Percutaneous Lipiodol Lymphangiogram in Chylous Leakage Successful Embolisation Post Mastectomy: A Case Report

@#Complication of chyle leakage is rare post mastectomy, ranging from 0.36 – 0.84%. This case report discuses a rare case of chylous leakage post mastectomy in a 79-year-old female. The complication was suspected when the draining colour of axillary drainage change from serous fluid to milky colour, diagnosis then confirmed clinically and biochemically as chyle. The patient was initially managed conservatively, but this was not successful and was referred to an interventional radiology for lymphangiogram and embolization. Percutaneous lipiodol embolization was performed with immediate success.

Critical Evaluation Of Complications Of Neck Dissection

BACKGROUND: Radical neck dissection is a reliable method of treating patients with head and neck cancer; it carries substantial morbidity and complications. This surgery has become a routine in many oncological centres but knowledge of possible complications and their management is a must for treating surgeons METHODS: In this study 60 patients undergoing neck dissection as elective or therapeutic, comprehensive or selective, as a sole procedure or combined with other surgery, with or without other modalities of treatment were selected and managed and all the complications were critically analysed. RESULTS: A total of 26 complications (43.3%) occurred in this study. There were 7 cases of thoracic duct injury (11.6%), 5 cases of post operative chyle leak (8.3%) and 2 cases of RLN injury (3.3%) and 1 case of injury to main trunk of facial nerve (1.6%), 2 patients had temporary paresis of marginal mandibular nerve (3.3%). Post operatively marginal necrosis of skin flap was present in 8 patients (13.3%) and 1 patient had facial and glottic oedema (1.6%). CONCLUSION: Despite the best planning, complications can still occur but their impact can be minimised by a vigilant and proactive emphasis in the entire peri-operative period.

Chyle test is not a valuable laboratory index in identifying chylothorax after pulmonary resection and lymph node dissection for primary non-small cell lung cancer

Objective: Chyle test is widely used to identify chylothorax after pulmonary resection and lymph node dissection for primary non-small cell lung cancer (NSCLC). Low accuracy of chyle test in identifying chylothorax is rarely reported. This observational study was designed to identify the diagnostic value of chyle test. Patients and Methods: From September 2016 to March 2017, 185 consecutive patients either suspected or histologically documented lung cancer were screened for this observational study. Except exclusion, 108 patients were eligible for further analysis. Daily chest-tube output as well as the postoperative day of chest tube removal was documented. Chyle test was analyzed with 108 cases, and the results were blinded to the thoracic surgeons. Chest tube was timely removed regardless of the results of chyle test. A high-output pleural effusion and an associated change in quality of the pleural fluid, from serous to milky yellowish after normal diet, led to the diagnosis of chylothorax. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of chyle test in identifying chylothorax were calculated. Results: Of 108 patients, 4 (3.7%) were observed with chylothorax after pulmonary resection and lymph node dissection for primary NSCLC. Postoperative chylothorax was conservatively managed in three patients and chest tubes were removed 12 days (from 10 to 16) after surgery. Failed in conservative treatment, one patient underwent thoracic duct ligation performed by video-assisted thoracic surgery. For patients without chylothorax, the median day of chest tube removal was postoperative day 4. Among the 108 patients, 75.9% (82/108) was found with a positive chyle test result, of which 95.1% (78/82) was false positive in identifying chylothorax. The sensitivity and specificity of chyle test in identifying chylothorax were 100% and 25%, respectively. The positive predictive value, negative predictive value, and accuracy of chyle test for chylothorax diagnosis were 4.9%, 100%, and 27.8%, respectively. Conclusions: It was suggested that the specificity and accuracy of chyle test in identifying chylothorax were relatively low. Chyle test is not a good laboratory index in identifying chylothorax. With highly positive result, chyle test should not preclude the removal of chest tube in patients after pulmonary resection and lymph node dissection for primary NSCLC

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.

