Lymph or Chyle Leak After Neck Dissection in Patients With Thyroid Carcinoma: Results of a Study on 1724 Patients

The Anatomy of the Thoracic Duct and Cisterna Chyli: A Meta-Analysis with Surgical Implications

Background: The thoracic duct (TD) and the cisterna chyli (CC) exhibit a high degree of variability in their topographical and morphometric properties. Materials and Methods: PubMed, Scopus, Embase, Web of Science, Cochrane Library, and Google Scholar were searched to identify all studies that included information regarding the morphometric and topographical characteristics of the TD and CC. Results: The most frequent location of the TD termination was the left venous angle, with a pooled prevalence of 45.29% (95% CI: 25.51-65.81%). Moreover, the TD terminated most commonly as a single vessel (pooled prevalence = 78.41%; 95% CI: 70.91-85.09%). However, it divides into two or more terminating branches in approximately a quarter of the cases. The pooled prevalence of the CC was found to be 55.49% (95% CI: 26.79-82.53%). Conclusions: Our meta-analysis reveals significant variability in the anatomy of the TD and CC, particularly regarding TD termination patterns. Despite the predominance of single-vessel terminations, almost a quarter of cases exhibit branching, highlighting the complexity of the anatomy of the TD. These findings demonstrate the importance of detailed anatomical knowledge for surgeons to minimize the risk of accidental injury during head and neck, as well as thoracic surgeries. Our study provides essential insights that can enhance surgical safety and efficacy, ultimately improving patient outcomes.

Usefulness of preoperative ice cream consumption and novel postoperative drainage management in patients undergoing left-sided neck dissection for thyroid cancer: a nonrandomized prospective study

PURPOSE

This study investigated the effects of ice cream consumption on chyle leakage after left lateral neck dissection in patients with thyroid cancer.

METHODS

A total of 491 patients with thyroid cancer underwent left lateral neck dissection with identification of the thoracic duct following ice cream consumption. Before closing the wound, the anesthesiologist increased the intrathoracic pressure to observe chyle leakage. If chyle leakage occurred postoperatively, the drain was removed using the drain negative pressure release test.

RESULTS

Postoperative chyle leakage was observed in 18 of the 491 patients who underwent left lateral neck dissection. We treated 17 patients conservatively and 1 patient surgically. Drains were removed within five days in all patients. After the drain negative pressure release test had been performed in eight patients, the drainage volume significantly decreased from an average of 175 ml to 31 ml per day. The average number of days until the removal of the drainage tube was 3.2 days. No perioperative complications were associated with ice cream consumption.

CONCLUSIONS

In left lateral neck dissection for thyroid cancer, performing surgery following ice cream consumption does not completely prevent chyle leakage; however, early drain removal is possible because there is only mild leakage.

Intranodal lymphangiography with lipiodol as a diagnostic and therapeutic approach for spontaneous cervical chyle leak

We present a case of spontaneous cervical chyle leak that showed as left-sided neck swelling. Spontaneous chyle leak is extremely rare. Lymphangiography with lipiodol is useful as a diagnostic and therapeutic approach for chyle leak.

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.

Pyriform sinus injury in thyroidectomy: the unknown complicating the known

Thyroidectomy is a common procedural skill in the armamentarium of an otolaryngologist but has its own set of complications. The more common complications are hypocalcaemia, recurrent laryngeal nerve palsy, injury to the external branch of the superior laryngeal nerve, postoperative bleeding, wound infection and, rarely, thyroid storm. High pyriform sinus injury during hemithyroidectomy is extremely rare, with this report being only the second reported case in the literature. A 61-year-old man presented with complaints of right-sided neck swelling. The patient had a 10cm × 8cm sized swelling in the anterior neck on examination. A contrast-enhanced computed tomography scan revealed a heterogeneously enhancing mass lesion involving the right lobe of the thyroid and isthmus with multiple nodules. The patient underwent right hemithyroidectomy with no intraoperative complications. The histopathology report describes a papillary thyroid carcinoma (cT3 N0 M0) with the presence of angioinvasion. On the fifth postoperative day, the patient complained of neck pain, suture site swelling and a change of voice. A volume of 50ml of whitish purulent fluid was evacuated. A laryngeal exam revealed restriction in mobility of the right vocal cord. The oesophagogram revealed the iatrogenic injury to the hypopharynx. The oesophageal leak gradually resolved after 6 weeks, as evidenced by multiple contrast oesophagogram, without any need for surgical intervention. We theorise that, while operating on long-standing monster thyroids, extra care should be given while dissecting in the tracheoesophageal groove as the stretched mucosa, an extracapsular extension of disease and lymphovascular invasion can all jeopardise the underlying structures.

Extent of cervical lymph node dissection: Recommendations from the Francophone Association for Endocrine Surgery, the French Society of Endocrinology and the French Society of Nuclear Medicine

When metastatic ipsilateral central lymph nodes from thyroid cancer are identified pre- or intraoperatively (cN1a), ipsilateral central lymph node dissection should be performed concomitantly with thyroidectomy. When the patient is N1a on one side, contralateral prophylactic central lymph node dissection can also be considered. Prophylactic ipsilateral lymph dissection is not recommended. Ipsilateral compartment lymph node dissection is recommended in the corresponding sector for treatment of thyroid cancer with lymph node involvement (cN1b). Lymph node dissection can be limited to sectors III and IV when one of these sectors (or both) is involved and ultrasound does not demonstrate involvement of the other lateral sectors. Associated prophylactic lymph node dissection of sectors IIA and IIB is not recommended, while lymph node dissection of sector V (and exceptionally sector I) is indicated only when metastatic lymph nodes are proven. Prophylactic lymph node dissection of sector VB can be considered when positive lymph nodes are identified in sectors II, III and IV. When isolated metastatic lateral lymph nodes are identified (cN1b), prophylactic central (sector VI) lymph node dissection is recommended on the same side as the lateral compartment in addition to ipsilateral lateral lymph node compartment dissection. The level of evidence is insufficient to recommend prophylactic lateral lymph node dissection on the contralateral side for unilateral cN1b tumors. This type of lymph node dissection can be discussed for tumors that are at high risk of recurrence, bilateral tumors, in case of ipsilateral lateral lymph nodes > 3cm or in presence of > 4 metastatic lymph nodes in the central compartment.

An effective method to reduce lymphatic drainage post-lateral cervical lymph node dissection of differentiated thyroid cancer: a retrospective analysis

Background

Lymph or chyle leak (LL/CL) is severe complications after lateral cervical lymph node dissection (LLND), mainly due to iatrogenic injury of the lymphatic duct. Efficient and well-operated methods to reduce postoperative drainage are still lacking. This was a feasibility study to evaluate a new method of preventing LL/CL compared to conventional treatment.

Method

We retrospectively analyzed 20 consecutive patients who used the “pedicled omohyoid flap covering (POFC)” method during LLND from January 2019 to December 2021 in our center as an observation group. Another 20 consecutive patients used the conventional method during LLND in this period as a control group. The clinical and pathological features of the two groups were compared, and the related factors that affected postoperative lymphatic drainage were analyzed with Cox proportional hazards models.

Results

The drainage volume per 24 h and the incidence of LL/CL in the control group were both higher than that in the observation group (all P < 0.05), and the number of lymph nodes dissected in the IV region > 10 and the use of the POFC method were the independent risk factors that significantly affected the incidence of LL/CL post LLND (all P < 0.05).

Conclusions

POFC is a safe and useful method for reducing drainage and preventing LL/CL post-LLND, especially for patients with heavy metastasis of the lymph nodes in the IV region.