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Kimizuka S, Yamada H, Kawaguchi K, Horiuchi T, Takeda A, Hamada Y. Bilateral chylothorax following left neck dissection and literature review. J Surg Case Rep 2024; 2024:rjad723. [PMID: 38213403 PMCID: PMC10781942 DOI: 10.1093/jscr/rjad723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 11/28/2023] [Indexed: 01/13/2024] Open
Abstract
Chylothorax without chyle cervical leakage after neck dissection it is extremely rare. We report a case of bilateral chylothorax without chyle cervical leakage after left neck dissection, wherein partial left upper jaw resection and left radical neck dissection were performed in a 46-year-old woman who was diagnosed with left upper gingival cancer. The thoracic duct was ligated and cut during surgery and, although no obvious leakage of lymph was observed, dyspnea and cough reflex during deep inhalation were observed from the third postoperative day. Approximately 600 mL of yellowish-white pleural effusion was aspirated during bilateral thoracentesis, and chylothorax was diagnosed based on clinical findings and biochemical analysis results. The patient was put on a low-fat diet on the fourth postoperative day. Pleural effusion disappeared on imaging examination 16 days after thoracentesis.
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Affiliation(s)
- Sachiko Kimizuka
- Department of Oral and Maxillofacial Surgery, Tsurumi University, School of Dental Medicine, 2-1-3 Tsurumi, Tsurumi-ku, Yokohama-city, Kanagawa, 230-8501, Japan
- Department of Plastic and Aesthetic Surgery, Kitasato University, School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara-city, Kanagawa 252-0374, Japan
| | - Hiroyuki Yamada
- Division of Oral and Maxillofacial Surgery, Department of Reconstructive Oral and Maxillofacial Surgery, School of Dentistry, Iwate Medical University, 19-1 Uchimaru, Morioka, Iwate 020-8505, Japan
| | - Koji Kawaguchi
- Department of Oral and Maxillofacial Surgery, Tsurumi University, School of Dental Medicine, 2-1-3 Tsurumi, Tsurumi-ku, Yokohama-city, Kanagawa, 230-8501, Japan
| | - Toshikatsu Horiuchi
- Department of Oral and Maxillofacial Surgery, Saiseikai Yokohamashi Tobu Hospital, 3-6-1 Shimosueyoshi, Tsurumi-ku, Yokohama-city, Kanagawa 230-8765, Japan
| | - Akira Takeda
- Department of Plastic and Aesthetic Surgery, Kitasato University, School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara-city, Kanagawa 252-0374, Japan
| | - Yoshiki Hamada
- Department of Oral and Maxillofacial Surgery, Tsurumi University, School of Dental Medicine, 2-1-3 Tsurumi, Tsurumi-ku, Yokohama-city, Kanagawa, 230-8501, Japan
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2
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Tsuzaka S, Aiyama T, Kamachi H, Kakisaka T, Orimo T, Nagatsu A, Asahi Y, Maeda T, Kamiyama T, Taketomi A. Lymphaticovenous anastomosis for treatment of refractory chylous ascites: A case report. Microsurgery 2023; 43:606-610. [PMID: 37016794 DOI: 10.1002/micr.31042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 01/17/2023] [Accepted: 03/09/2023] [Indexed: 04/06/2023]
Abstract
Chylous ascites, the leakage of lymphatic fluid into the abdominal cavity caused by lymphatic fluid stasis or lymphatic vessel damage, can be treated by lymphaticovenous anastomosis (LVA). We report rarely performed abdominal LVA to treat a case of refractory ascites possibly caused by ligation of the thoracic duct and pleurodesis in a man aged 60 years requiring weekly ascites drainage. Ligation was abandoned because the leakage site was not determined. The greater omentum (GO) was generally edematous and showed lymphatic effusion by gross appearance, and was considered suitable for LVA. We performed once LVA in the lymphatic vessels and veins of the GO using common microsurgical instrumentation and lateral anastomosis. Lymphatic vessels in the omentum were dilated to 2-3 mm, and LVA was simple. After LVA, GO edema improved. Postoperatively, the patient developed paralytic ileus, which improved within a few days, and the patient was discharged without any increase in ascites after starting to diet. One year post-surgery, there was no recurrence of ascites. LVA at the GO may be effective for the treatment of refractory chylous ascites because of its absorptive lymphatic draining capabilities and large transverse vessels.