Chyle Leak after a Simple Hemithyroidectomy: An Extremely Rare Situation

@#Chyle leak is a well-known complication that can occur after a thyroidectomy with neck dissection; however, it rarely occurs after thyroidectomy alone. Here, we report a case of chyle leak following a left hemithyroidectomy for a benign solitary thyroid nodule. Based on the literature search, this is only the second reported case of a chyle leak after a simple hemithyroidectomy without any central or lateral neck dissection. Amongst the possible causes, we hypothesize that the use of intraoperative nerve monitor may be a contributing factor. Treatment options are explored and the patient was treated successfully with nonoperative management.

Analysis of chyle leakage after central lymph node dissection for thyroid carcinoma / 中华耳鼻咽喉头颈外科杂志

Objective@#To analyze the clinical characteristics, treatment and prognosis of chyle leakage after central lymph node dissection for thyroid cancer.@*Methods@#A retrospective analysis was made of 985 patients who underwent surgical for thyroid carcinoma plus central lymph node dissection from January 2017 to June 2018 in Renji Hospital Affiliated to Medical College of Shanghai Jiaotong University. Patients were divided into those without (group A, n=973) and with (group B, n=12) chyle leakage. Patients with chyle leakage who underwent left central lymph node dissection were divided into group B1 (n=5) and right central lymph node dissection into group B2 (n=7). Patients with chyle leakage were treated with fat-free diet and negative pressure drainage. SPSS 20.0 software was used to analyze the general condition, surgical pathology, postoperative drainage, hospitalization days, treatment and prognosis of patients in B1 and B2 groups.@*Results@#The incidence of chyle leakage after central lymph node dissection for thyroid cancer was 1.2% (12/985). There were no significant differences in age, sex, size of primary lesion, number of lymph node dissection in central area and number of lymph node metastasis in central area between group A and group B (all P>0.05). The drainage volume on the first day after operation [((51.7±26.7)) ml] and the average hospitalization days [(3.4±0.8) d] in group A were significantly lower than those in group B ([131.3±56.0)]ml, [10.4±2.6)]d). The differences were statistically significant (t value was -5.442, -11.238, respectively, both P<0.001). There were no significant differences in age, size of primary lesion, number of lymph node dissection, number of lymph node metastasis, drainage volume on the first day after operation and average hospitalization days between group B1 and group B2 (all P>0.05). All chyle leakages in group B stopped after conservative management without surgical intervention.@*Conclusion@#The occurrence of chyle leakage after central lymph node dissection is a rare complication. It can be cured by conservative treatment such as diet control, pressure bandaging and negative pressure drainage, and generally does not require secondary surgery.

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.

The establishment of a chyle testing method based on n-hexane extraction system / 中华检验医学杂志

Objective@#To set up a chyle (n-hexane) testing method based on n-hexane extraction system.@*Methods@#The hydrothorax specimen which was positive in chyle testing was selected and the feasibility was evaluated by replace Diethyl ether with n-hexane. The optimal extraction volume ratio for the new chyle testing was confirmed and sultan Ⅲ dye process was improved. Then, the new chyle testing method and its standard operation process was established.A total of 120 specimens with triglyceride(TG)in different levels were collected and divided into three groups with 40 specimens for each group (group A. TG≤1.7 mmol/L; B. 5.6<TG<12.8 mmol/L; C. TG≥12.8 mmol/L). Then, 50 body fluid specimens were collected and used to confirm the above test results. A total of 134 real body fluid specimens were used to assessment the clinical using by review and calculating the clinical coincidence rate.@*Results@#N-hexane can replace Diethyl ether in the Chyle test. The extraction volume ratio of 1 ml sample plus 400 μl N-hexane is the best one and the sultan Ⅲ tube dying method is better than former direct smear. Compared with the old Chyle test using Diethyl ether, the new Chyle test using N-hexane is in good consistency with the Kappa value 0.95. The clinical coincidence rate of the above Chyle test reaches 94.8%(127/134) after the verification of 134 specimens.@*Conclusions@#A new N-hexane test is established successfully. It was convenient to operate with high security and little contamination and thus has a wide clinical application value.(Chin J Lab Med, 2018, 41: 527-530)

