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.

The application of a medium-chain fatty diet and enteral nutrition in post-operative chylous leakage: analysis of 63 patients.

Background: Post-operative chylous leakage (CL) is the pathologic leakage of chylomicron fluid after surgery. This retrospective study was performed to evaluate a uniform oral nutrition management strategy on the post-operative CL. Methods: We retrospectively reviewed patients who developed post-operative CL and received consultation from a clinical nutritionist in seven departments of the Second Affiliated Hospital of Dalian Medical University from May 2020 to April 2022. We designed the oral nutrition intervention program which mainly standardized the type and amount of foods contained in the medium-chain triglyceride (MCT) diet. The influencing factors of curative efficacy were analyzed. Finally, binary logistic regression analysis was conducted to observe the relationship between curative efficacy and potentially predictive variables, including post-operative albumin, post-operative hemoglobin, surgical procedure, and drainage volume at consultation. Results: Sixty-three patients with post-operative CL were included in this analysis. Of this number, 58 patients were cured successfully without other treatments. Three patients had a significantly prolonged recovery period, and the remaining two cases were treated by reoperation therapy. The leakage volume at the initiation of enteral intervention had no statistically significant difference in seven surgical departments and surgical sites (left, right, median, and bilateral). The length of stay (LOS) of patients with CL after the intervention was not significantly increased in cardiac, hepatobiliary, gastrointestinal, and urological surgeries. Patients with CL had longer LOS than those without CL in gynecology (P=0.044) and thyroid surgery departments (P=0.008). Each unit increase in post-operative hemoglobin would increase the probability of an effective outcome by 8%, which was statistically significant (P = 0.037). Conclusion: In treating patients with post-operative CL, we recommend the MCT diet and EN as the first option, rather than fasting, parenteral nutrition (PN), or octreotide.

OK432 sclerotherapy for refractory chylous leakage after neck dissection.

Chylous leakage is a rare but serious postoperative complication of neck dissection (ND). Most chylous leakages are successfully treated either by drainage or ligation of the thoracic duct, but the resolution is occasionally prolonged. OK432 sclerotherapy is used to treat various refractory cystic diseases of the head and neck. Three patients were treated with OK432 sclerotherapy for refractory chylous leakage following ND. Case 1 involved a 77-year-old man with chylous leakage after a total laryngectomy and bilateral ND. Case 2 involved a 71-year-old woman who underwent total thyroidectomy and left ND for thyroid cancer. Case 3 involved a 61-year-old woman who underwent right ND for oropharyngeal cancer. In all patients, chylous leakage rapidly improved after OK432 injection without any complications. Our results suggest the efficacy of OK432 sclerotherapy in patients with refractory chylous leakage after ND.

Horner's Syndrome and Lymphocele Following Thyroid Surgery.

