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Campbell A, Velazquez-Pimentel D, Seager M, Hesketh R, Hague J, Raja J, Brookes J, Ngo A, Walkden M, Papadopoulou A, Smith D, Mohammadi B, Barod R, Akhtar MR, Tun JK, Low DE, Renfrew ID, Fotheringham T, von Stempel C. Lymphatic leaks - success of intranodal lymphangiogram first strategy. CVIR Endovasc 2025; 8:4. [PMID: 39786468 PMCID: PMC11718034 DOI: 10.1186/s42155-024-00499-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2024] [Accepted: 11/18/2024] [Indexed: 01/12/2025] Open
Abstract
BACKGROUND Lymphatic leaks are associated with significant mortality and morbidity. Intranodal lymphangiography (ILAG) involves the direct injection of ethiodised lipid into the hilum of lymph nodes. It is diagnostic procedure that can have therapeutic effects secondary to a local sclerosant effect. The aim of the study is to describe the technical and clinical success of ILAG and adjunctive lymphatic interventions performed as first line interventional techniques for lymphatic leaks refractory to conservative and medical management in a multicentre cohort of patients with symptomatic large volume lymphatic leaks. METHODS Multicentre retrospective study of all lymphatic interventions performed between 2017-2023 in patients with large volume lymphatic leaks (> 500 ml a day). Intranodal lymphangiography was performed initially with technical success defined as opacification of the lymphatics at the aortic bifurcation and demonstration of lymphatic leak on the index ILAG procedure or immediate post procedural CT was recorded. Lymphatic embolisation was performed with a combination of direct puncture or transvenous cannulation with glue and or coil embolisation of the thoracic duct or leak point and in cases with refractory leak. Clinical success was defined as reduction in drain output to less than 20 mL per 24 h, or no further insensible lymph leak. Time to clinical success after ILAG and adjunctive embolisation was recorded. RESULTS ILAG alone lead to clinical success in 14 of 32 (44%) patients after a median of 14 days. Subsequent embolisation was performed in 12 refractory cases; this was successful in 8 (67%) at median of 8 days. Overall clinical success of all lymphatic interventions was 69% (22 of 32 patients) at a median of 11 days (IQR 5-34). No statistically significant correlation between the site of leakage, aetiology or embolisation technique correlated with clinical success. Decision to proceed to repeat ILAG or an adjunct procedure was made on a clinical basis, following multidisciplinary discussion. CONCLUSIONS ILAG can be employed a first line interventional therapeutic technique to treat clinically significant lymphatic leaks that are refractory to conservative and medical management. Adjunctive procedures, including embolisation, can be considered as part of clinical decision making after a period of 1-2 weeks' watchful waiting in continuingly refractory cases.
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Affiliation(s)
- Alan Campbell
- University College London Hospital NHS Foundation Trust, London, UK
| | | | - Matthew Seager
- King's College Hospital NHS Foundation Trust, London, UK
| | | | - Julian Hague
- University College London Hospital NHS Foundation Trust, London, UK
| | - Jowad Raja
- University College London Hospital NHS Foundation Trust, London, UK
| | - Jocelyn Brookes
- University College London Hospital NHS Foundation Trust, London, UK
| | - An Ngo
- University College London Hospital NHS Foundation Trust, London, UK
| | - Miles Walkden
- University College London Hospital NHS Foundation Trust, London, UK
| | | | - Daron Smith
- University College London Hospital NHS Foundation Trust, London, UK
| | | | - Ravi Barod
- Royal Free London NHS Foundation Trust, London, UK
| | | | - Jimmy Kyaw Tun
- Barts Health NHS Trust, London, UK
- National University Hospital, Singapore, Singapore
| | | | | | | | - Conrad von Stempel
- University College London Hospital NHS Foundation Trust, London, UK.
- Royal Free London NHS Foundation Trust, London, UK.
- Division of Surgery and Interventional Science, University College London, London, UK.
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Wang Y, Liu X, Wang X, Tian Y, Liu Q, Wang J, Xue J. Bilateral chylothorax following total thyroidectomy with neck lymph node dissection for thyroid cancer: a case report and literature review. Front Oncol 2025; 14:1489410. [PMID: 39845321 PMCID: PMC11751029 DOI: 10.3389/fonc.2024.1489410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2024] [Accepted: 12/16/2024] [Indexed: 01/24/2025] Open
Abstract
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.
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Affiliation(s)
| | | | | | | | | | | | - Jincai Xue
- Department of Head and Neck Surgery, Gansu Provincial Cancer Hospital, Lanzhou, China
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3
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Zhou J, Li D, Xiao Q, Zhuang Y, Yang T, Xue S, Gao H, Su X. Bilateral chylothorax following papillary thyroid carcinoma with cervical lymph node dissection: Case report and comprehensive review of the literature. Medicine (Baltimore) 2024; 103:e40371. [PMID: 39533596 PMCID: PMC11556962 DOI: 10.1097/md.0000000000040371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2024] [Accepted: 10/16/2024] [Indexed: 11/16/2024] Open
Abstract
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.