Role of nutritional support in the treatment of infants with primary chylous reflux obstacle / 中华临床营养杂志

Objective To evaluate the effectiveness of nutritional support in the treatment of primary chylous reflux obstacle caused by primary lymphatic dysplasia among infants and investigate the effects of the essential components of therapeutic formula milk in treating this disease.Methods Seven infants,who were diagnosed at Beijing Shijitan Hospital between 2012 and 2014 with primary chylous reflux obstacle and aged (8.9±4.6) months at the onset,were retrospectively analyzed to evaluate effectiveness of the nutrition support and prognosis of the disease.Results After personalized enteral nutrition support (using proteins,short peptides and medium-chain triglyceride) of (8.3±2.8) months,heights and weights of all the seven infants were kept between the 3rd and 97th percentile lines,and the growth curve showed onward and upward trend.Their plasma albumin levels reached (43.7±4.4) g/L.The infants defecated 1-2 times a day and the texture of feces was formed and soft with yellow color.Conclusion Clinical symptoms and physical signs of the seven infants were improved after nutrition support,which contributed to the recovery.

Diagnosis and treatment progress of postoperative abdominal chyle leakage / 国际外科学杂志

Chylous fistula after abdominal operation is a rare complication which easily lead to malnutrition or immunosuppression and even cause death due to constant loss protein and lymphocytes.The therapeutics of the chylous fistula after abdominal operation includes conservative treatment,surgery and special management modalities at present.The most of the patient can be cured by non-surgical treatment,which should be considered as the first treatment regimen,surgery should be choosen if it failed.Only the obove methads have failed can we take the special treatments cound be taken into consideration.In this paper,new progress in diagnosis and therapeutics of the chylous fistula after abdominal operation will be reviewed.

Effect of Octreotide Injection on Postoperative Drainage After Neck Dissection: A Preliminary Report of a Prospective, Matched Case-Control Study

OBJECTIVES: Somatostatin inhibits lymph production and reduces lymph flow into the lymphatic duct. We hypothesized that octreotide, a long-acting somatostatin analog, would reduce drainage after neck dissection (ND) by reducing the overall lymphatic flow in the neck as well as thoracic duct flow. METHODS: From 2012 to 2014, total 123 patients who had undergone left-sided comprehensive ND, were divided into an octreotide group (49 patients) and a control group (74 patients). Seventeen patients from the octreotide group and 17 from the control group were individually matched by age (±10 years), sex, body mass index (±1 kg/m2), type of cancer, surgeon, and the extent of surgery. These 34 patients were finally included in the study. RESULTS: The total fluid drainage volume (540.9 mL vs. 707.9 mL) and drainage volume during the period of octreotide use (the first 5 postoperative days) (461.1 mL vs. 676.4 mL) were significantly lower in the octreotide group. The duration of drain placement (6.3 days vs. 9.4 days) was also shorter in the octreotide group. In the octreotide group, the mean triglyceride concentration in the drainage fluid was significantly lower than that in the control group (43.1 mg/dL vs. 88.8 mg/dL). There was no complication associated with the use of octreotide. CONCLUSION: Our study has shown that postoperative octreotide injections reduce postoperative drainage and the duration of drain placement. Further studies with larger patient populations are warranted to confirm these results and to evaluate the clinical benefits for patients.

