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

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.

Topical Application of Pseudomonas aeruginosa-Mannose Sensitive Hemagglutinin (PA-MSHA) for Refractory Lymphatic Leakage Following Lymphadenectomy in Patients with Gynecological Malignancies

PURPOSE

To observe the feasibility and efficacy of Pseudomonas aeruginosa-mannose sensitive hemagglutinin (PA-MSHA) in refractory lymphatic leakage following lymphadenectomy among patients with gynecological cancers.

PATIENTS AND METHODS

Ten cases with post-operative massive lymphatic leakage were collected, in which patients failed to respond to conservative treatment. Topical PA-MSHA injection of a single dose (2mL) was performed through drainage tube or transvaginal catheter into pelvic or peritoneal cavity. Drainage volumes and side effects were recorded.

RESULTS

The incidence of refractory lymphatic leakage following pelvic and para-aortic lymphadenectomy was 2.44% (10/409). All ten patients (100%) had quick recovery and were discharged within 72 hours. Among them, one patient (10%) experienced fever and six patients (60%) experienced abdominal pain, one of which was moderate and relieved by routine analgesic treatment. During 11 (6-38) months of follow-up time, no long-term side effect was observed.

CONCLUSION

Topical injection of PA-MSHA of a single dose appears a feasible and effective treatment for refractory post-operative lymphatic leakage.

The effect of subcutaneous local spraying of Pseudomonas aeruginosa preparation to reduce postoperative drainage time in patients with breast cancer

Background

To evaluate the efficacy of subcutaneous local spraying of Pseudomonas aeruginosa (P. aeruginosa) preparation (PAP) to reduce the postoperative drainage time in patients with breast cancer (BC).

Methods

The PAP was prepared from an inactivated P. aeruginosa-mannose sensitive hemagglutinin (PA-MSHA) strain, a genetically engineered heat-inactivated PA strain with, mannose-sensitive binding activity, which can induce tumor cell apoptosis. This study is its retrospective nature, a total of 65 BC patients (PAP group) who underwent subcutaneous local spraying of PAP in the operation area at West China Hospital of Sichuan University between June 2019 and October 2019, and 32 BC patients without treatment (non-PAP group, without intraoperative subcutaneous local spraying of PAP in the operation area) were enrolled. Daily drainage volume, drainage time, presence of seroma after extubation, and treatment complications (such as fever, incision infection, and flap necrosis) were recorded.

Results

No significant differences in age, height, weight, age of initial menstruation, menopause, body mass index (BMI), tumor size, lymph node metastasis, or treatment complications were found between the two groups (P>0.05). Drainage volume and drainage time in the PAP group were significantly lower than those in the non-PAP group (P<0.001). Additionally, the incidence of seroma after extubation was significantly lower in the PAP group compared to the non-PAP group (P=0.009).

Conclusions

Subcutaneous local spraying of PAP on the operation area may be helpful to reduce drainage volume, shorten drainage time, and prevent the occurrence of seroma after BC surgery.

Pseudomonas aeruginosa injection decreases drainage in lateral neck dissection for metastatic thyroid cancer

Background

Pseudomonas aeruginosa injection (PAI) has been proven effective against chylous fistula but not in decreasing drainage after lateral neck dissection (LND). To verify the safety of spraying PAI onto the surface of the traumatic cavity after total thyroidectomy with LND and to evaluate whether its application can reduce the drainage volume.

Methods

A total of 85 patients with metastatic papillary thyroid cancer (PTC) who agreed to total thyroidectomy with unilateral LND were recruited from March 2016 to September 2017. During the operation, PAI was applied in 44 patients, while 41 remaining patients served as the control group. The thyroid function and parathyroid function, drainage volume, hospital stay, and incidence of complications were compared between the two groups.

Results

The groups had few differences in age, gender, BMI, thyroid function, parathyroid function, diameter of tumor, and the number of the harvested lymph nodes. The median total drainage volume was significantly smaller and the mean hospital stay was obviously shorter in the PAI group compared to the non-PAI group. But the median volumes of peak 24-hour drainage which appeared during the first day after operation had few differences in the two groups. Postoperative fever in the PAI group was higher than in the non-PAI group. None of the patients had permanent recurrent laryngeal nerve paralysis and tumor recurrence on the 12^th month after operation.

Conclusions

The application of PAI to the wound cavity after LND is safe and effective for reducing the drainage volume and hospital stay.