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Affiliation(s)
- Shoichi Tsuzaka
- Department of Gastroenterological Surgery I, Hokkaido University Hospital, Kita-ku, Kita 15, Nishi 7, Sapporo, 060-8638, Hokkaido, Japan
| | - Takeshi Aiyama
- Department of Gastroenterological Surgery I, Hokkaido University Hospital, Kita-ku, Kita 15, Nishi 7, Sapporo, 060-8638, Hokkaido, Japan
| | - Hirofumi Kamachi
- Department of Gastroenterological Surgery I, Hokkaido University Hospital, Kita-ku, Kita 15, Nishi 7, Sapporo, 060-8638, Hokkaido, Japan
| | - Tatsuhiko Kakisaka
- Department of Gastroenterological Surgery I, Hokkaido University Hospital, Kita-ku, Kita 15, Nishi 7, Sapporo, 060-8638, Hokkaido, Japan
| | - Tatsuya Orimo
- Department of Gastroenterological Surgery I, Hokkaido University Hospital, Kita-ku, Kita 15, Nishi 7, Sapporo, 060-8638, Hokkaido, Japan
| | - Akihisa Nagatsu
- Department of Gastroenterological Surgery I, Hokkaido University Hospital, Kita-ku, Kita 15, Nishi 7, Sapporo, 060-8638, Hokkaido, Japan
| | - Yoh Asahi
- Department of Gastroenterological Surgery I, Hokkaido University Hospital, Kita-ku, Kita 15, Nishi 7, Sapporo, 060-8638, Hokkaido, Japan
| | - Taku Maeda
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine, Graduate School of Medicine, Hokkaido University Hospital, Kita-ku, Kita 15, Nishi 7, Sapporo, 060-8638, Hokkaido, Japan
| | - Toshiya Kamiyama
- Department of Gastroenterological Surgery I, Hokkaido University Hospital, Kita-ku, Kita 15, Nishi 7, Sapporo, 060-8638, Hokkaido, Japan
| | - Akinobu Taketomi
- Department of Gastroenterological Surgery I, Hokkaido University Hospital, Kita-ku, Kita 15, Nishi 7, Sapporo, 060-8638, Hokkaido, Japan
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3
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Lee J, Bae IE, Yoon J, Lee K, Yu HW, Kim SJ, Chai YJ, Choi JY, Lee KE. Postoperative Chylothorax after Modified Radical Neck Dissection for Thyroid Carcinoma: A Missable Rare Complication of Thyroid Surgery. ACTA ACUST UNITED AC 2020; 56:medicina56090481. [PMID: 32967181 PMCID: PMC7557742 DOI: 10.3390/medicina56090481] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 09/15/2020] [Accepted: 09/18/2020] [Indexed: 11/16/2022]
Abstract
Background and objectives: Currently, few studies have been conducted on postoperative chylothorax, specifically in total thyroidectomy with modified radical neck dissection (MRND) in papillary thyroid carcinoma patients. This study provides the actual incidence, etiology, and clinical features of postoperative chylothorax and reports the clinical outcomes after treatment, which were dependent upon the severity of the complications. Materials and Methods: The medical charts of 111 papillary thyroid cancer (PTC) patients who underwent total thyroidectomy with modified radical neck dissection from January 2016 to December 2018 were reviewed retrospectively. The results were compared in three groups: the no chylothorax group, the subclinical (asymptomatic) group, and the clinical (symptomatic) group. Results: Chylothorax occurred in 23 patients (20.7%, 23/111). Nineteen (82.6%, 19/23) were subclinical chylothorax cases, which implies a small amount of chyle leakage with no respiratory symptoms. Four (17.4%, 4/23) were clinical, meaning they had either respiratory symptoms, such as dyspnea, desaturation, or a large amount of chylothorax in the images. The incidence was significantly higher in patients who underwent left modified radical neck dissection, and this corresponds to the side in which chylothorax occurred. There were also statistical differences in the drainage color, peak amount, or drain removal time. Conclusions: Postoperative chylothorax is a rare complication following neck dissection. However, it can be fatal if the condition progresses. Therefore, patients who undergo total thyroidectomy with modified radical neck dissection, especially on the left side, should be monitored for respiratory symptoms, and serial chest x-ray images obtained.
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Affiliation(s)
- Junghyun Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do 13620, Korea; (J.L.); (J.Y.); (K.L.); (H.W.Y.)
| | - In Eui Bae
- Department of Surgery, Konyang University Hospital, Daejeon 35365, Korea;
| | - Jin Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do 13620, Korea; (J.L.); (J.Y.); (K.L.); (H.W.Y.)
| | - Keunchul Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do 13620, Korea; (J.L.); (J.Y.); (K.L.); (H.W.Y.)
| | - Hyeong Won Yu
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do 13620, Korea; (J.L.); (J.Y.); (K.L.); (H.W.Y.)
