Bilateral chylothorax following left neck dissection and literature review

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.

Chyluria secondary to disseminated tuberculosis in a 13-year-old female child: A case report

We report the case of chyluria secondary to disseminated tuberculosis in a 13-year-old female child who presented with passage of white colored urine since 5 months, progressive weight loss for 3 months, abdominal distension for 2 months, generalized swelling of body for 15 days, and pain in abdomen for 10 days. Child had good recovery following treatment with antitubercular drugs. Though chyluria is uncommon in children, tuberculosis could be considered as a differential, after ruling out filariasis.

Traumatic Chylothorax Following Pulmonary Segmentectomy: A Case Report and Review of Postoperative Investigation and Management

The incidence of iatrogenic traumatic chylothorax is on the rise secondary to the preferred use of minimally invasive thoracic surgery over thoracotomy. Most reported causes of chylothorax occur following pneumonectomy or lobectomy. There have been no reported cases of traumatic chylothorax following segmentectomy according to our literature review. Complications following lung resection typically include pneumonia, atelectasis, or prolonged air leak. Here, we present a rare case of postoperative chylothorax following minimally invasive segmentectomy to diagnose an enlarging singular pulmonary nodule. This condition was diagnosed with fluid analysis after CT imaging revealed a postoperative unilateral pleural effusion. Interestingly, the patient had a loculated pleural effusion that mimicked a pericardial effusion and empyema. Our patient was managed conservatively with a low-fat diet and short-term pleural drainage without the need for repeat surgical intervention. The importance of imaging interpretation following lung resection along with a working differential diagnosis, appropriate examination, and testing can assist with the diagnosis of this known, but rare, postoperative complication.

Determination of the Optimal Wavelength of the Hemolysis Index Measurement

Many biochemical auto-analyzers have methods that measure the hemolysis index (HI) to quantitatively assess the degree of hemolysis. Past reports on HI are mostly in vitro studies. Therefore, we evaluated the optimal wavelength of HI measurement ex vivo using clinical samples. Four different wavelengths (410/451 nm: HI-1, 451/478 nm: HI-2, 545/596 nm: HI-3 and 571/596 nm: HI-4) were selected for HI measurement, and correlations were examined from the measurement results of 3890 clinical samples. Another set of 9446 clinical samples was used to examine the correlation of HI with lactate dehydrogenase (LDH), aspartate aminotransferase (AST) and potassium (K). Strong correlations were found between HI-4 and HI-1 and between HI-4 and HI-3. HI-1 and HI-2 cannot correctly assess hemolysis for high bilirubin samples, and HI-3 cannot correctly assess hemolysis for high triglyceride samples. LDH, AST and K correlated positively with HI-4 in clinical samples. For every 1-unit increase in HI-4, LDH increased by 19.51 U/L, AST by 1.03 U/L and K by 0.061 mmol/L, comparable to reports of other studies. In clinical samples, HI-4 was less susceptible to bilirubin and chyle and reflected well the changes in LDH, AST and K caused by hemolysis. This suggested that the optimal wavelength for HI measurement is 571 nm.

Effect of a Polyglycolic Acid Mesh Sheet (Neoveil™) in Thyroid Cancer Surgery: A Prospective Randomized Controlled Trial

Simple Summary

Papillary thyroid cancer (PTC) is the most common type of thyroid cancer. Surgery for PTC involves resection of the thyroid gland and lymph node dissection around thyroid. Lymph node dissection is associated with an increased amount of fluid from the dissection area and chyle leakage due to thoracic duct injury. A polyglycolic acid mesh sheet (Neoveil™) has been proven to prevent postoperative fluid leakage in other surgeries. So, we aim to evaluate whether Neoveil™ can reduce postoperative drainage and chyle leakage in surgery for PTC. With the use of Neoveil™, the amount of drainage significantly decreased on the postoperative 2nd day and postoperative total drainage amount was lower. Triglyceride level was lower in the Neoveil™ group but was not statistically significant. No adverse effect from the Neoveil™ was observed during 9 months follow up. Our study suggests that Neoveil™ can be applied to reduce postoperative drainage in thyroid surgery for PTC.

