Massive Chylous Leakage After Endoscopic Thyroidectomy with Central Lymph Node Dissection: A Case Report.

BACKGROUND Massive chylous leakage represents a rare yet potentially life-threatening complication following neck dissection, and its occurrence is even less common in the context of endoscopic thyroid surgery. Chylous leakage poses significant clinical management challenges, encompassing prolonged hospitalization, nutritional deficiencies, electrolyte imbalances, and the potential for infection. It is imperative for surgeons to remain vigilant and proactive in recognizing and managing chylous leakage to mitigate its potential impact on patient outcomes. CASE REPORT A 37-year-old woman presented with a thyroid nodule, and subsequent fine-needle aspiration biopsy confirmed the diagnosis of papillary thyroid carcinoma. She then underwent endoscopic thyroidectomy with central lymph node dissection via a bilateral areola approach and experienced significant postoperative chylous leakage. Various conservative management strategies were used to treat the leak, including fasting, parenteral nutrition, maintenance of electrolyte balance, and continuous infusion of somatostatin. After failure of a series of conservative treatments, the patient underwent a reoperation to address the leak via the initial approach. After identification of the leak site, the residual end of the lymphatic vessel was clamped with a biological clamp, and no further chylous leakage was observed. The drainage was removed 4 days after the second operation, and the patient was discharged on the fifth day. During follow-up, no abnormalities were observed. CONCLUSIONS Managing significant chylous leakage poses a challenge for surgeons. This complication is rare following endoscopic thyroidectomy with central lymph node dissection, and there remains a lack of experience in effective prevention and treatment. We aim to raise awareness through our case report.

Diagnosis and Treatment of a 64-Year-Old Man with Chyle Leak Following Laparoscopic Cholecystectomy: A Case Report.

BACKGROUND Chyle leakage with chylous ascites is a rare complication of abdominal surgery, and few cases have been reported following cholecystectomy. This report is of a 64-year-old man with chyle leak following laparoscopic cholecystectomy and describes the diagnosis and approach to treatment. Immediate diagnosis, although challenging, remains imperative. Frequently, patients manifest nonspecific symptoms, such as abdominal discomfort or nausea. They can also exhibit milky discharge from drains and wounds. Abdominal fluid analysis is fundamental for diagnosis. The existence of elevated triglyceride levels in peritoneal fluid is indicative of chyle leakage. CASE REPORT We present a case report of a 64-year-old man with chyle leakage after laparoscopic cholecystectomy for acute cholecystitis, on postoperative day 2. A milky-white fluid was drained, and diagnosis was confirmed with elevated triglycerides upon fluid analysis. Chyle leakage decreased gradually until complete resolution at postoperative day 7, after dietary modifications and the closed-suction silicone drain was removed. The patient was symptom-free at a 2-month follow-up. CONCLUSIONS Although chyle leakage is a rare postoperative complication of laparoscopic cholecystectomy, early diagnosis and rapid multidisciplinary management are required. It is vital to consider this diagnosis even if the course of laparoscopic cholecystectomy was uncomplicated and with no anatomical variation. Thus, a closed-suction silicone drain and close monitoring of output is essential for early diagnosis. The dietary modification constitutes a cornerstone in the management of chyle leakage, and a surgical approach should be preserved for patients for whom the conservative approach fails or who have large volumes of chyle.

Venous resection increases risk of chyle leak after total pancreatectomy for pancreatic tumors.