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Affiliation(s)
- Jing Zhou
- Department of Breast and Thyroid Department, Women and Children’s Hospital of Chongqing Medical University: Chongqing Health Center for Women and Children, Chongqing, China
| | - Daxue Li
- Department of Breast and Thyroid Department, Women and Children’s Hospital of Chongqing Medical University: Chongqing Health Center for Women and Children, Chongqing, China
| | - Qian Xiao
- Department of Breast and Thyroid Department, Women and Children’s Hospital of Chongqing Medical University: Chongqing Health Center for Women and Children, Chongqing, China
| | - Yuchen Zhuang
- Department of Breast and Thyroid Department, Women and Children’s Hospital of Chongqing Medical University: Chongqing Health Center for Women and Children, Chongqing, China
| | - Ting Yang
- Department of Breast and Thyroid Department, Women and Children’s Hospital of Chongqing Medical University: Chongqing Health Center for Women and Children, Chongqing, China
| | - Song Xue
- Intelligent Integrated Circuits and Systems Laboratory (SICS Lab), University of Electronic Science and Technology of China, Chengdu, China
| | - Han Gao
- Department of Breast and Thyroid Department, Women and Children’s Hospital of Chongqing Medical University: Chongqing Health Center for Women and Children, Chongqing, China
| | - Xinliang Su
- Department of Breast and Thyroid Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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4
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Smith R, Higginson J, Breik O, Praveen P, Parmar S. Nutritional management of chyle leak after head and neck surgery: a systematic review and proposed protocol for management. Oral Maxillofac Surg 2024; 28:51-62. [PMID: 37014458 DOI: 10.1007/s10006-023-01152-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/26/2023] [Indexed: 04/05/2023]
Abstract
PURPOSE Chyle leaks are a rare complication of neck surgery causing local damage, impairing healing and compromising free flaps. High output leaks can result in electrolyte imbalances and malnutrition. Nutritional management such as restricting the absorption of triglycerides is believed to reduce chyle, allowing spontaneous resolution of a leak. Dietary preparations and management can aid in reducing chyle production. There are no clear guidelines to aid nutritional decision-making in this complex scenario. METHODS A systematic review of the literature was carried out to identify studies evaluating nutritional management of chyle leaks in patients after neck dissections. RESULTS Ten studies were identified evaluating the role of nutritional therapy in the management of patients with chyle leaks after neck dissections. The level of evidence was low. Several studies identified that low volume leaks (defined as < 1000 mls per day) often resolved by dietary management and other conservative measures. High volume leaks rarely resolved with conservative measures alone. Parenteral nutrition had an established role in this context. CONCLUSIONS There is limited evidence to guide dietary restriction and introduction of oral diet in patients with chyle leak after major head and neck surgery. Based on available evidence, local guidelines for the nutritional management of patients identified with a chyle leak were produced and adopted by the Trust and the head and neck MDT. A national database for voluntary contribution of prospective data would help to generate better quality management protocols.
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Affiliation(s)
- Rebekah Smith
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
| | - James Higginson
- Faculty of Medicine, Imperial College London, and the International Centre for Recurrent Head & Neck Cancer, Royal Marsden Hospital, London, UK
| | - Omar Breik
- Royal Brisbane and Womens Hospital, Brisbane, Australia
| | - Prav Praveen
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Sat Parmar
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Cuong NN, Hoan L, Tra My TT, Luu DT, Tuan Linh L, Canh PH, Tinh TQ, Khanh Chi TN, Trung NQ, Hoa TQ. Minimally Invasive Treatment of Chyle Leak After Thyroidectomy and Cervical Lymph Node Dissection in Patients with Thyroid Carcinoma: Results of a Study Involving 36 Patients. Ther Clin Risk Manag 2024; 20:75-82. [PMID: 38351953 PMCID: PMC10863455 DOI: 10.2147/tcrm.s446113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 02/01/2024] [Indexed: 02/16/2024] Open
Abstract
Objective Chyle leak (CL) after head and neck surgery is a rare but well-known complication. In patients with high-output leakage, the treatment can be complicated. This study aims to report on a recent innovation in lymphatic intervention for treating such patients. Materials and Methods A retrospective review of 36 patients with chyle leak after neck surgery for thyroid cancer was conducted to assess the efficacy of percutaneous lymphatic embolization and thoracic duct (TD) disruption. Results Antegrade catheterization of the thoracic duct was achieved in 31 of 36 patients (86.1%). Therefore, embolization of the thoracic duct and thoracic duct branches was performed in 26 and 5 patients, respectively. In 5 cases of unsuccessful antegrade catheterization into the thoracic duct, transcervical access embolization was performed in 2 patients, and TD disruption (TDD) was performed in 3 patients. The pooled overall technical success rate of lymphatic embolization was 33/36 patients (91.7%). One patient who underwent thoracic duct embolization (TDE) with technical success (1/33 patients) but clinical failure had additional treatment directly sclerosing the TD under computed tomography scan. Cervical fluid collection sclerotherapy was done in 7 patients as an additional treatment. Resolution of the chyle leak after procedures was observed in all patients (100%). The mean time to resolution was 3 days (1-7 days). There was no complication intra and after procedures. Conclusion TDE, selective TD branches embolization and TDD are safe and effective minimally invasive treatments for CL post-surgery for thyroid carcinoma. Sclerosing cervical fluid collection contributes to clinical success.