Abstract

Papillary thyroid cancer (PTC) is the most common type of thyroid cancer. Surgery for PTC involves resection of the thyroid gland and central lymph node dissection. Central lymph node dissection is associated with an increased amount of fluid from the dissection area and chyle leakage due to thoracic duct injury. There are few studies that deal with reducing fluid drainage and preventing chyle leakage after thyroid surgery with central lymph node dissection. A polyglycolic acid mesh sheet (Neoveil™) has been demonstrated to prevent postoperative fluid leakage in other surgeries. This study aims to evaluate whether a polyglycolic acid mesh sheet can reduce postoperative drainage and chyle leakage in papillary thyroid cancer surgery, and this study was designed as a prospective, open-label, randomized controlled trial in a single university hospital. The patients were randomly assigned to having only fibrin glue used in the central node dissection area (control group) or to having a polyglycolic acid mesh sheet applied after fibrin glue (treatment group). A total of 330 patients were enrolled, of which 5 patients were excluded. A total of 161 patients were included in the treatment group, and 164 patients were included in the control group. The primary outcome was the drainage amount from the Jackson-Pratt drain, and the secondary outcome was the triglyceride level in the drained fluid on the 1st and 2nd postoperative days. The drainage amount was significantly lower in the treatment group on the 2nd postoperative day (60.9 ± 34.9 mL vs. 72.3 ± 38.0 mL, p = 0.005). The sum of drainage amount during the whole postoperative days (1st and 2nd days) was also significantly lower in the treatment group (142.7 ± 71.0 mL vs. 162.5 ± 71.5 mL, p = 0.013). The postoperative triglyceride levels were lower in the treatment group but were not statistically significant (92.1 ± 60.1 mg/dL vs. 81.3 ± 58.7 mg/dL on postoperative day 1, p = 0.104 and 67.6 ± 99.2 mg/dL vs. 53.6 ± 80.4 mg/dL on postoperative day 2, p = 0.162). No adverse effects were observed in the treatment groups during the postoperative 9-month follow-up. Our study suggests that polyglycolic acid mesh sheets can be safely applied to reduce postoperative drainage amount in thyroidectomy patients who need lymph node dissection.

Chylothorax: A Stepwise Approach to Diagnosis and Treatment

Chylothorax, a lymphatic flow disorder characterized by an abnormal circulation of lymph fluid into the pleural cavity, is the most common cause of pleural effusions during the neonatal period. This condition affects 1/15,000 neonates every year. Affected neonates often manifest with respiratory distress, electrolyte imbalances, sepsis, and even immunodeficiencies. Mortality risk is highest among neonates undergoing cardiac surgery as well as those with associated hydrops fetalis. Conservative treatment options include bowel rest with administration of parenteral nutrition, followed with medium-chain triglyceride enteral feedings, and octreotide therapy. Severe or persistent cases require surgical intervention. This can involve a unilateral or bilateral pleurectomy and thoracic duct ligation, with or without pleurodesis. Early identification and successful treatment of this condition is contingent upon awareness of the most current evidence and a timely cross-disciplinary approach to care.

Strategic Approach to Massive Chylous Leakage after Neck Dissection

(1) Background: A high volume of chylous leakage (>1 L/day) is a potentially lethal complication after neck dissection. However, a strategic treatment for when the leakage progresses from high to massive (>4 L/day) is lacking. (2) Methods: The PubMed database was searched for articles on neck dissection-associated chylous leakage. Nine articles that included 14 cases with >1 L/day chylous leakage (CL) were analyzed. (3) Results: Of the nine patients with 1-4 L/day CL, three were successfully managed with conservative treatment, two with thoracic ductal ligation, three with ductal embolization, and one with local repair with a strap muscle flap. Of the remaining five cases with >4 L/day chylous leakage, three were successfully treated with the pectoralis major myocutaneous flap (PMMF) and one was successfully treated with thoracic ductal ligation and one case died. (4) Conclusions: In this review, when leakage was >4 L/day, the aforementioned interventions were ineffective, but applying the PMMF could rescue the intractable complication. We propose a strategic treatment for high (1-4 L/day) and massive (>4 L/day) chylous leakage.