- Cancer research institute, Seoul National University College of Medicine, Seoul 10408, Korea; (S.-j.K.); (K.E.L.)
| | - Su-jin Kim
- Cancer research institute, Seoul National University College of Medicine, Seoul 10408, Korea; (S.-j.K.); (K.E.L.)
- Department of Surgery, Seoul National University Hospital, Seoul 03080, Korea
| | - Young Jun Chai
- Department of Surgery, Seoul National University Boramae Medical Center, Seoul 07061, Korea;
| | - June Young Choi
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do 13620, Korea; (J.L.); (J.Y.); (K.L.); (H.W.Y.)
- Cancer research institute, Seoul National University College of Medicine, Seoul 10408, Korea; (S.-j.K.); (K.E.L.)
- Correspondence: ; Tel.: +82-31-787-7107
| | - Kyu Eun Lee
- Cancer research institute, Seoul National University College of Medicine, Seoul 10408, Korea; (S.-j.K.); (K.E.L.)
- Department of Surgery, Seoul National University Hospital, Seoul 03080, Korea
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4
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Bae JS, Park JH, Jang IT. Bilateral chylothorax following anterior cervical spine surgery. Acta Neurochir (Wien) 2017; 159:2019-2021. [PMID: 28836030 DOI: 10.1007/s00701-017-3294-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 08/01/2017] [Indexed: 12/14/2022]
Abstract
Bilateral chylothorax following anterior cervical spine surgery is very rare. This report documents the first case of chylothorax after anterior cervical spine surgery through a right-side surgical approach. Unidentified chyle leakage can easily remain unrecognized and, thus, is difficult to treat. For early diagnosis and treatment, it is very important to consider the possibility of chylothorax following anterior cervical spine surgery, even when using a right-side surgical approach.
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Affiliation(s)
- Jung Sik Bae
- Department of Neurosurgery, Nanoori Gangseo Hospital, Seoul, South Korea
| | - Jeong Hyun Park
- Department of Neurosurgery, Nanoori Jooan Hospital, Incheon, South Korea
| | - Il-Tae Jang
- Department of Neurosurgery, Nanoori Gangnam Hospital, 731 Eonju-ro, Gangnam-gu, Seoul, 06048, Republic of Korea.
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Delaney SW, Shi H, Shokrani A, Sinha UK. Management of Chyle Leak after Head and Neck Surgery: Review of Current Treatment Strategies. Int J Otolaryngol 2017; 2017:8362874. [PMID: 28203252 PMCID: PMC5288539 DOI: 10.1155/2017/8362874] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 12/07/2016] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Sean W. Delaney
- Department of Otolaryngology Head and Neck Surgery, Keck School of Medicine, University of Southern California, 1540 Alcazar St, Suite 204Q, Los Angeles, CA 90033, USA
| | - Haoran Shi
- Department of Biochemistry and Molecular Biology, University of Southern California, Los Angeles, CA, USA
| | - Alireza Shokrani
- Department of Otolaryngology Head and Neck Surgery, Keck School of Medicine, University of Southern California, 1540 Alcazar St, Suite 204Q, Los Angeles, CA 90033, USA
| | - Uttam K. Sinha
- Department of Otolaryngology Head and Neck Surgery, Keck School of Medicine, University of Southern California, 1540 Alcazar St, Suite 204Q, Los Angeles, CA 90033, USA
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Merki V, Pichler J, Giger R, Mantokoudis G. Chylothorax in thyroid surgery: a very rare case and systematic review of the literature. J Otolaryngol Head Neck Surg 2016; 45:52. [PMID: 27756377 PMCID: PMC5070362 DOI: 10.1186/s40463-016-0166-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 10/12/2016] [Indexed: 11/10/2022] Open
Abstract
Background Chylothorax is a very rare but major complication in thyroid surgery and should be apparent to clinicians in this field. Case presentation We report a case with chylothrax after thyroid surgery in our department that drew our attention. Methods Systematic review of the literature to evaluate the incidence and the contributing factors of chylothorax after thyroid surgery. Database (PubMed) and hand searches to identify patients with thyroid surgery and postoperative chylothorax. Keywords included chylothorax, thyroidectomy, thyroid surgery and complications. Two independent reviewers screened studies against inclusion and exclusion criteria. Patient characteristics, risk factors, symptoms, treatments and etiopathogenesis were investigated. Results We identified 13 articles in the literature describing 19 patients with chylothorax after thyroidectomy and described our own case. Ninety percent of the patients underwent thyroidectomy for thyroid cancer. Sixteen patients (80 %) underwent thyroidectomy with at least a left lateral neck dissection, 2 patients (10 %) underwent thyroidectomy with sternotomy, and in the remaining 2 patients (10 %), thyroidectomy with lateral neck dissection on both sides was performed with partial sternotomy. Our calculated incidence for chylothorax with total thyroidectomy and neck dissection was 1.85 %; for a thoracic approach the calculated incidence was 7.3 %. Conclusions There are no reports of chylothorax after thyroidectomy without at least a left lateral neck dissection due to advanced thyroid cancer and/or sternotomy due to the thyroid size. The extension of thyroid surgery seems to be the main risk factor in developing chylothorax either through direct surgical trauma or through increased intraductal pressure after thoracic duct ligation. An early diagnosis of chylothorax may avoid severe metabolic or cardiopulmonary complications.