BACKGROUND: Existing research on chyle leak (CL) after pancreatic surgery is mostly focused on pancreaticoduodenectomy and lacks investigation on total pancreatectomy (TP). This study aimed to explore potential risk factors of CL and develop a predictive model for patients with pancreatic tumor undergoing TP. METHODS: This retrospective study enrolled 90 consecutive patients undergoing TP from January 2015 to December 2023 at Peking Union Medical College Hospital. According to the inclusion criteria, 79 patients were finally included in the following analysis. The LASSO regression and multivariate logistic regression analysis were performed to identify risk factors associated with CL and construct a predictive nomogram. Then, the ROC analysis, calibration curve, decision curve analysis (DCA), and clinical impact curve (CIC) were performed to assess its discrimination, accuracy, and efficacy. Due to the small sample size, we adopted the bootstrap resampling method with 500 repetitions for validation. Lastly, we plotted and analyzed the trend of postoperative drainage volume in CL patients. RESULTS: We revealed that venous resection (OR = 4.352, 95%CI 1.404-14.04, P = 0.011) was an independent risk factor for CL after TP. Prolonged operation time (OR = 1.473, 95%CI 1.015-2.237, P = 0.052) was also associated with an increased incidence of CL. We included these two factors in our prediction model. The area under the curve (AUC) was 0.752 (95%CI 0.622-0.874) after bootstrap. The calibration curve, DCA and CIC showed great accuracy and clinical benefit of our nomogram. In patients with CL, the mean drainage volume was significantly higher in venous resection group and grade B CL group. CONCLUSION: Venous resection was an independent risk factor for chyle leak after TP. Patients undergoing vascular resection during TP should be alert for the occurrence of CL after surgery. We then constructed a nomogram consisted of venous resection and operation time to predict the odds of CL in patients undergoing TP.

Thoracic duct identification with indocyanine green fluorescence to prevent chyle leaks during minimally invasive esophagectomy.

INTRODUCTION: Chylothorax (CT) is a rare yet serious complication after esophagectomy. Identification of the thoracic duct (TD) during esophagectomy is challenging due to its anatomical variation. Real-time identification of TD may help to prevent its injury. Near infra-red imaging with Indocyanine green (ICG) is a novel technique that recently has been used to overcome this issue. METHODS: Patients who underwent minimally invasive esophagectomy for esophageal cancer were divided into two groups with and without ICG. We injected ICG into bilateral superficial inguinal lymph nodes. Identification of TD and its injuries during the operation was evaluated and compared with the non-ICG group. RESULTS: Eighteen patients received ICG, and 18 patients underwent surgery without ICG. Each group had one (5.5%) TD ligation. In the ICG group injury was detected intraoperative, and ligation was done at the site of injury. In all cases, the entire thoracic course of TD was visualized intraoperatively after a mean time of 81.39 min from ICG injection to visualization. The Mean extra time for ICG injection was 11.94 min. In the ICG group, no patient suffered from CT. One patient in the non-ICG group developed CT after surgery that was managed conservatively. According to Fisher's exact test, there was no significant association between CT development and ICG use, possibly due to the small sample size. CONCLUSIONS: This study confirms that ICG administration into bilateral superficial inguinal lymph nodes can highlight the TD and reduce its damage during esophagectomy. It can be a standard method for the prevention of postoperative CT.

Lymphatic Chyle Duct Injury and Identification During Laparoscopic Sleeve Gastrectomy Preventing Postoperative Chylous Ascites.

We present a case of intraoperative detection of an iatrogenic chyle duct injury during laparoscopic sleeve gastrectomy. The chyle duct injury was identified and managed by ligature, preventing postoperative chylous ascites.

Early Interventional Treatment of High Output Chyle Leak After Esophagectomy is Associated With Improved Survival.