Octreotide versus oral dietary modification for the treatment of chylous fistula following neck dissection: A systematic review and meta-analysis

AIMS

Chylous fistula following neck surgery is a rare, but significant complication. Currently, there is no standardised treatment, which may comprise pressure dressings, oral dietary modification (ODM), surgery or a combination of such measures. Octreotide is a somatostatin analogue that has gained popularity in the management of cervical chyle leaks. The effectiveness of octreotide compared with ODM is unclear. We provide a comprehensive, systematic review of the literature pertaining to the management of chylous fistulae, comparing both treatment strategies.

METHODS

The bibliographic databases MEDLINE, Cochrane, PubMed, EMBASE and Google Scholar were searched from inception to October 2019. Search terms included (chyle [title/abstract]) OR (chylous [title/abstract]) AND (fistula [title/abstract]) OR (fistulae [title/abstract]) OR (leak [title/abstract]) AND (neck [title/abstract]) OR (dissection [title/abstract]). The study was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Risk of bias was assessed using guidelines from the Joanna Briggs Institute. Outcome measures included the proportion of chylous fistulae that spontaneously resolved without the need for surgery and time taken until resolution, for both DM and octreotide, respectively.

RESULTS

The primary search identified 20 articles for review, comprising 313 patients. Two studies were suitable for pooled analysis. There was no statistically significant difference in the time taken for chylous fistula to resolve between groups (octreotide 10.0 days; ODM 12.0 days; P = .38). The overall rate of resolution was 89.6% and 81.5%, respectively (P = .25). Surgery was highly effective in cases failing to resolve following intervention with either method (96% [53/55] patients).

CONCLUSION

The use of octreotide for chylous fistula following neck dissection surgery is associated with a high rate of spontaneous resolution. However, significant heterogeneity, bias and concurrent use of ODM/TPN for patients in studies investigating octreotide precludes universal recommendation at this time. Further research in the form of randomised controlled trials is required to establish an independent treatment effect.

Chyloma formation after anterior cervical disc fusion

Chyle leak from iatrogenic thoracic duct injury is a rare but serious complication of head and neck surgery. The chyloma in this case took months to recognize and required open thoracic ligation. He fully recovered.

An Unusual Cause of Chylothorax after Esophagectomy

Chylothorax due to inadvertent thoracic duct injury after esophagectomy is a well-known complication and requires careful postoperative management and timely intervention to prevent potential morbidity and mortality. We present a case of high-output chylothorax after esophagectomy where the source of chyle leak was not in the thorax.

Congenital Chylothorax: Common and Uncommon Findings in an Infant with Chylous Effusions

Congenital chylothorax is defined as an abnormal accumulation of lymphatic fluid in the pleural space. It is a rare condition in the neonate that causes significant respiratory, nutritional, and immunologic problems resulting in a high mortality rate. Presented here is a case of congenital bilateral chylothorax in a preterm infant. Fetal ultrasound at 33 weeks' gestation showed polyhydramnios, bilateral pleural effusions, ascites, and subcutaneous edema. Fetal pleuracentesis was done on the right side with 118 mL of fluid aspirated. This article addresses the management of this difficult disease process, complications, and implications for research of controversial therapies.

Milky White Urine After Relief of Urinary Retention

BACKGROUND

Chyluria is a rare condition where chyle is excreted into the urine. Clinically, most patients manifest with intermittent passage of milky urine. Patients may also present with dysuria, urinary frequency, urgency, retention, or with the sequelae of chronic malnutrition.