Horner's syndrome (HS), caused by lesions of the 3-neuron oculosympathetic nerve pathway (ONP), includes the triad: blepharoptosis, miosis and anhidrosis (ipsilateral with ONP damage). Thyroid−related HS represents an unusual entity underling thyroid nodules/goiter/cancer−HS (T-HS), and post-thyroidectomy HS (Tx-HS). We aim to overview Tx-HS. This is a narrative review. We revised PubMed published, full-length, English papers from inception to November 2022. Additionally, we introduced data on post-thyroidectomy lymphocele/chylous leakage (Tx-L), and introduced a new pediatric case with both Tx-HS and Tx-L. Tx-HS: the level of statistical evidence varies from isolated case reports, studies analyzing the large panel of post-thyroidectomy complications reporting HS among the rarest side effects (as opposite to hypocalcemia), or different series of patients with HS due to various disorders, including T-HS/Tx-HS. Tx-HS is related to benign or malignant thyroid conditions, regardless the type of surgery. A pre-operatory rate of T-HS of 0.14%; a post-operatory rate of Tx-HS between 0.03% and 5% (mostly, 0.2%) are identified; a possible higher risk on endoscopic rather than open procedure is described. Incomplete HS forms, and pediatric onset are identified, too; the earliest identification is after 2 h since intervention. A progressive remission is expected in most cases within the first 2−6 months to one year. The management is mostly conservative; some used glucocorticoids and neurotrophic agents. One major pitfall is an additional contributor factor like a local compression due to post-operatory collections (hematoma, cysts, fistula, Tx-L) and their correction improves the outcome. The prognostic probably depends on the severity of cervical sympathetic chain (CSC) lesions: indirect, mild injury due to local compressive masses, intra-operatory damage of CSC like ischemia and stretching of CSC by the retractor associate HS recovery, while CSC section is irreversible. Other iatrogenic contributors to HS are: intra-operatory manipulation of parathyroid glands, thyroid microwave/radiofrequency ablation, and high-intensity focused ultrasound, and percutaneous ethanol injection into thyroid nodules. Tx-L, rarely reported (mostly <0.5%, except for a ratio of 8.3% in one study), correlates with extended surgery, especially lateral/central neck dissection, and the presence of congenitally­aberrant lymphatic duct; it is, also, described after endoscopic procedures and chest-breast approach; it starts within days after surgery. Typically low-fat diet (even fasting and parental nutrition) and tube drainage are useful (as part of conservative management); some used octreotide, local sealing solutions like hypertonic glucose, Viscum album extract, n-Butyl-2-cyanoacrylate. Re-intervention is required in severe cases due to the risk of lymphorrhoea and chylothorax. Early identification of Tx-HS and Tx-L improves the outcome. Some iatrogenic complications are inevitable and a multifactorial model of prediction is still required, also taking into consideration standardized operatory procedures, skillful intra-operatory manipulation, and close post-operatory follow-up of the patients, especially during modern era when thyroid surgery registered a massive progress allowing an early discharge of the patients.

Interventional treatment of chylous leakage in 60 cases: a preliminary study / 中华放射学杂志

Objective:To evaluate the feasibility, safety, treatment outcome, and the individualized surgical procedure selection of the interventional treatments of chylous leakage.Methods:From July 2019 to January 2022, the clinical data of 60 consecutive patients with chylous leakage underwent interventional treatment were respectively analyzed. The cases included chylothorax ( n=37), chylous ascites ( n=10), chyluria ( n=4), chylothorax combined with chylous ascites ( n=5), chylothorax combined with chylopericardium ( n=2), and pelvic chylous effusion ( n=2). Conservative treatment was considered to have failed for all patients. The lymphangiography was firstly performed to detect chylous leakage, then an individualized procedure was selected according to the lymphangiography results. The treatment outcomes and complications were recorded, and follow-up was performed. Results:Lymphangiography was technically successful in 55 of 60 patients (91.7%), and no cisterna chyli and thoracic duct opacification was observed in 5 patients. The procedures for the patients included lymphangiography alone ( n=23), thoracic duct embolization ( n=23), thoracic duct disruption ( n=5), lymphatic embolization for pelvic chylous effusion ( n=4), and balloon plasty for thoracic duct ( n=5). Clinical success was achieved in 53 of 60 cases (88.3%). The complication rate was 8.3% (5/60), and all complications were minor. The median follow-up time was 11 months (range 0.5-30 months) for 56 patients, and 4 patients were lost to follow-up. There was one patient presenting the reoccurrence of symptom, and 8 patients died. Conclusions:The interventional treatment of chylous leakage is safe with good outcomes and low complication rate. Individualized treatment procedures based on the lymphangiography findings is feasible and with good curative effect.

Multimodal Treatment of Chylous Fistula: A Retrospective Case-Control Study.

Chylous fistulas (CF) are rare surgical complications and there is no standard treatment. This study presents the treatment modalities performed on patients who developed CF over a 10-year period. During the observation period, CF developed in 29 patients, 16 of whom were women. The mean age was 55.76± 13.48. Lymphatic duct injury was mostly seen in the abdomen (58.6%) and the most common reason was nephrectomy (20.7%). Extended lymphatic dissection due to malignancy was performed in 82.7% of all cases. Chylous leakage started postoperatively on 3.78±3.94 days (range: 1-19 days). Fasting, total parenteral nutrition (TPN), and somatostatin treatment were applied to all patients, and 75.8% of the fistulas were resolved completely with medical treatment. Surgical ligation of the lymphatic canal was performed in 7 patients. One was not successful and underwent percutaneous embolization of the thoracic lymphatic leakage cavity. All fistulas were resolved in 18.18±10.4 days. The resolution time and hospital stay were significantly higher in thoracic fistulas (p=0.017; p=0.003, respectively). In addition, malignant cases had longer resolution time (32.40±28.72 vs 16.27±11.25, p=0.036) and hospital stay (35.0±29.74 vs 16.25±14.05p= 0.002 respectively) than non-malignant. There was no chylothorax, chylous ascites, or recurrence at 20.55±22.88 months follow-up. Treatment of CF with fasting, TPN, and somatostatin analogs are effective. Other interventions such as surgical ligation with or without fibrin glue and interventional radiology treatments may be considered when conservative treatments fail.