OBJECTIVE: To investigate overall survival and length of stay (LOS) associated with differing management for high output (>1 L over 24 hours) leaks (HOCL) after cancer-related esophagectomy. BACKGROUND: Although infrequent, chyle leak after esophagectomy is an event that can lead to significant perioperative sequelae. Low-volume leaks appear to respond to nonoperative measures, whereas HOCLs often require invasive therapeutic interventions. METHODS: From a prospective single-institution database, we retrospectively reviewed patients treated from 2001 to 2021 who underwent esophagectomy for esophageal cancer. Within that cohort, we focused on a subgroup of patients who manifested a HOCL postoperatively. Clinicopathologic and operative characteristics were collected, including hospital LOS and survival data. RESULTS: A total of 53/2299 patients manifested a HOCL. These were mostly males (77%), with a mean age of 62 years. Of this group, 15 patients received nonoperative management, 15 patients received prompt (<72 hours from diagnosis) interventional management, and 23 received late interventional management. Patients in the late intervention group had longer LOSs compared with early intervention (slope = 9.849, 95% CI: 3.431-16.267). Late intervention (hazard ratio: 4.772, CI: 1.384-16.460) and nonoperative management (hazard ratio: 4.731, CI: 1.294-17.305) were associated with increased mortality compared with early intervention. Patients with early intervention for HOCL had an overall survival similar to patients without chyle leaks in survival analysis. CONCLUSIONS: Patients with HOCL should receive early intervention to possibly reverse the prognostic implications of this potentially detrimental complication.

Chylous leakage after esophagectomy for esophageal cancer: a systematic review.

BACKGROUND: Chylous leakage is a rare complication following esophagectomy; however, it can lead to mortality. We aimed to systematically evaluate the factors that may lead to increased chylous leakage after esophagectomy. METHODS: Three databases (PubMed, Embase, and Cochrane Library) were systematically searched for all studies investigating the occurrence of chylous leakage after esophagectomy. RESULTS: A total of 32 studies were identified, including 26 randomized controlled trials and 3 cohort and case-control studies, each. The overall incidence of chylous leakage was 4.7% (278/5,971 cases). Analysis of preoperative, intraoperative, and postoperative factors showed that most of the qualitative analysis results did not significantly increase the incidence of chylous leakage. In some quantitative analyses, the chylous leakage rate was significantly lower in the thoracic duct mass ligation group than in the conservative treatment group (relative risk [RR] = 0.33; 95% confidence interval [CI], 0.13-0.83; I2 = 0.0%; P = 0.327). Direct oral feeding significantly reduced chylous leakage compared with jejunostomy (RR = 0.06; 95% CI 0.01-0.33; I2 = 0.0%; P = 0.335). However, preoperative inspiratory muscle training (RR = 1.66; 95% CI, 0.21-12.33; I2 = 55.5%; P = 0.134), preoperative chemoradiotherapy (RR = 0.99; 95% CI, 0.55-1.80; I2 = 0.0%; P = 0.943), and robotic assistance (RR = 1.62; 95% CI, 0.92-2.86; I2 = 0.0%; P = 0.814) did not significantly reduce the incidence of chylous leakage. CONCLUSIONS: Ligation of the thoracic duct and direct oral feeding can reduce the incidence of chylous leakage after esophagectomy in patients with esophageal cancer. Other contributing factors remain unclear and require validation in further high-quality studies.

Incidence and Risk Factors for Chyle Leaks After Neuroblastic Tumor Resection: A Systematic Review of Published Studies.

BACKGROUND: Chyle leakage/ascites after surgical resection of neuroblastic tumors may delay the start of chemotherapy and worsen prognosis. Previous studies have reported a highly variable incidence and risk factors remain largely unknown. This study aims to analyze the true incidence of chyle leaks and ascites and seeks to identify risk factors and optimal treatment strategies. METHODS: Medline/Embase databases were searched according to PRISMA guidelines. Literature reviews, case reports, and non-English papers were excluded. Data were extracted independently following paper selection by 2 authors. RESULTS: The final analysis yielded 15 studies with N = 1468 patients. Chylous ascites was recorded postoperatively in 171 patients (12%). Most patients experiencing chyle leaks were successfully treated conservatively with drainage, bowel rest, parenteral nutrition and octreotide with variable combinations of these treatment options. 7/171 (4%) patients required operative exploration to control troublesome persistent chyle leaks. In risk factor analysis, higher tumor stage was significantly associated with the risk of chyle leak (P < 0.0001) whereas no correlation was observed with adrenal vs non-adrenal tumor location, INRG risk groups and tumor laterality. CONCLUSION: Chyle leakage after surgery for neuroblastic tumors is a common morbid complication occurring in some 12% of patients. Higher INSS tumor stage portends greater risk(s). Conservative therapy strategies appear successful in the majority of cases. To avert this complication meticulous mesenteric lymphatic ligation is recommended especially for those patients with higher tumor stage(s) requiring extensive radical surgery including retroperitoneal lymph node resection. LEVEL OF EVIDENCE: III. TYPE OF STUDY: Systematic review.