CASE REPORT

We present a 55-year-old African American man who presented to the emergency department complaining of milky white urine, dysuria, decreased urine output, and suprapubic abdominal pain once a day. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Patients may present to the emergency department complaining of milk-colored urine, hematuria, urinary retention, or the sequelae of malnutrition. Initial evaluations should include laboratory investigations of common causes of chyluria and the severity of the potential malnutrition. If the patient presents with urinary retention, after relieving the obstruction in the emergency department, assessment for clot/chyle burden and likelihood of recurrence of urinary retention should be performed by urology. Arrangements for proper outpatient follow-up should be made if the disease manifestations are not severe enough to warrant admission.

Chyle leakage after robotic and open pancreaticoduodenectomy

BACKGROUND

Chyle leakage is a well-known but poorly characterized complication after pancreaticoduodenectomy (PD). No study examined the chyle leakage after robotic PD (RPD).

METHODS

Data regarding chyle leakage were prospectively collected and analyzed from patients undergoing RPD or open PD (OPD).

RESULTS

The study included 118 RPD and 165 OPD. Overall chyle leakage rate was 12.0%, with 13.6% for RPD and 10.9% for OPD. Chyle leakage was eventually resolved in all patients through conservative treatment. The drainage volumes were significantly higher in chyle leakage group from postoperative days (PODs) 1-7, with a median of 240 mL on POD 1 and POD 7, as compared to 160 mL on POD 1 and 70 mL on POD 7 for those without chyle leakage. The number of lymph nodes involved and resected and pancreatic head adenocarcinoma affected the risk of developing chyle leakage, whereas the surgical approach used (RPD or OPD) did not.

CONCLUSIONS

Chyle leakage after PD is not rare, and it can eventually be resolved through conservative treatment. The extent and radicality of the surgery probably have a significant effect on the risk of developing chyle leakage, but the surgical approach used does not.

Identification of lymphatic channels in the tracheoesophageal groove during central neck dissection for thyroid cancer

BACKGROUND

Chyle leakage after central neck dissection for thyroid carcinoma is an extremely rare condition. We investigated chyle leakage in patients with thyroidectomy and central neck dissection.

METHODS

We experienced 3 cases of chyle leakage. The patterns of lymphatic drainage from the central neck to the lateral neck (supraclavicular fossa) were reviewed. The amount and duration of chyle leakage were measured in patients with postoperative chyle leakages.

RESULTS

The lymphatic channels were found in 2 cases during central neck dissection on the tracheoesophageal groove. One case did not show chyle leakage and ducts during surgery but showed chyle leakage after surgery.

CONCLUSION

Chyle leakage can occur after thyroidectomy with central neck dissection. There have been no reports on identification of lymphatic channels during central neck dissection. This finding will aid in the recognition and treatment of this uncommon complication during or after central neck dissection in patients with thyroid cancer.

The Lymphatic Vasculature: Its Role in Adipose Metabolism and Obesity

Obesity is a key risk factor for metabolic and cardiovascular diseases, and although we understand the mechanisms regulating weight and energy balance, the causes of some forms of obesity remain enigmatic. Despite the well-established connections between lymphatics and lipids, and the fact that intestinal lacteals play key roles in dietary fat absorption, the function of the lymphatic vasculature in adipose metabolism has only recently been recognized. It is well established that angiogenesis is tightly associated with the outgrowth of adipose tissue, as expanding adipose tissue requires increased nutrient supply from blood vessels. Results supporting a crosstalk between lymphatic vessels and adipose tissue, and linking lymphatic function with metabolic diseases, obesity, and adipose tissue, also started to accumulate in the last years. Here we review our current knowledge of the mechanisms by which defective lymphatics contribute to obesity and fat accumulation in mouse models, as well as our understanding of the lymphatic-adipose tissue relationship.