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Affiliation(s)
- Verena Merki
- Department of Otorhinolaryngology-Head & Neck Surgery, Inselspital, Bern University Hospital, and University of Bern, 3010, Bern, Switzerland
| | - Juliane Pichler
- Department of Otorhinolaryngology-Head & Neck Surgery, Inselspital, Bern University Hospital, and University of Bern, 3010, Bern, Switzerland
| | - Roland Giger
- Department of Otorhinolaryngology-Head & Neck Surgery, Inselspital, Bern University Hospital, and University of Bern, 3010, Bern, Switzerland.
| | - Georgios Mantokoudis
- Department of Otorhinolaryngology-Head & Neck Surgery, Inselspital, Bern University Hospital, and University of Bern, 3010, Bern, Switzerland
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7
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Busquets JM, Rullan PJ, Trinidad-Pinedo J. Bilateral Chylothorax after Neck Dissection. Otolaryngol Head Neck Surg 2016; 130:492-5. [PMID: 15100652 DOI: 10.1016/j.otohns.2003.11.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Chylous fistula is a well-recognized complication of neck dissection, occurring in 1% to 2% of cases. 1 Cardiopulmonary complications, on the other hand, are rare. Bilateral chylothorax is an extremely rare occurrence following neck dissection. Severe respiratory, metabolic, and immunologic derangements can occur secondary to chylothorax. We report a case of bilateral chylothorax after neck dissection and cervical thoracic duct ligation.
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Affiliation(s)
- José M Busquets
- Department of Otolaryngology-Head and Neck Surgery, University of Puerto Rico School of Medicine, San Juan, Puerto Rico.
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8
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Singh R, Krishnan S, George NA, Gowri BP, Iqbal Ahamed M, Sebastian P. Bilateral Chylothorax Following Neck Dissection: Case Report & Review of Literature. Indian J Surg Oncol 2016; 7:115-8. [PMID: 27065696 PMCID: PMC4811813 DOI: 10.1007/s13193-015-0445-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Accepted: 07/07/2015] [Indexed: 12/28/2022] Open
Abstract
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.
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Affiliation(s)
- Rajesh Singh
- Department of Surgical Oncology, Regional Cancer Centre, Thiruvananthapuram, Kerala 695011 India
| | - Sharath Krishnan
- Department of Surgical Oncology, Regional Cancer Centre, Thiruvananthapuram, Kerala 695011 India
| | - Nebu Abraham George
- Department of Surgical Oncology, Regional Cancer Centre, Thiruvananthapuram, Kerala 695011 India
| | | | - M. Iqbal Ahamed
- Department of Surgical Oncology, Regional Cancer Centre, Thiruvananthapuram, Kerala 695011 India
| | - Paul Sebastian
- Department of Surgical Oncology, Regional Cancer Centre, Thiruvananthapuram, Kerala 695011 India
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9
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Ray A. Pathogenesis of bilateral chylothorax after injury of thoracic duct during central venous catheterization. Lung India 2015; 32:673-5. [PMID: 26664195 PMCID: PMC4663892 DOI: 10.4103/0970-2113.168115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Animesh Ray
- Department of Pulmonary Critical Care and Sleep Medicine, Fortis Flt. Lt. Rajan Dhall Hospital, Vasantkunj, New Delhi, India E-mail:
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10
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Runge T, Borbély Y, Candinas D, Seiler C. Bilateral chylothorax following neck dissection: a case report. BMC Res Notes 2014; 7:311. [PMID: 24885488 PMCID: PMC4036830 DOI: 10.1186/1756-0500-7-311] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2014] [Accepted: 05/14/2014] [Indexed: 11/11/2022] Open
Abstract
Background Chylothorax is an extremely rare but potentially life-threatening complication after radical neck dissection. We report the case of a bilateral chylothorax after total thyroidectomy and cervico-central and cervico-lateral lymphadenectomy for thyroid carcinoma. Case presentation A 40-year-old European woman underwent total thyroidectomy and neck dissection for papillary thyroid carcinoma. Postoperatively she developed dyspnoea and pleural effusion. A chylothorax was found and the initial conservative therapy was not successful. She had to be operated on again and the thoracic duct was legated. Conclusion The case presentation reports a very rare complication after total thyroidectomy and neck dissection, but it has to be kept in mind to prevent dangerous complications.