Refractory ascites after laparoscopic cholecystectomy: a case report.

BACKGROUND: Laparoscopic cholecystectomy is a common surgical option for gallstone disease with minimal trauma and rapid recovery. Ascites is a relatively uncommon complication after laparoscopic cholecystectomy and is more frequently observed in patients with preoperative abnormal liver function. However, patients without underlying liver disease develop refractory ascites after laparoscopic cholecystectomy are rare. We report a case of massive ascites caused by lymphatic injury after laparoscopic cholecystectomy. CASE PRESENTATION: A 63-year-old woman complained of abdominal discomfort and distension at the twelfth day after a laparoscopic cholecystectomy for gallbladder stones. Subsequently, the patient developed spontaneous bacterial peritonitis and a decreased output of urine. Abdominal computed tomography (CT) identified abdominal effusion. The patient received abdominocentesis and the volume of slightly turbid yellow ascites averaged 1500-2000 ml per day. The results of laboratory analysis of ascitic fluid showed the following: serum-ascites albumin-gradient (SAAG), 11-12 g/L; albumin, 11-14 g/L; triglycerides, 0.91 mmol/L. After the diuretic therapy, repeated large-volume paracentesis with albumin supplementation, administration of antibiotics and renal vasodilating medications, the patient's symptoms did not relieve. Lymphoscintigraphy found a small amount of radioactive filling in the abdominal cavity. The patient finally received surgery with detection and ligation of the lymphatic leak. The ascites disappeared and the patient recovered well. CONCLUSIONS: For patients with atypical characteristics of chylous ascites, lymphoscintigraphy could help to localize and qualify the diagnosis. Surgical treatment could be considered when conservative treatment fails.

First Recurrence of Synovial Sarcoma Presenting With Solitary Pancreatic Mass.

Synovial sarcoma usually presents in the lower extremities and metastasizes to the lungs; however, unusual patterns of recurrence can occur. For patients with recurrent synovial sarcoma to a proximal peripancreatic lymph node, a pancreaticoduodenectomy or Whipple procedure is the best option for a cure. Lymph node metastasis from synovial sarcoma is exceptionally rare, and data guiding the use of the Whipple procedure for curative resection of metastatic synovial sarcoma are even more sparse. In this report, we describe the management of a patient with metastatic synovial sarcoma to a proximal peripancreatic lymph node with a pancreaticoduodenectomy.

Chylous Leakage After Breast-Conserving Surgery and Axillary Clearance: Case Report and Management Strategies.

Chylous leakage is a rare complication of breast and axillary surgery. We present a case of chylous leakage inside the breast following breast-conserving surgery and axillary lymph node dissection. The majority of chylous leakages in the breast are managed with conservative measures aimed at reducing lymphatic fluid production and outflow. Surgical intervention is required in cases of conservative treatment failure and high output chylous leakage. To the best of our knowledge, this is the first case report of chyles leaks inside the breast following breast-conserving surgery that was successfully treated surgically.

Complications and their management following retroperitoneal lymph node dissection in conjunction with retroperitoneal laparoscopic radical nephroureterectomy.