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Affiliation(s)
- Nguyen Ngoc Cuong
- Diagnostic Imaging and Interventional Center, Hanoi Medical University Hospital, Ha Noi, Viet Nam
| | - Le Hoan
- Respiratory Department, Hanoi Medical University Hospital, Ha Noi, Viet Nam
| | - Thieu Thi Tra My
- Diagnostic Imaging and Nuclear Medicine Department, Vinmec Times City International Hospital, Ha Noi, Viet Nam
| | - Doan Tien Luu
- Diagnostic Imaging and Interventional Center, Hanoi Medical University Hospital, Ha Noi, Viet Nam
| | - Le Tuan Linh
- Diagnostic Imaging and Interventional Center, Hanoi Medical University Hospital, Ha Noi, Viet Nam
| | - Pham Hong Canh
- Diagnostic Imaging and Interventional Center, Hanoi Medical University Hospital, Ha Noi, Viet Nam
| | - Trieu Quoc Tinh
- Diagnostic Imaging and Interventional Center, Hanoi Medical University Hospital, Ha Noi, Viet Nam
| | - Tran Nguyen Khanh Chi
- Diagnostic Imaging and Interventional Center, Hanoi Medical University Hospital, Ha Noi, Viet Nam
| | - Nguyen Quang Trung
- Diagnostic Imaging and Interventional Center, Hanoi Medical University Hospital, Ha Noi, Viet Nam
| | - Tran Quoc Hoa
- Urology Surgery department, Hanoi Medical university, Ha Noi, Viet Nam
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Baker A, Tassone P, Dooley LM, Galloway TI, Zitsch RP. Postoperative Chyle Leak Rate Following Neck Dissection for Squamous Cell Carcinoma Versus Papillary Thyroid Cancer. Laryngoscope 2023; 133:2959-2964. [PMID: 36825523 DOI: 10.1002/lary.30627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 02/09/2023] [Accepted: 02/10/2023] [Indexed: 02/25/2023]
Abstract
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.
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Affiliation(s)
- Austin Baker
- Department of Otolaryngology-Head and Neck Surgery, University of Missouri School of Medicine, Columbia, Missouri, U.S.A
| | - Patrick Tassone
- Department of Otolaryngology-Head and Neck Surgery, University of Missouri School of Medicine, Columbia, Missouri, U.S.A
| | - Laura M Dooley
- Department of Otolaryngology-Head and Neck Surgery, University of Missouri School of Medicine, Columbia, Missouri, U.S.A
| | - Tabitha I Galloway
- Department of Otolaryngology-Head and Neck Surgery, University of Missouri School of Medicine, Columbia, Missouri, U.S.A
| | - Robert P Zitsch
- Department of Otolaryngology-Head and Neck Surgery, University of Missouri School of Medicine, Columbia, Missouri, U.S.A
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Gupta V, Dwivedi G, Chugh R, Sahu PK, Gupta DK, Basu A, Upadhyay K, Patnaik U, Bhatia R. Role of Octreotide in Conservative Management of Chyle Leak Post Neck Dissection in Cases of Head Neck Cancer: A Retrospective Analysis. Indian J Otolaryngol Head Neck Surg 2022; 74:6078-6086. [PMID: 36742480 PMCID: PMC9895617 DOI: 10.1007/s12070-021-02746-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 06/27/2021] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- Vikas Gupta
- Department of ORL-HNS, Command Hospital, Lucknow, Uttar Pradesh India
| | - Gunjan Dwivedi
- Department of ORL-HNS, Command Hospital, Pune, Maharashtra India
| | - Rajeev Chugh
- Department of ORL-HNS, Army Hospital (Research and Referral), New Delhi, India
| | | | | | - Abhijit Basu
- Department of ORL-HNS, Command Hospital, Lucknow, Uttar Pradesh India
| | - Kiran Upadhyay
- Department of ORL-HNS, Command Hospital, Lucknow, Uttar Pradesh India
| | - Uma Patnaik
- Department of ORL-HNS, Command Hospital, Pune, Maharashtra India
| | - Ritika Bhatia
- Department of ORL-HNS, Command Hospital, Lucknow, Uttar Pradesh India
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Fujiogi M, Konishi T, Michihata N, Hashimoto Y, Matsu H, Ishimaru T, Fushimi K, Yasunaga H, Fujishiro J. Perioperative outcomes of thyroid cancer surgery in children and adults: a nationwide inpatient database study in Japan. ANNALS OF CLINICAL EPIDEMIOLOGY 2022; 5:20-29. [PMID: 38505377 PMCID: PMC10760474 DOI: 10.37737/ace.23004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 09/06/2022] [Indexed: 03/21/2024]
Abstract
BACKGROUND Little is known about perioperative outcomes after pediatric thyroidectomy. This study was performed to compare perioperative outcomes between children and adults undergoing thyroid cancer surgery using a nationwide inpatient database in Japan. METHODS Using the Japanese Diagnosis Procedure Combination database, we identified patients aged 0 to 40 years with thyroid cancer who underwent thyroidectomy from July 2010 to March 2020. To compare the occurrence of in-hospital morbidities including local complications (e.g., recurrent laryngeal nerve paralysis, postoperative bleeding), duration of anesthesia, postoperative length of stay, and total hospitalization costs between children (0-18 years) and adults (19-40 years), we used multivariable logistic regression analysis for the occurrence of in-hospital morbidities and linear regression for other outcomes. RESULTS For 16,016 eligible patients (666 children vs. 15,350 adults), no significant differences between the two groups were found in any in-hospital morbidity (5.4% vs. 5.9%; adjusted odds ratio [OR], 0.80; 95% confidence interval [CI], 0.57-1.14; P = 0.23), local complications (5.0% vs. 5.5%; OR, 0.80; 95% CI, 0.55-1.15; P = 0.22), recurrent laryngeal nerve paralysis (2.1% vs. 2.4%; OR, 0.78; 95% CI, 0.45-1.35; P = 0.37), or postoperative bleeding (1.7% vs. 1.4%; OR, 0.99; 95% CI, 0.53-1.87; P = 0.98). Children showed a longer duration of anesthesia (difference, 20 minutes; 95% CI, 13-27; P < 0.001) and higher total costs (difference, 445 US dollars; 95% CI, 239-651; P < 0.001) than adults. CONCLUSION This large nationwide cohort study showed no significant difference in perioperative complications between children and adults undergoing thyroid cancer surgery.
