Efficacy of octreotide against chylothorax following lateral neck dissection for thyroid cancer: A case report

Bilateral chylothorax following total thyroidectomy with neck lymph node dissection for thyroid cancer: a case report and literature review

Purpose

Investigating the diagnosis and treatment of bilateral Chylothorax after neck lymph node dissection for thyroid cancer.

Methods

The clinical data of a patient with bilateral chylothorax after neck lymph node dissection for thyroid cancer were retrospectively analyzed, and the relevant literature was reviewed.

Results

The patient underwent a total thyroidectomy and left neck lymph node dissection, with no evidence of lymph fluid leakage observed during the operation. The patient experienced chest tightness, shortness of breath, dyspnea, and decreased lung auscultation breath sounds on the 7th day after the surgery. The chest X-ray examination revealed the presence of bilateral pleural effusion. Under ultrasound guidance, bilateral thoracic closed drainage tube was implanted, and a small sample of the milky white fluid was tested for chylothorax, yielded positive results. The patient is diagnosed with bilateral chylothorax. After received conservative treatment, the patient's drainage flow gradually decreased. Subsequent review of a chest X-ray showed no signs of chest hydrops, and as a result, the thoracic drainage tube was removed. The patient eventually recovered and was subsequently discharged.

Conclusion

Bilateral chylothorax is a rare complication following neck lymph node dissection for thyroid cancer. It is deemed safe and effective to administer active conservative treatment upon early detection.

Bilateral chylothorax following papillary thyroid carcinoma with cervical lymph node dissection: Case report and comprehensive review of the literature

RATIONALE

This case analysis and literature review aim to identify the causes of bilateral chylothorax following thyroid cancer surgery, a rare yet serious complication.

PATIENT CONCERNS

We report 2 East Asian women who developed bilateral chylothorax after undergoing total thyroidectomy with neck lymph node dissection. Both patients presented with dyspnea and significant pleural effusion postoperatively.

DIAGNOSES

Both patients were diagnosed with bilateral chylothorax based on clinical examination and imaging studies, including chest ultrasonography and X-rays.

INTERVENTIONS

In both cases, conservative management was initially implemented, involving chest tube drainage, total parenteral nutrition, and octreotide therapy. Surgical intervention was considered if conservative measures failed to control the chylous output.

OUTCOMES

Both patients showed gradual improvement with conservative treatment, ultimately resulting in successful resolution of pleural effusion and discharge from the hospital without complications.

LESSONS

For patients with bilateral chylothorax, conservative treatment should be the initial approach for small effusions. For moderate to large effusions, placement of a chest drainage tube is recommended, and surgical intervention should be considered if chyle volume exceeds 10 mL/(kg/d) for 48 to 72 hours or persists for more than 11 days following conservative treatment.

Surgical intervention in a complicated persistent chyle leak

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The involved patient had a persistent right sided chyle leak status post total neck dissection and radiation treatment one month prior to hospital presentation.

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Conservative treatment was unsuccessful, and the surgical oncology team then attempted focal control within the neck.

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The output remained persistent post focal ligation, and the patient was inevitably worked up for a right sided VATs thoracic duct ligation by the cardiothoracic surgical team.

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VATs thoracic duct ligation was postponed due to a developing cellulitis of his surgical wound, resultant elevated WBC of 21,000, 39.5 °C oral temperature, and positive blood cultures (bacteremia).

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The right VATs thoracic duct ligation was performed once two negative blood cultures had returned from the lab.

Introduction

Chyle leak following cervical surgery has a reported incidence of around 2% annually, and the injury primarily favors a left sided involvement. Our patient presented with a right sided neck persistent chyle leak status post cervical neck dissection and radiation therapy. Infection complicated the patient's clinical course, and he inevitably required a right sided VATS thoracic duct ligation.

Presentation of case

The patient was a 53-year-old African American male, with a past medical history of T1N0 right tonsil carcinoma status post chemo-radiation in 2016. He was found to have a residual right-sided neck mass, and then underwent a total neck dissection of the mass and the involved lymph node levels.

Discussion

Our patient presented with a right sided lymphatic injury following a total cervical neck dissection. His presentation was uncharacteristic for that the chyle leak was on the right side of his neck, and that he subsequently developed cellulitis and bacteremia due to a prolonged period to surgical intervention. His refractory response to initial conservative measures could have been affected by his prior radiation treatment.

Conclusion

Chyle leakage is a rare complication of total cervical neck dissection, and should always be considered even with right sided involvement. Conservative management is appropriate in the initial presentation; however, if a patient has a prior history of radiation treatment to the involved site, thoracic duct ligation implemented early may prevent complications such as infection, or a prolonged hospital stay.

The following case report has been reported in line with the SCARE criteria.