OBJECTIVES: To describe the detailed perioperative complications and their management after retroperitoneal lymph node dissection with retroperitoneal laparoscopic radical nephroureterectomy for patients with upper tract urothelial carcinoma at three institutions. METHODS: Retroperitoneal lymph node dissection was performed on patients with upper tract urothelial carcinoma located at the pelvis and/or upper or middle ureter, and its template included the renal hilar and para-aortic lymph nodes (left side) and the renal hilar, paracaval, retrocaval, and intra-aortocaval lymph nodes (right side). The lymph nodes and kidneys were removed en bloc. The primary endpoint was postoperative complication rates, and the secondary endpoints were intraoperative findings and chylous leakage management. The associations of retroperitoneal lymph node dissection with postoperative complications were examined using logistic regression with propensity score techniques. RESULTS: Eighty-eight (31%) and 195 (69%) patients underwent and did not undergo retroperitoneal lymph node dissection, respectively. There was no significant difference in postoperative complications and other perioperative findings in the entire cohort, except for prolonged operation time. Retroperitoneal lymph node dissection was not statistically significantly associated with total and serious complications in propensity score analyses. Postoperative chylous leakage could be conservatively managed even though it is common in patients with retroperitoneal lymph node dissection (14/88 (16%)). The incidence of chylous leakage was significantly lower in patients whose lymphatic vessels were meticulously clipped completely during retroperitoneal lymph node dissection (5.3% vs 24%; P = 0.017). CONCLUSION: There was no association between retroperitoneal lymph node dissection with laparoscopic radical nephroureterectomy and postoperative complications. However, chylous leakage is often observed after retroperitoneal lymph node dissection and careful management is highly required. The use of clips during retroperitoneal lymph node dissection is recommended to minimize chylous leakage risk.

Percutaneous sclerosing injection to the thoracic duct under CT guidance for cervical chylous leakage post thyroidectomy: A case report.

Chylous leakage after thyroidectomy is rare, and almost all patients with this complication can be treated conservatively. However, in patients with high-flow leakage, treatments can be complicated. In this study, we report a case that was successfully treated by disrupting the thoracic duct using two sessions of percutaneous interventions. The first intervention was a thoracic duct embolization, and the second intervention was a sclerosing injection to the thoracic duct under computed tomography guidance.

Topical Application of Pseudomonas aeruginosa-Mannose Sensitive Hemagglutinin (PA-MSHA) for Refractory Lymphatic Leakage Following Lymphadenectomy in Patients with Gynecological Malignancies.

PURPOSE: To observe the feasibility and efficacy of Pseudomonas aeruginosa-mannose sensitive hemagglutinin (PA-MSHA) in refractory lymphatic leakage following lymphadenectomy among patients with gynecological cancers. PATIENTS AND METHODS: Ten cases with post-operative massive lymphatic leakage were collected, in which patients failed to respond to conservative treatment. Topical PA-MSHA injection of a single dose (2mL) was performed through drainage tube or transvaginal catheter into pelvic or peritoneal cavity. Drainage volumes and side effects were recorded. RESULTS: The incidence of refractory lymphatic leakage following pelvic and para-aortic lymphadenectomy was 2.44% (10/409). All ten patients (100%) had quick recovery and were discharged within 72 hours. Among them, one patient (10%) experienced fever and six patients (60%) experienced abdominal pain, one of which was moderate and relieved by routine analgesic treatment. During 11 (6-38) months of follow-up time, no long-term side effect was observed. CONCLUSION: Topical injection of PA-MSHA of a single dose appears a feasible and effective treatment for refractory post-operative lymphatic leakage.

Diagnosis and treatment of chylous leakage after modified radical mastectomy for breast cancer: a case report.

The post-operative complication of chylous leakage after breast cancer is relatively rare, and few clinical studies have been published. We report a 64-year-old woman with chylous leakage following modified radical mastectomy. We describe the patient's diagnostic and treatment process in detail. The patient was diagnosed with grade II (left) breast invasive ductal carcinoma. Post-operatively, the patient's chest wall and axilla were pressurized, and negative pressure drainage was initiated. On the fifth post-operative day, the drainage from the chest wall and axilla increased significantly, and the patient developed chylous leakage on the eighth postoperative day. We injected meglumine diatrizoate (100 mL) and elemene (10 mL) into the patient's axilla, and the chylous leakage gradually resolved 18 days post-operatively. In this report, we focus on managing a case of chylous leakage after modified radical mastectomy for breast cancer. Meglumine diatrizoate combined with elemene is a possible treatment for the management of this rare complication.

Chyloma: A Manifestation of Chyle Leak Six Months After Neck Dissection.