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Affiliation(s)
- Michimasa Fujiogi
- Department of Pediatric Surgery, Graduate School of Medicine, The University of Tokyo
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo
| | - Takaaki Konishi
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo
- Department of Breast and Endocrine Surgery, Graduate School of Medicine, The University of Tokyo
| | - Nobuaki Michihata
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo
| | - Yohei Hashimoto
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo
- Department of Ophthalmology, Graduate School of Medicine, The University of Tokyo
| | - Hiroki Matsu
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo
| | - Tetsuya Ishimaru
- Department of Pediatric Surgery, Saitama Children’s Medical Center
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo
| | - Jun Fujishiro
- Department of Pediatric Surgery, Graduate School of Medicine, The University of Tokyo
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Ashoor A, Lissidini G, Datta U, Bertoldi L, Veronesi P, Tan MLH. Chyle Leak After Axillary Node Clearance in Breast Cancer Surgery-A Rare Complication and a Proposed Management Strategy from the British and Italian Experience. Ann Surg Oncol 2022; 29:7992-7999. [PMID: 35849297 DOI: 10.1245/s10434-022-12094-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 06/17/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Chyle leak after axillary surgery is a rare complication that lacks consensus and management guidelines. This study aimed to present the experiences of two centers in chyle leak management after axillary node clearance for breast cancer. Furthermore the authors provide a review of its pathophysiology and clinical diagnostic methods. They compare approaches for management of the axilla with those for other locations. METHODS A multicentre case series descriptive analysis of chyle leak after breast cancer axillary node clearance between 1 January 2013 and 31 May 2020 was performed. RESULTS The center in the United Kingdom and the center in Italy performed 655 and 4969 axillary node clearances, respectively. Four patients experienced chyle leaks. All the leaks had left-sided surgery (3 patients had level 3 clearances with mastectomy and implant-based breast reconstructions; 1 patient had level 2 clearance with therapeutic mammoplasty). All the leaks appeared within 3 days after surgery. Leak duration was between 11 and 29 days. The maximum daily output was 600 mL. All the leaks were treated conservatively with nutritional team support together with close drainage monitoring. The management strategy included a low-fat diet, a high-protein diet, total parenteral nutrition, and medium chain triglyceride supplements, as well as other elements. No negative effects on oncoplastic and reconstructive breast surgery wound-healing and no delays in adjuvant treatment were observed. CONCLUSION The incidence of chyle leak after breast cancer axillary node clearance was 0.07%. Early diagnosis and close monitoring together with conservative management involving nutritional team support can result in successful treatment of chyle leak without negative sequalae of breast cancer oncologic treatment.
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Affiliation(s)
- Arwa Ashoor
- Breast Surgery Department, City Hospital Birmingham, Sandwell and West Birmingham NHS Trust, Birmingham, UK.
| | - Germana Lissidini
- Division of Breast Surgery, IEO, European Institute of Oncology, IRCCS, 20141, Milan, Italy
| | - Uttaran Datta
- Breast Surgery Department, City Hospital Birmingham, Sandwell and West Birmingham NHS Trust, Birmingham, UK
| | - Lorenzo Bertoldi
- Division of Breast Surgery, IEO, European Institute of Oncology, IRCCS, 20141, Milan, Italy
| | - Paolo Veronesi
- Division of Breast Surgery, IEO, European Institute of Oncology, IRCCS, 20141, Milan, Italy.,Department of Oncology and Hemato-Oncology, University of Milan, 20133, Milan, Italy
| | - Melissa Ley-Hui Tan
- Breast Surgery Department, City Hospital Birmingham, Sandwell and West Birmingham NHS Trust, Birmingham, UK
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Sasaki H, Kowatari R, Kondo N, Taguchi R, Minakawa M. Right-Sided Chylothorax: A Case Report of an Uncommon Manifestation After Cervical Debranching Thoracic Endovascular Aneurysm Repair. Vasc Endovascular Surg 2022; 56:602-604. [PMID: 35452337 DOI: 10.1177/15385744221090909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A 70-year-old man was admitted to our hospital with a thoracic aortic aneurysm. He underwent elective thoracic endovascular aneurysm repair with left common carotid artery-left subclavian artery bypass via the left supraclavicular approach. During the bypass, the thoracic duct was injured and ligated. On postoperative day 3, the patient complained of dyspnea. Chest radiography revealed a massive right-sided pleural effusion. On postoperative day 5, he was diagnosed with right-sided chylothorax and underwent chest tube insertion. The next day, a left-sided chylothorax was noted, and chest tube drainage was performed. Conservative management, including nil per os and subcutaneous octreotide (300 μg/day) injection, was carried out for 2 weeks; subsequently, the chylothorax improved. This report highlights the diagnostic challenge of right-sided chylothorax after debranching thoracic endovascular aneurysm repair.
