Anatomic Landmarks for the Cervical Portion of the Thoracic Duct

Proposal for Manual Osteopathic Treatment of the Phrenic Nerve

The article reviews the anatomical path of the phrenic nerve and its anastomoses, with the most up-to-date knowledge reported in the literature. We have briefly reviewed the possible phrenic dysfunctions, with the final aim of presenting an osteopathic manual approach for the treatment of the most superficial portion of the nerve, using a gentle technique. The approach we propose is, therefore, a theory based on clinical experience and the rationale that we can extrapolate from the literature. We hope that the article will be a stimulus for further experimental investigations using the technique illustrated in the article. To the authors' knowledge, this is the first article that takes into consideration the hypothesis of an osteopathic treatment with gentle techniques for the phrenic nerve.

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.

Lymph drainage and cervical fascia anatomy-oriented differential nodal CTV delineation at the supraclavicular region for esophageal cancer and nasopharyngeal cancer

PURPOSE

To determine the differences in supraclavicular lymph node metastasis between esophageal cancer (EC) and nasopharyngeal cancer (NPC) and explore the feasibility of differential supraclavicular clinical target volume (CTV) contouring between these two diseases based on the involvement of different fascial spaces.

MATERIALS AND METHODS

One hundred patients with supraclavicular nodes positive for EC or NPC were enrolled, and their pre-treatment images were reviewed. The distribution patterns of nodes between the two diseases were compared in the context of node levels defined by the 2017 Japanese Esophageal Society and 2013 International Consensus on Cervical Lymph Node Level Classification. Grouping supraclavicular nodes based on sub-compartments formed by the cervical fascia was discussed, and the feasibility of differential CTV contouring based on the differences in the involvement of these sub-compartments between EC and NPC was explored.

RESULTS

The 2013 Consensus on cervical node levels and 2017 Japanese Esophageal Society node station could not practically guide supraclavicular CTV contouring. We divided the supraclavicular space into six sub-compartments: the para-esophageal space (PES), carotid sheath space (CSS), sub-thyroid pre-trachea space (STPTS), pre-vascular space (PVS), and vascular lateral space (VLS) I and II. EC mainly spread to the PES, STPTS, CSS, and VLS I, whereas NPC tended to spread to the CSS, VLS I, and VLS II. These combinations of sub-compartments may help constitute the supraclavicular CTVs for EC and NPC.

CONCLUSIONS

The fascia anatomy-based sub-compartments sufficiently distinguished metastasis to the supraclavicular space between EC and NPC, thus facilitating differential CTV contouring between these two diseases.

Management of Chyle Leak After Head and Neck Surgery; Our Meritorious Experience in 52 Cases and Review of Literature

Iatrogenic chyle leak is commonly seen when dissection happens very low in neck. Management of chyle leak is conservative with compression dressing, fat restricted diet, somatostatin analogues. Surgery is required in extreme cases with failure of conservative treatment. This is a retrospective observational study carried out from a prospectively maintained database. A total of 6482 head and neck surgeries with neck dissections were carried out between January 2015 till July 2020 at our tertiary cancer center. Out of which there were 52 cases of chyle leak reported post neck dissection. All details regarding age, sex, primary tumor location, surgery performed, level of nodal dissection performed, details related to chyle leak from beginning day and its progression and management offered. The median age in the study group was 42 years (24-70 years). Chyle leak was most commonly seen on left side (88.5%). Low output leaks(n = 43) resolved within a median period of 9 days (5-13 days) period of conservative management. High output leak (n = 9) had leak resolution within a median period of 12 days (7-19 days). Patients who had received preoperative radiotherapy and who had extra nodal extension in lymph nodes had significantly higher incidence of high output leaks. Chyle leak is a rare but serious complication in head and neck surgery. Timely identification and management is crucial. Conservative management is mainstay. Surgical management is instituted in cases of failure of conservative management.

Bilateral Chylothorax Following Total Thyroidectomy with Neck Dissection for Papillary Thyroid Cancer: Case report

Bilateral chylothorax is a rare condition that occurs after a thyroidectomy and neck dissection, which can lead to severe morbidity and, potentially, death, if not managed properly. We report a rare complication of neck surgery and subsequent bilateral pleural effusion in a 35-year-old female patient who presented at Sultan Qaboos University Hospital in 2018 with shortness of breath and respiratory distress. The bilateral pleural effusion and related symptoms occurred one week after a total thyroidectomy with central and left lateral neck dissection. The patient was managed conservatively and subsequently recovered.

Anterolateral approach for subaxial vertebral artery decompression in the treatment of rotational occlusion syndrome: results of a personal series and technical note

OBJECTIVES

To report the results of a retrospective series and a technical note about the anterolateral approach for the treatment of the rotational occlusion syndrome (ROS) involving the subaxial V2 segment of the vertebral artery (VA).

METHODS

We retrospectively reviewed the data of a cohort of patients that underwent an anterolateral approach to decompress the VA as they suffered from ROS secondary to a subaxial compression. A dynamic study with ultrasonography, CT, MRI, and catheter-based angiography were obtained in all cases. Severe symptomatology and cerebellar-brainstem strokes were indications for surgery. The anterolateral approach involved a pre-sternocleidomastoid precarotid exposure. The retro-longus colli and pre-scalenic corridors were used to access the C5-C6 and C3-C4 segment, respectively, and to perform the decompression.

RESULTS

Twelve patients were treated. Recurrent drop attacks were present in all cases. Osteophytes at C5 and C6 were the most common causes of subaxial VA compression. Anterior decompression stand-alone was performed in all but 1 patient. A recurrent laryngeal nerve palsy and a numbness of the C5 nerve root were the only complications observed, both transient. A satisfactory untethering of the VA with a complete recovery was achieved in all patients, apart from those with severe infratentorial strokes.