Manejo conservador de una fistula de quilo por disección radical de cuello: reporte de un caso y revisión de la literatura / Conservative management of chyle fistula diseción by radical neck: a case report and literature review

Se expone el caso de un paciente masculino de 59 años con diagnóstico de carcinoma medular de tiroides con metástasis ganglionares, al cual se le realiza una tiroidectomía total bilateral con disección radical de cuello modificada tipo III. En el postoperatorio se documenta fístula del conducto torácico. Se dio un manejo conservador con dieta hiperprotéica sin carbohidratos y rica en triglicéridos de cadena media el cual fue satisfactorio.

We describe the case of a 59-year-old male patient with a diagnosis of medullar thyroid carcinoma with affection of a cervical lymph node surgically managed with total thyroidectomy and bilateral radical neck dissection. It was diagnosed with a thoracic duct fistula. A conservative management with a strict diet of proteins enriched with medium chain triglycerides was performed in a successful way. Because of the case a review of the literature was performed.

Influence of Severe Chyle Blood Serum to the Three Types of Common Biochemical Detection Method / 现代检验医学杂志

Objective Aim to explore how severe chyle blood serum effects on the End-point method of colorimetry,velocity method,immunological transmission turbidimetry(TIA)three types of common biochemical tests and their different influ-ences.Methods Collected 20 normal appearance serums,divided each pooled serum into A,B,C,D,E,F and G 7 experimen-tal groups and one control group.Each group contented for 1ml serum.Added intralipid 10,20,40,80,160μl and 320μl to the experimental groups from A to G in turn to prepare into different concentrations of simulate chylous samples.Tested each group by the End-point method of colorimetry,velocity method and TIA which represented by Glucose (Glu),uric acid (UA),Total bilirubin (TBil),aspartate aminotransferase (AST),gamma-glutamyl transpeptidase (GGT),lactate dehydro-genase (LDH),hypersensitive C reactive protein (hs-CRP),Apolipoprotein A1 (apoA1 )andβ2-microglobulin (β2-MG). Used pair T test for both experimental group and their control group.Results In terms of TIA,there were statistical differ-ences between all the experimental groups and their control groups in the three projects (t=-2.842~29.465,P0.05).In terms of velocity method,there were no statistical differences between all the experimental groups and their control groups (t=-1.532~1.619,P>0.05)except for the B and C groups in GGT experiment (t=2.234&5.006,P<0.05).Conclusion Severe chyle blood serum had significant influence on the End-point method of colorimetry and TIA,as well as less influ-ence on velocity method.

Prevention and treatment of chylous leakage after Whipple operation / 中华普通外科杂志

Objective To study the prevention and treatment of chylous leakage after Whipple operation.Methods Clinical data of 381 patients underwent Whipple operation from Jan 2010 to march 2013 were retrospectively analyzed.Results Among 381 patients,23 patients had chylous leakage,the incidence was 6.04％.While in 89 patients,in which intraoperative precautionary physical ligation or mattress suturing of the lymphatic vessels were undertaken,no chyle leakage occurred ; Most of chyle leakage occurred in malignant tumor after radical resection(21 patients),most chylous leakage was found 5-8 days after surgery,with daily volume of 260-450 ml.All patients of chylous leakage were cured by conservative treatment.Conclusions Chylous leakage are common in PD.Intraoperative preventive measures such as lymphatic duct ligation or safe suturing can effectively prevent chyle leakage.Conservative therapy heals most chylous leakage after Whipple operation.

Postmastectomy/Axillary Node Dissection Chyloma: The Additional Value of SPECT/CT Lymphoscintigraphy / 한국유방암학회지

After mastectomy and axillary node dissection, chylous leakage is rare. However, considerable anatomical variation in the termination of the thoracic duct has been reported. Hence, during breast surgery, injury to the lateral terminating branch is not unlikely and might lead to retrograde chyle leak. Herein, we describe a patient who had a chylous leakage at her wound site after a left simple mastectomy and axillary node dissection and for whom lymphoscintigraphy with Tc-99m albumin nanocolloid was performed. In this case, additional hybrid single-photon emission computed tomography/computed tomography study was done, and has helped with the accurate identification of the chyle leakage site, thus aiding in surgical management.