Impact of early enteral feed composition on the rate of chyle leak post-esophagectomy.

Patients undergoing esophagectomy are at risk of malnutrition and benefit from perioperative enteral feeding. Esophagectomy carries a risk of chyle leak, and this risk may be influenced by early enteral feed composition. We evaluated the impact of early enteral medium-chain triglyceride-rich feed on the prevalence and severity of chyle leak post-esophagectomy, length of stay, and postoperative weight change. This retrospective study included consecutive patients undergoing esophagectomy at a single center between January 2015 and December 2022. Patients received enteral feed on postoperative days 1-5 with Nutrison Energy or Protein Plus Energy ('standard') (January 2015- June 2021) or Nutrison Peptisorb Plus High Energy High Protein ('HEHP') enteral feed (June 2021 to December 2022). All patients transitioned to 'standard' supplemental jejunal feeding on postoperative day 6 onwards and were discharged on oral IDDSI level 4 diet. Patients who did not commence early enteral feeding were excluded from analysis. A total of 329 patients were included. Patients who received early HEHP feed had fewer chyle leaks (5/52; 9.6%) compared with patients who received standard feed (68/277; 24.5%, P = 0.017). The HEHP group had a shorter total length of hospital stay (P = 0.011). Weight change from preoperative baseline was equivalent in both groups at 6 weeks (P = 0.066) and 3 months (P = 0.400). In the context of routine jejunostomy use and early enteral feeding post-esophagectomy, HEHP feed on postoperative days 1-5 was associated with significantly fewer chyle leaks and shorter length of stay compared with standard feed. No difference was noted in postoperative weight change between groups.

Thoracic Duct Embolization for Treatment of Chyle Leakage After Thyroidectomy and Neck Dissection.

OBJECTIVE: This study aimed to evaluate the safety and efficacy of intranodal lymphangiography and thoracic duct embolization (TDE) for chyle leakage (CL) after thyroid surgery. MATERIALS AND METHODS: Fourteen patients who underwent intranodal lymphangiography and TDE for CL after thyroid surgery were included in this retrospective study. Among the 14 patients, 13 underwent bilateral total thyroidectomy with neck dissection (central compartment neck dissection [CCND], n = 13; left modified radical neck dissection (MRND), n = 11; bilateral MRND, n = 2), and one patient underwent left hemithyroidectomy with CCND. Ten patients (76.9%) had high-output CL (> 500 mL/d). Before the procedure, surgical intervention was attempted in three patients (thoracic duct ligation, n = 1; lymphatic leakage site ligation, n = 2). Lymphangiographic findings, technical and clinical successes, and complications were analyzed. Technical success was defined as the successful embolization of the thoracic duct after access to the lymphatic duct via the transabdominal route. Clinical success was defined as the resolution of CL or surgical drain removal. RESULTS: On lymphangiography, ethiodized oil leakage near the surgical bed was identified in 12 of 14 patients (85.7%). The technical success rate of TDE was 78.6% (11/14). Transabdominal antegrade access was not feasible due to the inability to visualize the identifiable cisterna chyli or a prominent lumbar lymphatic duct. Among patients who underwent a technically successful TDE, the clinical success rate was 90.1% (10/11). The median time from the procedure to drain removal was 3 days (with a range of 1-13 days) for the 13 patients who underwent surgical drainage. No CL recurrence was observed during the follow-up period (ranging from 2-44 months; median, 8 months). There were no complications, except for one case of chylothorax that developed after TDE. CONCLUSION: TDE appears to be a safe and effective minimally invasive treatment option for CL after thyroid surgery, with acceptable technical and clinical success rates.

