trials and 6 of 14 SP-trials. Lack of informed consent was not registered for AE/TE but LN (11) and SP (2).

CONCLUSION

Complicated cases following TE, TT, ATE, SP and LN are not systematically collected in Germany. It can be assumed, that not every complicated case is published in the medical literature or law journals and therefore not obtainable for scientific research. Alleged medical malpracice is proven for less than 6% before trial stage. Approximately half of all cases result in a plaintiff verdict or settlement at court. Proper documentation of a thourough counselling, examination, indication, informed consent and follow-up assists the surgeon in litigation. An adequate complication management of PTH is essential, including instructions for the patients/parents, instructions for the medical staff and readily available surgical instruments. Successful outcome of life-threatening PTH is widely based on a proper airway management in an interdisciplinary approach. Electrosurgical tonsillectomy techniques were repeatedly labeled as a risk factor for bleeding complications following TE. Institutions should analyse the individual PTH rate on a yearly basis. Contradictory expert opinions and verdicts of the courts concerning spinal accesory nerve lesions following LN are due to a lack of a surgical standard.

Drainage volume after pancreaticoduodenectomy is a warning sign of chyle leakage that inversely correlates with a diagnosis of pancreatic fistula

BACKGROUND

Chyle leakage is a rare complication of pancreaticoduodenectomy (PD), and its association with pancreatic fistula has not been established. The aim of this study was to (1) evaluate the incidence, management, and risk factors of chyle leakage after PD; (2) determine if there is a relation between chyle leakage and diagnosis of pancreatic fistula; and (3) predict chyle leakage with drainage volume early.

METHODS

A total of 222 patients underwent PD or pylorus-preserving PD. We used the clinical database registry system of the Gangnam Severance Hospital, Yonsei University Health System to establish a retrospective cohort with clinicopathologic data.

RESULTS

Altogether, 24 patients (10.8 %) developed chyle leakage. Chyle leakage was identified at a median 5 days after surgery and a mean 2 days after enteral intake. The mean drain triglyceride level was 315 mg/dl. Early enteral intake was independently associated with chyle leakage. Chyle leakage was inversely correlated with a diagnosis of pancreatic fistula with marginal significance (odds ratio 0.27; 95 % confidence interval 0.66-1.09). The receiver operating characteristic curve of the volume on postoperative day 4 demonstrated an area under the curve of 0.740 (p = 0.0001). Drainage >335 ml indicated possible chyle leakage.

CONCLUSIONS

Chyle leakage after PD is associated with early enteral intake. It was inversely correlated with a diagnosis of pancreatic fistula because of the dilution effect of drainage volume on the concentration of drained amylase. Because early diagnosis helps with appropriate management, prediction/suspicion of chyle leakage based on drainage volume may be useful.

The surgical anatomy and clinical relevance of the neglected right lymphatic duct: review

BACKGROUND

The major lymphatic vessels may be damaged during neck dissection or other cervical surgery, resulting in chyloma or chyle fistula. While commonly considered to be predominantly a complication of left-sided surgery, the thoracic duct may be damaged on either side of the neck due to the extreme variability in the anatomy of the central lymphatic system.

METHOD AND RESULTS

This paper reviews the variable anatomy and embryology of the thoracic and right lymphatic ducts, particularly aspects relevant to head and neck surgery.

Abdominal compression: a new intraoperative maneuver to detect chyle fistulas during left neck dissections that include level IV

BACKGROUND

Chyle fistulas may occur after left neck dissections that include level IV, due to injury of the thoracic duct or of 1 of its major branches. Despite being unusual, this complication carries substantial postoperative morbidity and even mortality. So far, no effective intraoperative maneuver has been reported to detect this fistula at the end of a neck dissection. In this cohort study, we sought to describe a simple new maneuver, intraoperative abdominal compression, which can effectively help to identify an open major lymphatic duct on level IV at the end of a neck dissection.

PATIENTS AND METHODS

From March 1989 to September 2010, 206 patients underwent neck dissections involving left level IV, and underwent intraoperative abdominal compression. There were 119 men and 87 women, with ages ranging from 18 to 81 years (median, 52 years). One hundred forty-four patients had squamous cell carcinomas, 54 had thyroid carcinomas, 5 had malignant melanomas, and 3 had salivary cancers. Distribution by type of left neck dissection was: selective including levels II, III, and IV (73 cases; 35.4%), selective including levels II, III, IV, and V (55 cases; 26.6%), selective including levels I, II, III, and IV (12 cases; 5.8%), modified radical (47 cases; 22.8%), and radical (19 cases; 9.2%). In all cases, at the end of the procedure, the endotracheal tube was temporarily disconnected from the ventilator. Keeping the dissected level IV area under clear visualization, an abdominal compression was performed. At this moment, any detected lymphatic leak was carefully clamped and tied with nonabsorbable sutures. After ventilating the patient, the intraoperative abdominal compression was repeated to reassure complete occlusion of the lymphatic vessel.

RESULTS

In 13 cases (6.3%), a chyle leak was detected after performing the intraoperative abdominal compression. All leaks except for 2 were successfully controlled after 1 attempt. In these 2 patients, a patch of muscle and fat tissue was applied with fibrin glue on the top. In 1 of these patients, another chyle leak in a different location was detected only at the second intraoperative abdominal compression, and was also effectively closed. Postoperatively, there were 2 (1%) chyle fistulas, both among these 13 cases, and all were successfully managed with clinical measures only. No fistulas occurred among the remaining 193 patients in whom intraoperative abdominal compression did not demonstrate lymphatic leak.

CONCLUSION

To our knowledge, this is the first description of a specific maneuver to actively detect a lymphatic fistula at the end of a left neck dissection involving level IV. In this study, intraoperative abdominal compression was able to detect an open lymphatic vessel in 6.3% of the cases, as well as to assure its effective sealing in the remaining 93.7% of the patients. Moreover, no life-threatening high-volume fistula was noted in this study.

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.