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Affiliation(s)
- Tina Runge
- Department of Visceral Surgery and Medicine, Inselspital, University of Bern, Bern 3000, Switzerland.
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11
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Yang DJ, Ren GS, Wang XY. Bilateral chylothorax following left supraclavicular lymph node dissection for breast cancer: one case report and literature review. CHINESE JOURNAL OF CANCER 2014; 33:317-20. [PMID: 24417875 PMCID: PMC4059869 DOI: 10.5732/cjc.013.10102] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Chylothorax is a rare complication of neck dissection, and bilateral chylothorax is even rarer. However, both are potentially serious and sometimes life-threatening, especially those that are associated with left neck dissection for head and neck neoplasms. We report one case of bilateral chylothorax following left supraclavicular dissection for breast cancer. This case was treated successfully with a new conservative management approach.
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Affiliation(s)
- De-Juan Yang
- Department of Breast and Endocrine Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, P. R. China.
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12
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Chylothorax after neck dissection for thyroid carcinomas: report of three cases. Surg Today 2011; 42:89-92. [PMID: 22075655 DOI: 10.1007/s00595-011-0015-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2010] [Accepted: 01/12/2011] [Indexed: 10/15/2022]
Abstract
Chylothorax is a rare complication of neck dissection. We report three cases of chylothorax after neck dissections for thyroid carcinoma and attribute this relatively high incidence to the assumption that most patients are asymptomatic. Thus, conventional chest X-ray or ultrasonography in the early postoperative period may be warranted to exclude asymptomatic chylothorax, especially if the thoracic duct is injured and ligated during the operation. We suggest that for chylothorax induced by ligation of the thoracic duct, which may be transient and resolve quickly, short-term thoracic drainage is enough.
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13
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Bilateral chylothorax following neck dissection for thyroid cancer. Int J Oral Maxillofac Surg 2009; 38:1119-22. [PMID: 19457642 DOI: 10.1016/j.ijom.2009.04.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2008] [Accepted: 04/21/2009] [Indexed: 11/22/2022]
Abstract
Bilateral chylothorax is mainly encountered following certain thoracic procedures. It is a rare complication following neck dissection, but can be serious and life threatening. The authors report a case of bilateral chylothorax following left modified radical neck dissection, right modified neck dissection and superior mediastinal dissection for bilateral medullary thyroid cancer. The patient was treated successfully with conservative management. The pathophysiology of this complication is discussed and multidisciplinary approach is advocated.