Chylous Ascites Following Open Abdominal Aortic Aneurysm Repair: An Unusual Complication

Chylous ascites is a rare complication after abdominal aortic aneurysm repair. Accumulation of chyle within the close space of the peritoneal cavity may cause severe discomfort to the patient, complicating the postoperative course. Prompt diagnosis is needed to adopt measures for reducing lymph leakage and contributing to lymphatic fistula closure. Fortunately, conservative treatment is successful in the majority of cases. In the rare cases that do not respond to conservative treatment, surgery becomes mandatory. Accurate preoperative localization of lymph leakage is a prerequisite for a successful outcome. Postoperative chyloperitoneum has a benign course and an excellent prognosis.

Clinical Experience With n-Butyl-2-Cyanoacrylate in Performing Lateral Neck Dissection for Metastatic Thyroid Cancer

Background Chyle leakage following lateral neck dissection (LND) is rare, but can induce metabolic disturbances, delay wound healing, and prolong hospitalization. n-Butyl-2-cyanoacrylate (NBCA) has been used to achieve hemostasis and seal tissues in several surgical settings. We here assessed whether application of NBCA to the thoracic duct area is effective in sealing chyle leakage. Methods The medical records of 163 patients who underwent total thyroidectomy with unilateral LND between March 2011 and September 2012 were reviewed. NBCA was applied to 84 patients and not applied to 79. Drainage volume, duration of hospital stay, and incidence of complications were compared between the 2 groups. Results The 2 groups were not different with regard to age, body weight, gender, primary tumor histology, and number of lateral neck nodes harvested. Mean hospital stay was significantly shorter (4.3 ± 1.8 vs 5.7 ± 3.0 days, P < .001), median total drainage volume was significantly smaller (270 mL; range: 97-931 mL vs 328 mL; range: 113-2636 mL; P < .001), and rate of chyle leakage was significantly lower (0% vs 6.3%, P = .025) in the NBCA than in the non-NBCA group. Conclusion NBCA application to the dissected area of the thoracic duct posterior to its angle of junction with the internal jugular and subclavian veins could be safe and effective in reducing surgical complications related to chyle leakage after LND.

Two cases of chylopericardium after aortic valve surgery

Chylopericardium is a rare clinical condition. It is largely idiopathic but could be iatrogenic from breached thoracic duct collaterals or secondary to thoracic duct flow obstruction. We describe 2 patients seen in a single cardiothoracic center within 6 weeks, and detail the clinicopathologic correlation of an unusual complication of cardiac surgery, as well as provide an algorithm for the diagnosis and management of postcardiotomy pericardial chylous effusion.

Chylous ascites

Context:

Chylous ascites is the accumulation of milky chyle in the peritoneal cavity. Chylous ascites has been reported after surgeries like abdominal aortic aneurysm repair, radical gastrectomy, duodenectomy, nephrectomy and Wilm's tumor resection. Our literature search did not reveal any reports of chylous ascites after a gastric ulcer resection. We report about an elderly woman with a rare complication of chylous ascites after an emergent surgery for a perforated gastric ulcer.

Case Report:

A 70-year-old woman developed sudden respiratory distress on 5^th post-operative day after an elective C3-C7 cervical discectomy and fusion. Her past medical history was significant for cervical spondylosis. The Computed Tomography (CT) scan of the chest revealed air under the diaphragm suspicious for hollow viscus perforation. She underwent an emergent surgery for drainage of hematoma in the neck along with an emergent laparotomy to repair a large perforated gastric ulcer distal to the gastro-esophageal junction. The patient had worsening of abdominal distention on 4^th post-operative day. The CT scan of abdomen showed fluid collection in the abdomen. The abdominal drain revealed large amount of serous milky fluid at the rate of 1500 ml per day. The fluid analysis showed that the triglyceride level was 170 mg/dl and cholesterol level was 15 mg/dl. The fluid cultures did not grow any organism. She responded to treatment with octreotide and a diet of medium chain triglyceride oil.

Conclusion:

Any obstruction or damage to the lymphatic channels results in chylous ascites. Lymphomas, metastatic malignancies, and abdominal surgeries commonly cause chylous ascites. Ascitic fluid triglyceride level greater than 110 mg/dl is diagnostic of chylous ascites. Chylous ascites is a rare complication of a peptic ulcer resection which can be managed effectively with octreotide.