Prevention, incidence, and risk factors of chyle leak after radical nephrectomy and thrombectomy.

BACKGROUND: To define the incidence and risk factors of chyle leak (CL) after radical nephrectomy and thrombectomy and to determine the impact of chyle leak on oncological outcomes. PATIENTS AND METHODS: A total of 445 patients who underwent radical nephrectomy and thrombectomy between January 2014 and January 2023 were included. CL is defined as the drainage of chyle with a triglyceride level greater than 110 mg/dL after oral intake or enteral nutrition. Multivariate logistic regression analysis was performed to identify the risk factors of postoperative (CL). The Kaplan-Meier curves were used to compare overall survival and cancer-specific survival. RESULTS: 44 patients (9.9%) were diagnosed as (CL). All patients developed CL within 6 days after the operation with a median time of 3 days. In multivariate logistic regression analysis, Mayo grade and side were independent patient-related risk factors. In addition, operation approach, operation time, and number of lymph nodes harvested were independent surgery-related risk factors. Between the CL group and the non-CL group, neither overall survival nor cancer-specific survival showed statistical differences. CONCLUSION: Based on this retrospective study of renal cell carcinoma and tumor thrombus patients in our center, we found that the risk factors were Mayo grade, side, operation approach, operation time, and number of lymph nodes harvested, and the occurrence of CL significantly prolonged hospital stay, but had no effect on long-term oncological outcomes.

Seudoquilotórax reumatoide / Rheumatoid pseudochylothorax

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Mantle Cell Lymphoma - a less frequent presentation

The clinical manifestations of non-Hodgkin's lymphomas (NHL) are unspecific and may vary with their location, growth rate or organs involved. Chylothorax consists of an accumulation of chyle in pleural space. galiLymphoproliferative diseases represent the main non-traumatic aetiology. The authors report the case of an 81-year-old woman admitted with right pleural effusion and lower limbs oedema, initially interpreted as decompensated heart failure. The thoracocentesis revealed a chylothorax and the aetiological study exposed a mantle cell lymphoma. The authors aim to alert to a less frequent presentation of NHL and remind that a low suspicion may delay the diagnosis

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Linforragia cervical masiva tras vaciamiento cervical izquierdo / Massive cervical chylous fistula after left cervical dissection

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Generalidades del quilotórax en el paciente adulto / Generalities of the chylothorax in the adult patient

Resumen El quilotórax se produce ante la ruptura, desgarro u obstrucción del conducto torácico o sus afluentes principales, lo que resulta en la liberación de quilo al espacio pleural. Ocurre más frecuentemente asociado a trauma o a lesiones malignas; pero han sido descritas otras causas. El diagnóstico se obtiene mediante toracocentesis y la determinación de las concentraciones de triglicéridos y colesterol en el líquido pleural. Las complicaciones incluyen la desnutrición, inmunosupresión y compromiso respiratorio. El tratamiento puede ser conservador o agresivo en función de la situación clínica.

Abstract Chylothorax occurs when there is rupture, laceration or obstruction of the thoracic duct or its main tributaries, resulting in the release of chyle into the pleural space. It most commonly occurs from trauma or malignancy, but other causes have been described. Diagnosis involves thoracocentesis and cholesterol and triglyceride measurement in the pleural fluid. Complications include malnutrition, immunosuppression and respiratory distress. Treatment may be either conservative or aggressive depending on the clinical scenario.

Povidone-Iodine Pleurodesis for Chylothorax in an Extremely Low Birth Weight Infant

Chylothorax, the accumulation of chyle in the pleural space, is a rare condition, but can lead to serious complications in neonates. Conservative therapy for chylothorax includes enteral feeding with medium-chain triglyceride-enriched diet or parenteral nutrition and administration of octreotide. Surgical management is considered in cases where there is no response to conservative therapy; however, the standardized approach to refractory neonatal chylothorax is still controversial. Chemical pleurodesis can be used when medical therapies for chylothorax fail, to avoid more invasive surgical procedures. We report an extremely preterm infant born at 26 weeks of gestation with refractory chylothorax after patent ductus arteriosus ligation. The infant was successfully treated with pleurodesis using 4% povidone-iodine, without long-term side effects.