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14
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van der Gaag NA, Verhaar AC, Haverkort EB, Busch ORC, van Gulik TM, Gouma DJ. Chylous ascites after pancreaticoduodenectomy: introduction of a grading system. J Am Coll Surg 2008; 207:751-7. [PMID: 18954789 DOI: 10.1016/j.jamcollsurg.2008.07.007] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2008] [Revised: 06/30/2008] [Accepted: 07/02/2008] [Indexed: 12/14/2022]
Abstract
BACKGROUND Chylous ascites (CA) is a complication that follows thoracic and abdominal surgery, recognized after provocation by enteral feeding and characterized by its milky appearance from an elevated triglyceride level. The aim of this study was to evaluate incidence, management, and predisposing factors of CA and its impact on outcomes after pancreaticoduodenectomy. STUDY DESIGN Between 1996 and 2007, 609 consecutive patients underwent pancreaticoduodenectomy. Patients having a drain output with a milky appearance, and with a triglyceride level greater than 1.2 mmol/L, were compared with patients without significant drain production or with a low triglyceride level. Management of CA was reviewed. RESULTS Sixty-six patients had isolated CA (11%) of any measurable volume, 440 patients (72%) had no CA, and 109 patients (16%) were excluded from analysis. CA was diagnosed on postoperative day 6 (median; interquartile range 5 to 8), generally after introduction of a normal (polymeric low-chain-triglyceride) diet. Female gender (odds ratio, 1.79; 95% CI, 1.05 to 3.03) and chronic pancreatitis at pathology (odds ratio, 2.52; 95% CI, 1.19 to 5.32) were independently associated with development of isolated CA. A low-chain-triglyceride-restricted diet was initiated in 47 patients, 3 were started on total parenteral nutrition, and an expectative approach was followed in 16 patients. CA resolved after 3.5 days (median; interquartile range, 2 to 5). Isolated CA was significantly associated with prolonged hospital stay (p=0.002). CONCLUSIONS We propose a novel definition and grading system for CA after pancreaticoduodenectomy, according to which the incidence is 9%, with clinically significant CA occurring in 4% (grades B and C). Although female gender and (focal) chronic pancreatitis were associated with development of isolated CA, no predisposing factors that could readily anticipate CA were identified. Isolated CA was associated with prolonged hospital stay.
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Affiliation(s)
- Niels A van der Gaag
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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15
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Raguse JD, Pfitzmann R, Bier J, Klein M. Lower-extremity lymphedema following neck dissection – an uncommon complication after cervical ligation of the thoracic duct. Oral Oncol 2007; 43:835-7. [PMID: 17418615 DOI: 10.1016/j.oraloncology.2007.01.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2007] [Accepted: 01/25/2007] [Indexed: 12/21/2022]
Abstract
Thoracic duct injuries and chylous fistula are well-known complications of neck dissection, occurring in 1-2% of cases. Management of these injuries can be conservative or operative. Conservative treatment consists of fat restricted diet or total parenteral nutrition reducing the volume of chyle production. Operative management includes exploration of the neck or if necessary open thoracotomy to ligate the thoracic duct. Following cervical thoracic duct ligation only few complications like chylothorax or chylous ascites are described in the literature. To the best authors knowledge, this is the first report in the english literature describing lower-extremity lymphedema following cervical thoracic duct ligation.
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Affiliation(s)
- Jan D Raguse
- Clinic for Oral and Maxillofacial Surgery, Charité Universitätsmedizin Berlin - CVK Augustenburger Platz 1, 13353 Berlin, Germany.
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Bae JS, Song BJ, Kim MR, Park WC, Kim JS, Jung SS. Bilateral chylothoraces without chyle leakage after left-sided neck dissection for thyroid cancer: report of two cases. Surg Today 2007; 37:652-5. [PMID: 17643207 DOI: 10.1007/s00595-006-3449-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2006] [Accepted: 11/16/2006] [Indexed: 11/25/2022]
Abstract
Bilateral chylothorax is a rare complication of neck dissection, but it is potentially serious and sometimes life threatening. Because of the rarity of chylothorax, surgeons are unfamiliar with its early signs, which allow a prompt diagnosis and effective management. Most cases reported in the literature were associated with a concurrent external chyle leakage, which occurred either during or after surgery. We report two cases of bilateral chylothoraces without concurrent external chyle leakage, which occurred after left-sided neck dissections for thyroid cancer. We treated both patients successfully with conservative management.
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Affiliation(s)
- Ja Seong Bae
- Department of Surgery, the Catholic University of Korea, Kangnam St. Mary's Hospital, 505 Banpo-Dong, Seocho-gu, 137-701 Seoul, South Korea
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17
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Tsukahara K, Kawabata K, Mitani H, Yoshimoto S, Sugitani I, Yonekawa H, Beppu T, Fukushima H, Sasaki T. Three cases of bilateral chylothorax developing after neck dissection. Auris Nasus Larynx 2007; 34:573-6. [PMID: 17466474 DOI: 10.1016/j.anl.2007.03.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2006] [Revised: 02/27/2007] [Accepted: 03/16/2007] [Indexed: 11/26/2022]
Abstract
Only 16 cases of bilateral chylothorax following neck dissection have been reported within 10 decades. In this paper, three cases of bilateral chylothorax which developed after neck dissection are reported. In all cases, conservative treatment resulted in resolution of the condition. Diagnosis may be delayed in those who are on total parenteral nutrition, and therefore particular attention should be paid to those patients. It may be difficult to treat cases of chylothorax that develop following neck dissection performed after radiotherapy.