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Affiliation(s)
- Hanae Sasaki
- Department of Thoracic and Cardiovascular Surgery, 92149Hirosaki University School of Medicine, Japan
| | - Ryosuke Kowatari
- Department of Thoracic and Cardiovascular Surgery, 92149Hirosaki University School of Medicine, Japan
| | - Norihiro Kondo
- Department of Thoracic and Cardiovascular Surgery, 92149Hirosaki University School of Medicine, Japan
| | - Ryo Taguchi
- Department of Thoracic and Cardiovascular Surgery, 92149Hirosaki University School of Medicine, Japan
| | - Masahito Minakawa
- Department of Thoracic and Cardiovascular Surgery, 92149Hirosaki University School of Medicine, Japan
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Konishi T, Fujiogi M, Michihata N, Niwa T, Morita K, Matsui H, Fushimi K, Tanabe M, Seto Y, Yasunaga H. Impact of body mass index on short-term outcomes after differentiated thyroid cancer surgery: a nationwide inpatient database study in Japan. Eur Thyroid J 2022; 11:ETJ-21-0081. [PMID: 34981742 PMCID: PMC9142812 DOI: 10.1530/etj-21-0081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 09/30/2021] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION Recent studies have shown worse post-operative outcomes following several surgeries in underweight or obese patients. However, the association between body mass index (BMI) and short-term outcomes following thyroid cancer surgery remains unclear because of the small number of patients, deficits in background data known as risk factors (e.g. cancer stage, operative procedure, intraoperative device use and hospital volume) and categorisation of BMI. METHODS We identified patients who underwent thyroidectomy for differentiated thyroid cancer from July 2010 to March 2017 using a Japanese nationwide inpatient database. We used restricted cubic spline (RCS) analyses to investigate potential non-linear associations between BMI (without categorisation) and outcomes: post-operative complications (local and general), duration of anaesthesia, post-operative length of hospital stay and hospitalisation costs. The analyses were adjusted for demographic and clinical backgrounds including the above-stated factors. We also performed multivariable regression analyses for the outcomes with categorisation of BMI. RESULTS Among 59,671 eligible patients, the median BMI was 22.9 kg/m2 (interquartile range (IQR), 20.7-25.6 kg/m2). In total, 3860 patients (6.5%) had local complications and 787 patients (1.3%) had general complications. Although there were no significant associations with local complications, such as bleeding, recurrent laryngeal nerve paralysis and surgical site infection, the occurrence of general complications was significantly associated with higher BMI. BMI showed a linear association with the duration of anaesthesia and U-shaped associations with post-operative length of stay and hospitalisation costs. The lowest points of the U-shaped curves occurred at a BMI of approximately 24 kg/m2. The multivariate regression analyses showed consistent results with the RCS analyses. DISCUSSION/CONCLUSION Whereas RCS analyses revealed no significant associations between BMI and post-operative local complications, obesity was significantly associated with the occurrence of general complications. The linear association between BMI and duration of anaesthesia corresponds to previous studies. Although post-operative length of stay and total hospitalisation costs demonstrated U-shaped associations, the slight differences would not be clinically important. Even if surgeons must pay attention to general complications in obese patients undergoing thyroid cancer surgery as well as other surgeries, underweight and overweight patients can undergo thyroidectomy as safely as patients with normal BMI.