Successful Treatment in a Newborn Infant with Chylous Ascites and Chylous Hydrocele

Chyle only occurs in the peritoneal cavity or around the pericardium through damage to the lymph nodes or improper drainage of the lymph and is characterized by a colostrum-like color and being rich in triglyceride. We encountered a case of a newborn infant with abdominal distention and further diagnosed chylous ascites and hydrocele by inspecting and analyzing the fluid obtained from the abdominal cavity and scrotum. Additionally, a lymphoscintigraphy was performed, which showed a decrease in the uptake of radioactive isotopes in the left iliac nodes and a delayed appearance. Here, we report a case of chyle diagnosed through puncture analysis and its subsequent successful treatment.

Biocompatibility of n-butyl-2-cyanoacrylate (Histoacryl) in cervical structures of rats: prospective in vivo study

PURPOSE: We investigated the biocompatibility of n-butyl-2-cyanoacrylate (NBCA) in the cervical deep tissues of rats to assess its biocompatibility. METHODS: A total of 30 Sprague-Dawley rats were injected with NBCA. After 30, 90, 180, and 360 days, cubes of tissue (1 cm × 1 cm × 1 cm) surrounding the NBCA and normal tissue from the other side of the neck were excised from each rat. The adhesion of NBCA to adjacent structures was examined histologically. Cells were counted per high-power field (HPF), and fibrosis was graded with the measurement of fibrotic thickening. RESULTS: All animals displayed normal behavior without any symptoms of distress throughout the study. There was no recognizable inflammatory reaction, foreign body reaction, or fibrosis in the 30 control samples. The analyses of experimental samples showed significantly decreased inflammatory cell counts over time (lymphoplasma cell count decreased from 100 (range, 70–100) to 30 (range, 30–50) per HPF, P = 0.010; neutrophil count decreased from 2 (range, 2–30) to 0 (range, 0–2) per HPF, P = 0.017). However, there was no significant difference in the number of multinuclear giant cells throughout the study period (a decrease from 22 [range, 16–34] to 16 [range, 12–22] per HPF, P = 0.287). The level of fibrosis was Common Toxicity Criteria ver. 4.0 Grade 1 without further thickening (P = 0.600). However, maturation of fibrosis progressed gradually. CONCLUSION: NBCA was biologically tolerable in the cervical deep tissues of rats. However, precautions are needed with respect to preventing a sustained foreign body reaction and fibrosis.

Resolution of Protein-Losing Enteropathy after Congenital Heart Disease Repair by Selective Lymphatic Embolization / 대한소아소화기영양학회지

With improving survival of children with complex congenital heart disease (CCHD), postoperative complications, like protein-losing enteropathy (PLE) are increasingly encountered. A 3-year-old girl with surgically corrected CCHD (ventricular inversion/L-transposition of the great arteries, ventricular septal defect, pulmonary atresia, post-double switch procedure [Rastelli and Glenn]) developed chylothoraces. She was treated with pleurodesis, thoracic duct ligation and subsequently developed chylous ascites and PLE (serum albumin ≤0.9 g/dL) and was malnourished, despite nutritional rehabilitation. Lymphangioscintigraphy/single-photon emission computed tomography showed lymphatic obstruction at the cisterna chyli level. A segmental chyle leak and chylous lymphangiectasia were confirmed by gastrointestinal endoscopy, magnetic resonance (MR) enterography, and MR lymphangiography. Selective glue embolization of leaking intestinal lymphatic trunks led to prompt reversal of PLE. Serum albumin level and weight gain markedly improved and have been maintained for over 3 years. Selective interventional embolization reversed this devastating lymphatic complication of surgically corrected CCHD.