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Affiliation(s)
- Kiyoaki Tsukahara
- Division of Head and Neck, Cancer Institute Hospital, 3-10-6 Ariake, Koto-ku, Tokyo 135-8550, Japan.
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18
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Huang Q, Jiang ZW, Jiang J, Li N, Li JS. Chylous ascites: Treated with total parenteral nutrition and somatostatin. World J Gastroenterol 2004; 10:2588-91. [PMID: 15300913 PMCID: PMC4572170 DOI: 10.3748/wjg.v10.i17.2588] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
AIM: To determine the effects of total parenteral nutrition and somatostatin on patients with chylous ascites.
METHODS: Five patients were diagnosed with chylous ascites on the basis of laboratory findings of ascites sample from Nov 1999 to May 2003. Total parenteral nutrition and somatostatin or its analogue was administered to 4 patients, while the other one only received total parenteral nutrition. All the patients had persistent peritoneal drainage, with the quantity and quality of drainage fluid observed daily. Necessary supportive treatments were given to the patients individually during the therapy.
RESULTS: Two of 4 patients who received somatostatin therapy obtained complete recovery within 10 d without any recurrence while on a normal diet. In these 2 patients, the peritoneal drainage reduced to zero in one and the other's decreased from 2000 mL to 80 mL with a clear appearance and negative qualitative analysis of chyle. Recurrent chylous ascites, though relieved effectively by the same method every time, developed in one patient with advanced pancreatic cancer. The other patient's lymphatic fistula was blocked with the fibrin glue after conservative treatment. The patient who only received total parenteral nutrition was cured 24 d after therapy.
CONCLUSION: Total parenteral nutrition along with somatostatin can relieve the symptoms and close the fistula in patients with chylous ascites rapidly. It appears to be an effective therapy available for the treatment of chylous ascites caused by various disorders.
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Affiliation(s)
- Qi Huang
- Institute of General Surgery, Jinling Hospital, 305 Zhongshan East Road, Nanjing 210002, Jiangsu Province, China
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19
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Suver DW, Perkins JA, Manning SC. Somatostatin treatment of massive lymphorrhea following excision of a lymphatic malformation. Int J Pediatr Otorhinolaryngol 2004; 68:845-50. [PMID: 15126030 DOI: 10.1016/j.ijporl.2004.01.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2003] [Revised: 01/13/2004] [Accepted: 01/17/2004] [Indexed: 11/24/2022]
Abstract
Postoperative lymphorrhea is a serious and occasionally lethal complication of neck dissection and cardiothoracic surgery. Management is not standardized, but usually centers around diet modification, drainage, pressure dressings, and reoperation. We report the successful use of the long acting somatostatin analogue octreotide in the management of massive lymphorrhea complicating excision of a large cervicomediastinal lymphatic malformation in an infant. Based on this report and a review of the available literature, we advocate the early consideration of somatostatin and its analogues in the control of lymphorrhea.
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Affiliation(s)
- Daniel W Suver
- University of Washington Medical School, University of Washington, Seattle, WA 98195, USA
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20
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Evans J, Clark MF, Mincher L, Varney VA. Chylous effusions complicating lymphoma: a serious event with octreotide as a treatment option. Hematol Oncol 2003; 21:77-81. [PMID: 12802812 DOI: 10.1002/hon.710] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Chylous effusions have an identical appearance to milk and occur when the thoracic duct is blocked. Since chyle represents direct absorption of fat from the small intestine lacteals, it is rich in fat, calories, vitamins and immunoglobulins. Drainage of this milk-like fluid from any cavity (chest or abdomen) results in rapid weight loss and profound cachexia. The recognition of this milk-like fluid as chyle is urgent for the implementation of the correct treatment. In adults, lymphoma is one of the commonest malignancies to cause blockages in the thoracic duct. Once the diagnosis is made, conservative treatment with strict dietary adjustment often fails to prevent weight loss or resolve the underlying cause. Since the condition is uncommon, no guidelines exist. Many surgeons recommend early surgical intervention before the patient becomes too weak. Surgery may also fail. We report the case of a 62-year-old man with chylous effusions and a weight loss of 30 kg. The nature of the effusion was unrecognized for the first 16 weeks. Upon diagnosis, dietary adjustment was made and a lymphangiogram organized with a view to surgery. Literature searches revealed two cases in which somatostatin was used after surgical procedures failed. We therefore used octreotide (a synthetic analogue of somatostatin). We report complete resolution of the condition within 72 h leading to the resumption of a normal diet and discharge within 2 weeks.