Lymphangiography as therapeutic management of chylothorax

Chylothorax is a rare post surgical complication. It is often initially treated using conservative management such as chest drain insertion, a medium chain triglyceride diet, total parenteral nutrition and somatostatin analogues. Lymphangiography has been used in the past, mainly to identify the site of a chyle leak, but there have been reports where lymphangiography has been therapeutic in the management of chylothorax and has led to resolution of the chyle leak. This paper describes the case of a 15-year-old male who presented with a post-operative chylothorax. He was initially managed conservatively, which failed to stop the chyle leak and lymphangiography was performed. Imaging confirmed that lymphangiography was successful in stopping the chyle leak, leading to resolution of the chylothorax.

CONCLUSION

This case demonstrates that lymphangiography can be used as a therapeutic measure in the management of a chylothorax.

Delayed chylous pericardial effusion after aortic valve replacement

Chylopericardium after cardiac surgery is rare, and there are few reports of its occurrence after aortic valve surgery. Chylous pericardial effusion 4 months after aortic valve replacement for endocarditis is highly unusual.Herein, we report the case of a 54-year-old man who had undergone bioprosthetic aortic valve replacement because of endocarditis and valvular dysfunction. Two months later, he underwent pericardiocentesis twice because of large pericardial effusions consisting of pinkish white fluid with predominant lymphocytes. Four months after valve replacement, he presented with recurrent effusion consistent with early tamponade, and a pericardial window was created. At surgery, 1,500 cc of milky white fluid was recovered, and the diagnosis of chylopericardium was made. Postoperative high-volume drainage prompted thoracic duct ligation, which was curative.

Isolated chylopericardium after intrapericardial procedures: possible role of inadvertent right efferent lymphatic trunk injury

Chylopericardium after an intrapericardial procedure is rare, and satisfactory explanations of its possible causes are lacking.Herein, we present 4 cases of chylopericardium that developed after intrapericardial surgery, and we review the literature. Our literature review revealed 29 cases of chylopericardium that complicated intrapericardial operations, to which we added our 4 cases for analysis. The 33 surgical procedures involved repair for congenital heart disease (n=21), valve surgery (n=5), coronary artery bypass grafting (n=6), and other (n=1). Causes were verified in 7 patients: small lymphatic injury in 3 and high venous pressure or venous thrombosis in 4. Of the 26 patients with chylopericardium of unknown origin, 15 had congenital heart disease. Ten of these 15 had chromosomal abnormalities, especially trisomy 21 (Down syndrome); these patients typically had increased lymphatic permeability, which raised the likelihood of chylopericardium. Five revascularizations for coronary artery disease required harvesting of the left internal thoracic artery for reconstruction, incurring a risk of damage to the drainage site of the right efferent lymphatic trunk. In addition, all 26 patients with chylopericardium of unknown origin underwent dissection of the ascending aorta and the main pulmonary artery, near the right efferent lymphatic trunk. Inadvertent injury to the trunk during the dissection would have increased the risk of chylopericardium. Accordingly, even though the overall incidence of chylopericardium during intrapericardial procedures is low, we recommend a meticulous dissection of the ascending aorta from the main pulmonary artery.

Chylopericardium presenting as cardiac tamponade secondary to an anterior mediastinal cystic teratoma

Cardiac tamponade, the accumulation of fluid in the pericardial space, leads to impaired venous return, loss of left ventricular preload, and hemodynamic collapse. The many causes of tamponade include malignancy, infection, inflammation, connective tissue disorders, and uremia. Herein, we report the case of a young woman who presented with syncope. She was found to have cardiac tamponade secondary to a chylous pericardial effusion that was due to a mature and benign anterior mediastinal cystic teratoma. Numerous reports have described pericardial effusions secondary to an anterior mediastinal cystic teratoma; however, to our knowledge, this is the 1st case of a teratoma causing chylopericardium that presented as tamponade.