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Affiliation(s)
- Takaaki Konishi
- Department of Breast and Endocrine Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
- Correspondence should be addressed to T Konishi:
| | - Michimasa Fujiogi
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nobuaki Michihata
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takayoshi Niwa
- Department of Breast and Endocrine Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kojiro Morita
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
- Department of Health Services, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
| | - Masahiko Tanabe
- Department of Breast and Endocrine Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yasuyuki Seto
- Department of Breast and Endocrine Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
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12
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Kashoob M, Bawain S, Al Badaai Y. Bilateral Chylothorax Following Total Thyroidectomy with Neck Dissection for Papillary Thyroid Cancer: Case report. Sultan Qaboos Univ Med J 2021; 21:481-484. [PMID: 34522417 PMCID: PMC8407900 DOI: 10.18295/squmj.4.2021.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 09/15/2020] [Accepted: 10/14/2020] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Musallam Kashoob
- Departments of Ear, Nose and Throat, Oman Medical Specialty Board, Muscat, Oman
| | - Saleh Bawain
- Department of Radiology & Molecular Imaging, Sultan Qaboos University Hospital, Muscat, Oman
| | - Yahya Al Badaai
- Department of Surgery, Sultan Qaboos University, Muscat, Oman
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13
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Parmeggiani D, Gualtieri G, Terracciano G, Gambardella C, Parisi S, Brusciano L, Ruggiero R, Docimo L. Prolonged iatrogenic thoracic duct chylous fistula in Neck Surgery: conservative management or surgery? A Literature review. Scand J Surg 2021; 110:550-556. [PMID: 33423617 DOI: 10.1177/1457496920987076] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Thoracic duct chylous fistula is a rare complication following neck surgery, especially for malignant disease. Despite its low incidence, it can be a life-threatening postoperative complication increasing the risk of infection, bleeding, hypovolemia, electrolyte imbalance, and malnutrition. Currently, the management of thoracic duct fistula is not standardized yet. It can range from conservative to surgical approaches, and even when surgery indication occurs, there is no unanimous agreement on timing and operative steps, so the surgical approach still remains mostly subjective, in accordance with clinical conditions of the patients and with surgeon's experience. AIMS The aim of the study was to search into Literature a common accepted behaviour in thoracic duct chylous fistula occurring. METHODS A literature review was carried out. Conservative treatments include fasting associated with total parental nutrition or low-fat diet, compressive dressings, and octreotide administration. If conservative treatment fails, in order to avoid dangerous consequences, functional repair of the thoracic duct injury with lymphovenous microanastomosis should be the preferred solution, rather than an approach that obliterates the thoracic duct or lymphatic-chylous pathways, such as thoracic duct embolization, therapeutic lymphangiography, and thoracic duct ligation. CONCLUSIONS In our experience, patients undergone thyroidectomy and neck dissection for thyroid-differentiated cancer, who report an unrecognized thoracic duct chylous fistula after surgery, must be treated via integrated conservative and surgical treatment. A literature review about thoracic duct chylous fistula following neck surgery, focusing on the current management and therapeutic approach, was furthermore carried out, in order to delineate the actual therapeutic options in case of thoracic duct chylous fistula occurrence.
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Affiliation(s)
- D Parmeggiani
- Division of General, Mini-invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli," Naples, Italy
| | - G Gualtieri
- Division of General, Mini-invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli," Naples, Italy
| | - G Terracciano
- Division of General, Mini-invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli," Naples, Italy
| | - C Gambardella
- Division of General, Mini-invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli," Naples, Italy
| | - S Parisi
- Division of General, Mini-invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli," Naples, Italy
| | - L Brusciano
- Division of General, Mini-invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli," Naples, Italy
| | - R Ruggiero
- Division of General, Mini-invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli," Naples, Italy
| | - L Docimo
- Division of General, Mini-invasive and Obesity Surgery, University of Study of Campania "Luigi Vanvitelli," Naples, Italy
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14
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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: 5] [Impact Index Per Article: 1.0] [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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15
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The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Thyroid Disease in Adults. Ann Surg 2020; 271:e21-e93. [PMID: 32079830 DOI: 10.1097/sla.0000000000003580] [Citation(s) in RCA: 281] [Impact Index Per Article: 56.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To develop evidence-based recommendations for safe, effective, and appropriate thyroidectomy. BACKGROUND Surgical management of thyroid disease has evolved considerably over several decades leading to variability in rendered care. Over 100,000 thyroid operations are performed annually in the US. METHODS The medical literature from 1/1/1985 to 11/9/2018 was reviewed by a panel of 19 experts in thyroid disorders representing multiple disciplines. The authors used the best available evidence to construct surgical management recommendations. Levels of evidence were determined using the American College of Physicians grading system, and management recommendations were discussed to consensus. Members of the American Association of Endocrine Surgeons reviewed and commented on preliminary drafts of the content. RESULTS These clinical guidelines analyze the indications for thyroidectomy as well as its definitions, technique, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Fine Needle Aspiration Biopsy Diagnosis, Molecular Testing, Indications, Extent and Outcomes of Surgery, Preoperative Care, Initial Thyroidectomy, Perioperative Tissue Diagnosis, Nodal Dissection, Concurrent Parathyroidectomy, Hyperthyroid Conditions, Goiter, Adjuncts and Approaches to Thyroidectomy, Laryngology, Familial Thyroid Cancer, Postoperative Care and Complications, Cancer Management, and Reoperation. CONCLUSIONS Evidence-based guidelines were created to assist clinicians in the optimal surgical management of thyroid disease.
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16
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Konishi T, Fujiogi M, Niwa T, Morita K, Matsui H, Fushimi K, Tanabe M, Seto Y, Yasunaga H. Comparison of outcomes after differentiated thyroid cancer surgery performed with and without energy devices: A population-based cohort study using a nationwide database in Japan. Int J Surg 2020; 77:198-204. [DOI: 10.1016/j.ijsu.2020.03.072] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 03/06/2020] [Accepted: 03/27/2020] [Indexed: 11/25/2022]
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Dasatinib-induced chylothorax: report of a case and review of the literature. Invest New Drugs 2020; 38:1627-1632. [PMID: 32248338 DOI: 10.1007/s10637-020-00932-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 03/27/2020] [Indexed: 02/05/2023]
Abstract
Dasatinib is a tyrosine kinase inhibitor for the treatment of BCR-ABL-positive chronic myeloid leukaemia (CML) or Philadelphia chromosome-positive acute lymphoblastic leukaemia (ALL). Although fluid retention is a common adverse event associated with dasatinib, chylothorax is exceptionally rare. The pathological mechanism, clinical manifestation and management of dasatinib-induced chylothorax are completely unclear. A 71-year-old man treated with dasatinib for CML was admitted for progressive dyspnea. Computed tomography (CT) showed a pleural effusion that was more prominent on the right thoracic cavity. Thoracentesis showed thick milky pleural fluid, which was then confirmed as chylothorax by chylum qualitative tests and triglyceride measurements. Radionuclide lymphoscintigraphy yielded an obstruction at the end segment of the thoracic duct, but no leakage points were found. After excluding common causes, drug-induced chylothorax was presumed. Then, dasatinib was withdrawn, and 1 week later, chylothorax resolved. To further elucidate the relationship between the medication and chylothorax, dasatinib was resumed tentatively for 2 days. As expected, pleural effusion recurred soon. Based on these clinical manifestations, the diagnosis of dasatinib-induced chylothorax was identified. The patient was suggested to stop dasatinib and use an alternative drug as recommended by the haematologist. Pleural effusion is the common adverse reaction of dasatinib, but chylothorax is rare. Only six cases of dasatinib-induced chylothorax have been reported, and our patient is the seventh case. Once a patient with dasatinib treatment develops chylothorax, dasatinib should be considered one of the possible causes. If no other definitive aetiological factor is identified, dasatinib discontinuation might be the optimum scheme.