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Affiliation(s)
- J Evans
- Department of Haematology and Respiratory Medicine, St Helier Hospital, Carshalton, Surrey, UK
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21
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Kamasaki N, Ikeda H, Wang ZL, Narimatsu Y, Inokuchi T. Bilateral chylothorax following radical neck dissection. Int J Oral Maxillofac Surg 2003; 32:91-3. [PMID: 12653241 DOI: 10.1054/ijom.2002.0312] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Bilateral chylothorax as a complication of radical neck dissection is extremely rare, but it is potentially serious and sometimes fatal. We found only 14 cases reported in the English literature. Here, we report a case of bilateral chylothorax following right modified and left radical neck dissections that was successfully treated with conservative management.
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Affiliation(s)
- N Kamasaki
- Second Department of Oral and Maxillofacial Surgery, Nagasaki University School of Dentistry, Nagasaki, Japan.
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22
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Abstract
Chylothorax is an unusual complication of surgical procedures within the chest. Early recognition is important so that appropriate conservative measures can be applied. Operative intervention after a short course of supportive therapy will control most chyle fistulas. Methods of diagnosis in the postoperative setting and literature supporting various treatment options are the focus of this article.
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Affiliation(s)
- David W Johnstone
- Department of Cardiothoracic Surgery, University of Rochester School of Medicine & Dentistry, 601 Elmwood Avenue, Box Surgery, Rochester, NY 14642, USA.
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Abstract
PURPOSE Postoperative chylous ascites is a rare complication of retroperitoneal and mediastinal surgery that represents a difficult management problem due to the serious mechanical, nutritional and immunological consequences of the constant loss of protein and lymphocytes. We reviewed the topic of postoperative chylous ascites with special emphasis on the relevant diagnostic and imaging modalities. We propose a novel management algorithm. MATERIALS AND METHODS We performed a MEDLINE search of the literature on chylous ascites using chyloperitoneum as the subject heading and chylous ascites as an additional key word. The search yielded 651 articles. We focused on 102 series, collective reviews and mainly case reports related to the issue of postoperative chylous ascites. RESULTS We propose a novel algorithm based on a step-up approach aimed at promoting decreased lymph production and flow as well as maintaining nutritional balance. The management algorithm integrates repeat palliative paracentesis, dietary measures, total parenteral nutrition therapy, peritoneovenous shunting and surgical closure of the lymphoperitoneal fistula. Due to the remarkable effectiveness of somatostatin therapy for the closure of lymphatic fistula somatostatin therapy should be attempted with or without total parenteral nutrition early in the course of treatment of chylous ascites before any invasive steps are taken. CONCLUSIONS Various management modalities may be used successfully to treat chylous ascites. Therefore, treatment should be individualized and adjusted to the severity of lymphatic leakage and its consequences. The outcome mostly depends on the underlying pathological condition. Thus, in the absence of malignant or congenital underlying pathology the prognosis in cases of postoperative chylous ascites is good with the majority responding to conservative measures.
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Affiliation(s)
- Ilan Leibovitch
- Department of Urology, Chaim Sheba Medical Center, Tel Hashomer and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Leibovitch I, Mor Y, Golomb J, Ramon J. Chylous ascites after radical nephrectomy and inferior vena cava thrombectomy. Successful conservative management with somatostatin analogue. Eur Urol 2002; 41:220-2. [PMID: 12074412 DOI: 10.1016/s0302-2838(01)00034-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Postoperative chylous ascites is a rare complication of retroperitoneal surgery. The treatment of postoperative chylous ascites is primarily conservative, consisting of repeated paraceteses, medium chain triglyceride (MCT) diet, salt restriction, diuretics and bowel rest with total parenteral nutrition. Occasionally, chylous ascites may take a protracted course which may necessitate insertion of peritoneo-venous shunts or direct surgical lymphostasis. Recently, Somatostatin was shown to be highly effective in closure of refractory lymphatic fistulas. We present a case of refractory chylous ascites following radical nephrectomy with inferior vena caval thrombectomy that failed to respond to conventional conservative measures and resolved rapidly following the administration of Somatostatin.
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Affiliation(s)
- Ilan Leibovitch
- Department of Urology, The Chaim Sheba Medical Center, Tel Hashomer, Israel.
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