Intraoperative application of inactivated Pseudomonas aeruginosa in patients undergoing lateral neck dissection for metastatic thyroid cancer: A randomized, parallel group, placebo-controlled trial

BACKGROUND

We hypothesize that the intraoperative, prophylactic application of Pseudomonas aeruginosa can decrease postoperative chylous fistula and enhance recovery after surgery in patients with thyroid cancer undergoing lateral neck lymph node dissection.

METHOD

In this single-center trial, we assigned randomly 200 patients with thyroid cancer who had proven lateral lymph node metastasis to groups receiving either 2 mL Pseudomonas aeruginosa spray (Pseudomonas aeruginosa group) or 2 mL saline spray (control group) in the lateral cervical surgical field. The primary end points were the rate of chylous fistula, mean difference in the duration and volume of drainage fluid, days of postoperative hospital stay, and overall cost. The secondary end points included the red blood cell count and triglyceride level in the drainage, the white blood cell count in the blood, fever, local pain, development of a pleural effusion, and tumor recurrence.

RESULTS

Patients treated with Pseudomonas aeruginosa had a decrease in macroscopic chylous fistula compared with controls (0 vs 6%, P = .025). There were fewer days to drain-tube removal, a less volume of drainage fluid, fewer postoperative days of hospital stay, and a lesser red blood cell count in the drainage fluid in the Pseudomonas aeruginosa group than in the control group (all P < .05). No severe side effects of the Pseudomonas aeruginosa spray with respect to fever, pain, or pleural effusion were observed. Pseudomonas aeruginosa spraying did not affect postoperative recurrence of the thyroid cancer.

CONCLUSION

Intraoperative spraying of inactivated Pseudomonas aeruginosa in the lateral neck compartment can decrease the development of chylous fistula and enhance postoperative recovery.

Ultrasound-guided percutaneous injection of Pseudomonas aeruginosa-mannose sensitive hemagglutinin for treatment of chyle fistula following neck dissection: Two case reports

RATIONALE

Chyle fistula is a rare but troublesome complication of neck dissection. Topical application of Pseudomonas aeruginosa-mannose sensitive hemagglutinin (PA-MSHA) injection has been reported as a novel, viable, and effective approach in the treatment of chyle fistula following neck dissection. However, there have been no reports regarding the treatment of chyle fistula using ultrasound (US)-guided percutaneous injection of PA-MSHA.

PATIENT CONCERNS

We describe 2 patients with thyroid cancer who developed chyle fistula following neck dissection, which remained unresolved despite the use of conservative treatment.

DIAGNOSES

Both the patients were diagnosed with chyle fistula by laboratory testing, which showed that drainage fluid triglyceride concentration was >100 mg/dL.

INTERVENTIONS

When conservative treatment failed, a 2 mL undiluted PA-MSHA preparation was percutaneously injected at the effusion site of the left supraclavicular area under US guidance with aseptic technique. Concomitantly, the drainage tube was clamped for at least 30 minutes.

OUTCOMES

Chyle fistula in both patients were successfully resolved with this technique within 2 or 4 days, without notable side effects.

LESSONS

US-guided percutaneous injection of PA-MSHA is a simple and effective method to treat chyle fistula following neck dissection, which may serve as a useful addition to the medical treatment for cervical chyle fistula.

Pseudomonas aeruginosa-mannose sensitive hemagglutinin injection therapy for the treatment of chyle fistula following neck dissection

BACKGROUND

The efficacy of Pseudomonas aeruginosa-mannose sensitive hemagglutinin (PA-MSHA) injection therapy in the treatment of chyle fistula following neck dissection is unclear.

METHODS

This prospective study enrolled 26 patients who developed chyle fistula after neck dissection. Patients were divided into high-output (>500 mL) and low-output groups (≤500 mL) and were initially treated conservatively for 5 days in the high-output group or 7 days in the low-output group. When conservative treatment failed, topical PA-MSHA therapy was applied.

RESULTS

Twelve of 26 patients were cured with conservative treatment, and the remaining 14 patients were all successfully resolved by PA-MSHA therapy. Chyle fistula got resolved in the low-output and high-output groups after the initiation of therapy were at a median 1 days and 6 days, respectively. Among them, 12 (85.7%) patients experienced fever and 11 (78.6%) patients experienced neck pain.

CONCLUSIONS

Topical PA-MSHA injection therapy could effectively manage chyle fistula following neck dissection.