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18
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Xiang D, Liu Z, Yang T, Bai B, Zhang J, Wang C, Ye M, Li Z. Finger-pressing: a simple and efficient way to stop chyle leak post neck dissection. Endocrine 2020; 67:374-378. [PMID: 31673955 DOI: 10.1007/s12020-019-02119-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 10/16/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE Postoperative chyle leak (CL) is a rare but severe complication after neck dissection. Conservative first-line treatments, such as total parenteral nutrition (TPN), octreotide and pressure dressing, can significantly prolong the hospital stay. Efficient and well-tolerated conservative treatment options are still lacking. METHODS We have developed a new maneuver to treat CL called "finger-pressing." A thumb is pressed against the point of leakage between the two muscle heads of the sternocleidomastoid. Finger-pressing continues for about 24 h until CL stops. We used this maneuver to treat six CL patients. Drainage output and duration of hospital stay were compared with another six CL patients treated using the traditional pressure dressing. RESULTS The finger-pressing maneuver cured all six CL patients. Most CLs (5/6) could be controlled after about 24 h pressing. Only one high-output CL required 72 h of finger-pressing to stop the leak. All patients had their drainage tubes removed within 3 days after pressing started and all patients tolerated the treatment well. In the control group, the traditional pressure dressing time varied from 2 to 5 days, until the patient was no longer able to cooperate. Three patients underwent a second operation that cured the CL in two cases. The average hospital stay was significantly longer than that in the finger-pressing group (20 vs 9 days, p = 0.037). CONCLUSIONS Finger-pressing is an efficient and well-tolerated method for treating CL post neck dissection. This maneuver could be a useful adjuvant therapy to traditional methods in treating CL.
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Affiliation(s)
- Dapeng Xiang
- Department of General Surgery, Second Affiliated Hospital School of Medicine, Zhejiang University, No. 1511 Jianghong Avenue, Hangzhou, 310000, China
| | - Zhenjie Liu
- Department of Vascular Surgery, Second Affiliated Hospital School of Medicine, Zhejiang University, Hangzhou, China
| | - Tianyao Yang
- Department of General Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Zhejiang Tiantai People's Hospital, Taizhou, China
| | - Binglong Bai
- Department of General Surgery, Second Affiliated Hospital School of Medicine, Zhejiang University, No. 1511 Jianghong Avenue, Hangzhou, 310000, China
| | - Jingying Zhang
- Department of General Surgery, Second Affiliated Hospital School of Medicine, Zhejiang University, No. 1511 Jianghong Avenue, Hangzhou, 310000, China
| | - Chengchen Wang
- Department of General Surgery, Second Affiliated Hospital School of Medicine, Zhejiang University, No. 1511 Jianghong Avenue, Hangzhou, 310000, China
| | - Mao Ye
- Department of General Surgery, Second Affiliated Hospital School of Medicine, Zhejiang University, No. 1511 Jianghong Avenue, Hangzhou, 310000, China
| | - Zhiyu Li
- Department of General Surgery, Second Affiliated Hospital School of Medicine, Zhejiang University, No. 1511 Jianghong Avenue, Hangzhou, 310000, China.
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19
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Riley LE, Ataya A. Clinical approach and review of causes of a chylothorax. Respir Med 2019; 157:7-13. [PMID: 31454675 DOI: 10.1016/j.rmed.2019.08.014] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 08/12/2019] [Accepted: 08/20/2019] [Indexed: 12/16/2022]
Abstract
A chylothorax, also known as chylous pleural effusion, is an uncommon cause of pleural effusion with a wide differential diagnosis characterized by the accumulation of bacteriostatic chyle in the pleural space. The pleural fluid will have either or both triglycerides >110 mg/dL and the presence of chylomicrons. It may be encountered following a surgical intervention, usually in the chest, or underlying disease process. Management of a chylothorax requires a multidisciplinary approach employing medical therapy and possibly surgical intervention for post-operative patients and patients who have failed medical therapy. In this review, we aim to discuss the anatomy, fluid characteristics, etiology, and approach to the diagnosis of a chylothorax.