Primary chylous reflux syndrome Ⅰ : a case report / 中华皮肤科杂志

An 18-year-old woman was admitted to the hospital for swelling of the right lower limb and vulva with milky-white vesicles for 3 years.Skin examination revealed swollen and enlarged right lower limb and labium,numerous clustered or scattered pinhead-to millet-sized whitish thick-walled vesicles over the right labium majus,bilateral labium minus,vaginal orifice,and right thigh,with milky-white chylous fluid draining from the vagina.Magnetic resonance imaging revealed obvious lymphangiectasia in the lower abdominal cavity and right side of the pelvis,dilation and distortion of lymphatic vessels in the skin and subcutaneous tissue of the right inner thigh,the vaginal wall and at the medial side of the right labium majus,but no abnormality in the uterus.Histopathological examination of the milky-white vesicles showed cystic dilation of lymphatic vessels in the superficial dermis,and fibrous hyperplasia of the middle and lower dermis.A diagnosis of primary chylous reflux syndrome Ⅰ was made.

Chyle Leakage after Total Thyroidectomy and Central Neck Dissection: Report of Three Cases / 대한내분비외과학회지

Chyle leakage is a rare complication of surgery for thyroid cancer that generally develops after lateral neck dissection. Here, we describe chyle leakages experienced after central neck dissection (CND). A total of 615 patients with thyroid cancer were treated by total thyroidectomy with CND between Jan 2012 and Dec 2012 at our facility, and three (0.49%) developed chyle leakages. The amounts of leakage were all less than 100 ml/day. One patient was resolved with conservative management, while the others were treated with conservative treatment and fibrin glue injection in chylous lymphocele. Chyle leakage after CND is very uncommon, and most cases involve minor leakage. Fibrin glue could be a treatment option for chyle leakage following CND.

Somatostatin Treatment in Two Cases of Chyle Fistula after Neck Dissection / 대한이비인후과학회지

The use of somastostatin in chyle fistula that occurs after neck dissection is a new approach that has been reported in few cases. We report two cases of chyle fistula that occurred after neck dissection, which were successfully managed with somatostatin subcutaneous injection. Somatostatin treatment resulted in an immediate reduction of chyle leakage in both patients, and might have contributed to the reduction of patients' morbidity and duration of hospital stay. However, optimal treatment regimen with somatostatin is unclear because of its limited case and various administration methods. Further studies are required to clarify the usefulness and optimal regimen of somatostatin injection in the treatment of chyle fistula following neck dissection.

Chylous Leakage: A Rare Complication after Axillary Lymph Node Dissection in Breast Cancer and Surgical Management / 한국유방암학회지

Chylous leakage is an extremely rare complication of surgery for breast cancer. We experienced a case of chylous leakage after axillary lymph node dissection. A 38-year-old woman with invasive ductal carcinoma in the left breast underwent a modified radical mastectomy after four cycles of neoadjuvant chemotherapy. The postoperative serosanguinous drainage fluid became "milky" on the fourth postoperative day. After trying conservative management, we re-explored the axilla and ligated the lymphatic trunk. Although the success of many cases supports conservative management, timely surgical intervention represents an alternative in cases where leakage persists or where the output is high.

Chylous ascites caused by acute pancreatitis with portal vein thrombosis / 대한외과학회지

Chylous ascites is defined as the accumulation of chyle in the peritoneum due to obstruction or rupture of the peritoneal or retroperitoneal lymphatic glands. Chylous ascites that arises from acute pancreatitis with portal vein thrombosis is very rare. We report here on a case of chylous ascite that was caused by acute pancreatitis with portal vein thrombosis, in which the patient showed an impressive response to conservative therapy with total parenteral nutrition and octerotide. We also review the relevant literature about chylous ascites with particular reference to the management of this rare disease.