DISCUSSION READ

Anterolateral approach allows for an effective and safe treatment of the ROS involving the subaxial portion of the VA. Retro-longus colli and pre-scalenic corridors, developed through a precarotid exposure, have an anatomical rationale in decreasing the risks of complications. Decompression stand-alone is adequate in almost the totality of cases.

Subaxial Vertebral Artery Rotational Occlusion Syndrome: An Overview of Clinical Aspects, Diagnostic Work-Up, and Surgical Management

Extrinsic compression of the subaxial vertebral artery (VA) may cause rotational occlusion syndrome (ROS) and contribute to vertebrobasilar insufficiency potentially leading to symptoms and in severe cases, to posterior circulation strokes. The present literature review aimed to report the main clinical findings, diagnostic work-up, and surgical management of the subaxial VA-ROS, the diagnosis of which can be difficult and is often underestimated. An illustrative case is also presented. A thorough literature search was conducted to retrieve manuscripts that have discussed the etiology, diagnosis, and treatment of ROS. Total 41 articles were selected based on the best match and relevance and mainly involved case reports and small cases series. The male/female ratio and average age were 2.6 and 55.6±11 years, respectively. Dizziness, visual disturbances, and syncope were the most frequent symptoms in order of frequency, while C5 and C6 were the most affected levels. Osteophytes were the cause in >46.2% of cases. Dynamic VA catheter-based angiography was the gold standard for diagnosis along with computed tomography angiography. Except in older patients and those with prohibitive comorbidities, anterior decompressive surgery was always performed, mostly with complete recovery, and zero morbidity and mortality. A careful neurological evaluation and dynamic angiographic studies are crucial for the diagnosis of subaxial VA-ROS. Anterior decompression of the VA is the cure of this syndrome in almost all cases.

Bilateral chylothorax following reoperative central neck dissection for metastatic papillary thyroid cancer

Locoregional recurrence of papillary thyroid cancer (PTC) can occur in up to 30% of patients within 10 years after initial treatment. Reoperative surgery can be challenging due to scarring, fibrosis and distorted anatomy and may be associated with increased complications compared with initial operations. Chylothorax is an extremely rare and potentially life-threatening complication that can be associated with neck dissections and thyroid surgery. In this report, we describe an unusual case of bilateral chylothorax following a left central neck dissection for recurrent PTC.

The anatomy and physiology of the terminal thoracic duct and ostial valve in health and disease: potential implications for intervention

The thoracic duct (TD) transports lymph drained from the body to the venous system in the neck via the lymphovenous junction. There has been increased interest in the TD lymph (including gut lymph) because of its putative role in the promotion of systemic inflammation and organ dysfunction during acute and critical illness. Minimally invasive TD cannulation has recently been described as a potential method to access TD lymph for investigation. However, marked anatomical variability exists in the terminal segment and the physiology regarding the ostial valve and terminal TD is poorly understood. A systematic review was conducted using three databases from 1909 until May 2017. Human and animal studies were included and data from surgical, radiological and cadaveric studies were retrieved. Sixty-three articles from the last 108 years were included in the analysis. The terminal TD exists as a single duct in its terminal course in 72% of cases and 13% have multiple terminations: double (8.5%), triple (1.8%) and quadruple (2.2%). The ostial valve functions to regulate flow in relation to the respiratory cycle. The patency of this valve found at the lymphovenous junction opening, is determined by venous wall tension. During inspiration, central venous pressure (CVP) falls and the valve cusps collapse to allow antegrade flow of lymph into the vein. During early expiration when CVP and venous wall tension rises, the ostial valve leaflets cover the opening of the lymphovenous junction preventing antegrade lymph flow. During chronic disease states associated with an elevated mean CVP (e.g. in heart failure or cirrhosis), there is a limitation of flow across the lymphovenous junction. Although lymph production is increased in both heart failure and cirrhosis, TD lymph outflow across the lymphovenous junction is unable to compensate for this increase. In conclusion the terminal TD shows marked anatomical variability and TD lymph flow is controlled at the ostial valve, which responds to changes in CVP. This information is relevant to techniques for cannulating the TD, with the aid of minimally invasive methods and high resolution ultrasonography, to enable longitudinal physiology and lymph composition studies in awake patients with both acute and chronic disease.

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.

Thoracic duct fistula after thyroid cancer surgery: towards a new treatment?

The use of somatostatin analogs is a new conservative therapeutic approach for the treatment of chyle fistulas developing after thyroid cancer surgery. The combination therapy with a total parenteral nutrition should avoid the high morbidity of a re-intervention with an uncertain outcome. This promising trend is supported by the present case report of a chyle leak occurring after total thyroidectomy with central and lateral neck dissection for a papillary carcinoma, which was treated successfully without immediate or distant sequelae.

Use of N-butyl-2-cyanoacrylate tissue glue in thoracic duct injury during neck dissection surgery

Although thoracic duct injury is an uncommon complication of neck dissection, it can have a significant physiological and immunological impact on the patient's recovery as well as having more serious effects. We report a novel technique of using cyanoacrylate tissue glue for managing thoracic duct damage when this is noted at the time of neck dissection surgery. We have used this technique in four patients with no post-operative chyle leak or added complications.

Anatomic landmarks for nerves of the neck: a vade mecum for neurosurgeons

Anatomic landmarks are often quite useful in localizing structures within the human body, especially in the surgical realm. We have reviewed the medical literature and multiple texts of surgery and anatomy and culled together many anatomic landmarks regarding important nerves of the neck. This region is complicated by formidable anatomy, and a single collection of the relationships of the nerves in this region is lacking in the literature. It is our hope that this collection will serve to assist the surgeon who operates in this region of the body.