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Affiliation(s)
- Leonard E Riley
- University of Florida College of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Gainesville, FL, USA
| | - Ali Ataya
- University of Florida College of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Gainesville, FL, USA.
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20
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Sharma AK, Sahli ZT, Mathur A. Bilateral chylothorax following reoperative central neck dissection for metastatic papillary thyroid cancer. BMJ Case Rep 2018; 2018:bcr-2018-224916. [PMID: 29666104 DOI: 10.1136/bcr-2018-224916] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
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.
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Affiliation(s)
- Ashwyn K Sharma
- Endocrine Surgery, Johns Hopkins Hospital and Health System, Baltimore, Maryland, USA
| | - Zeyad T Sahli
- Endocrine Surgery, Johns Hopkins Hospital and Health System, Baltimore, Maryland, USA
| | - Aarti Mathur
- Endocrine Surgery, Johns Hopkins Hospital and Health System, Baltimore, Maryland, USA
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Abstract
Background Chyle fistula (CF) is a rare but challenging condition for the surgeon and the patient's health. Methods A retrospective review of single surgeon's case load in a 12-year period is presented, reviewing the case of those patients presenting with a CF. Results Three patients were found during this study period from more than 1,050 surgeries performed due to thyroid cancer. Patients underwent extensive lymph node dissection for advanced, metastatic and infiltrative disease. In all patients, a long hospital stay and surgical re-interventions were required. Conclusions A description of the management of CF is presented along with a review of current Literature.
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Affiliation(s)
- Carlos S Duque
- Head and Neck Surgeon, Hospital Pablo Tobón Uribe, Clínica Las Américas, Medellín, Colombia
| | - Juan Guillermo Sánchez
- Department of Otolaryngology, Universidad de Antioquia School of Medicine, Medellín, Colombia
| | - Gianlorenzo Dionigi
- Division of Endocrine Surgery, Department of Human Pathology in Adulthood and Childhood "G. Barresi", University Hospital-Policlinico "G. Martino", University of Messina, Messina, Italy
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22
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Albåge A. Editorial: postoperative chylothorax-a cause for concern. Acta Neurochir (Wien) 2017; 159:2023-2024. [PMID: 28812163 DOI: 10.1007/s00701-017-3297-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 08/01/2017] [Indexed: 10/19/2022]
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23
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Ierardi AM, Pappalardo V, Liu X, Wu CW, Anuwong A, Kim HY, Liu R, Lavazza M, Inversini D, Coppola A, Floridi C, Boni L, Carrafiello G, Dionigi G. Usefulness of CBCT and guidance software for percutaneous embolization of a lymphatic leakage after thyroidectomy for cancer. Gland Surg 2016; 5:633-638. [PMID: 28149811 DOI: 10.21037/gs.2016.12.13] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Lymphatic leakage can develop as an iatrogenic complication of thoracic, cardiac, and neck surgery. The management of this complication may be challenging and involves more specialists. Percutaneous, image-guided techniques may offer two advantages: mini-invasivity and ability to image and identify the anatomy and the site of the leakage. We report a case of refractory cervical chylous leakage after thyroidectomy and lymphadenectomy for cancer that was successfully treated with an ultrasound-guided intranodal lymphangiography and a percutaneous puncture of the leak performed using CBCT as imaging guidance.
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Affiliation(s)
- Anna Maria Ierardi
- Insubria University, Interventional Radiology, Department of Radiology, Varese, Italy
| | - Vincenzo Pappalardo
- 1st Division of General Surgery, Research Center for Endocrine Surgery, Department of Surgical Sciences and Human Morphology, University of Insubria, Varese, Italy
| | - Xiaoli Liu
- Jilin Provincial Key Laboratory of Surgical Translational Medicine, Japan Union Hospital of Jilin University, Division of Thyroid Surgery, Changchun 130033, China
| | - Che-Wei Wu
- Department of Otolaryngology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung City, Taiwan
| | - Angkoon Anuwong
- Department of Surgery, Police General Hospital, Faculty of Medicine, Siam University, Pathumwan, Bangkok, Thailand
| | - Hoon Yub Kim
- KUMC Thyroid Center Korea University, Anam Hospital, Seoul, Korea
| | - Renbin Liu
- The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Matteo Lavazza
- 1st Division of General Surgery, Research Center for Endocrine Surgery, Department of Surgical Sciences and Human Morphology, University of Insubria, Varese, Italy
| | - Davide Inversini
- 1st Division of General Surgery, Research Center for Endocrine Surgery, Department of Surgical Sciences and Human Morphology, University of Insubria, Varese, Italy
| | - Andrea Coppola
- Insubria University, Interventional Radiology, Department of Radiology, Varese, Italy
| | - Chiara Floridi
- Insubria University, Interventional Radiology, Department of Radiology, Varese, Italy
| | - Luigi Boni
- 1st Division of General Surgery, Research Center for Endocrine Surgery, Department of Surgical Sciences and Human Morphology, University of Insubria, Varese, Italy
| | - Gianpaolo Carrafiello
- Diagnostic and Interventional Radiology Unit, Department of Health Sciences, University of Milan, Milan, Italy
| | - Gianlorenzo Dionigi
- 1st Division of General Surgery, Research Center for Endocrine Surgery, Department of Surgical Sciences and Human Morphology, University of Insubria, Varese, Italy
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