Chyle leaks after a neck dissection usually manifest within the immediate postoperative period. However, masked chyle leaks may present as a chyloma months later. A 54-year-old male patient with squamous cell carcinoma of the tongue underwent bilateral neck dissection, subtotal glossectomy, anterolateral thigh flap reconstruction and postoperative radiotherapy. Intraoperatively, chyle leak was encountered in level IV of the left neck. We managed it by ligation of the thoracic duct, application of Tisseel™ sealant (Baxter Inc., Illinois, USA) and one week of prophylactic fat-free feeds. Six months later, an asymptomatic chyloma of the left neck was identified on surveillance MRI. Five weeks after the diagnosis, streptococcal infection developed within the chyloma. However, initiation of fat-free diet, serial aspiration, pressure dressing and antibiotic therapy allowed the chyloma to resolve within two weeks. Further surveillance MRI over three years showed no recurrence of the chyloma. Low-volume chyle leaks may manifest as an occult chyloma. Prophylactic measures cannot replace meticulous ligation of chylous channels in left level IV neck dissection.

Linfografía como opción diagnóstica y terapéutica en la fuga quilosa posoperatoria de cáncer colorrectal.

La fuga quilosa es una complicación muy poco frecuente tras la cirugía colorrectal. Se presenta el caso de un paciente de 70 años con neoplasia de recto medio intervenido de forma electiva tras un ciclo largo de neoadyuvancia mediante una resección anterior de recto por laparoscopia. El cuarto día de posoperatorio presentó un drenaje pélvico de aspecto quiloso y el día 13 se confirmó la fuga quilosa en la linfografía. Posteriormente el débito se redujo de forma rápida. La linfografía no solo es un método diagnóstico, sino que en el 35-70% de los casos puede también ser terapéutica.Chylous leakage is an extremely rare complication after colorectal surgery. We report the case of a 70 year-old male with a mid-rectal cancer who underwent a laparoscopic anterior resection of the rectum after long course neoadjuvant therapy. On postoperative day 4 the patient presented with chylous pelvic drainage, and a chylous leakage was proved by lymphography on postoperative day 13. Hereinafter, the drainage was drastically reduced. The lymphography is not only a diagnostic technique, but it can be also a therapeutic method in up to 35-70% of the cases.

A case of left renal atrophy following the development of an infected giant retroperitoneal chylous cyst after laparoscopic para-aortic lymphadenectomy for endometrial cancer.

Chylous leakage is caused by interruption of lymphatic vessels carrying triglyceride-rich lymph during para-aortic lymph node dissection in patients with gynecological malignancies. Our search of literature revealed no report like our case that the renal atrophy was late onset after healing of the chylous cyst infection. A case is 60-year-old. She was preoperatively diagnosed with endometrial cancer, endometrioid carcinoma FIGO grade 3, stage IA of the FIGO system. Laparoscopic-modified radical hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymphadenectomy and partial omentectomy were performed. On the 16th postoperative day, a percutaneous drainage was performed, and revealed chylous effusion from the lymph cyst. The drainage tube was removed, and she discharged on the 34th postoperative day. On the 99th postoperative day, a follow-up plain CT to check for a recurrence of endometrial cancer revealed atrophy of left kidney. It is probable that the chylous leakage was the primary cause of renal atrophy. Therefore, it is crucial to prevent chylous leakage during surgery to avoid repeating the same complication again.

[The clinical application of gelatin sponge in prevention and treatment of chylous leakage during left neck lymph node dissection].

Objective:The aim of this study is to explore the preventive and therapeutic effects of gelatin sponge on the occurrence and development of chylous leakage by combining the biological characteristics of gelatin sponge with the mechanism of left neck lymph node dissection. Method: Eight hundred and twenty-eight patients who underwent left neck lymph node dissection in our department were retrospectively analyzed, 568 of whom underwent routine chylous leakage prevention and treatment （group A）, 260 underwent gelatin sponge tamponade fixation. The prevention and treatment of chyle leakage （group B） were analyzed. Result:Twenty-six cases of chyle leakage occurred in group A and 8 cases of chyle leakage occurred in group B. The incidence of chyle leakage in group B （3.1%） was not significantly different from that in group A （4.6%）. However, the incidence of chyle leakage within three days after operation was better than that in group A, and the amount of chyle leakage was significantly less than that in group A. The time of improving chylous leakage by positive pressure bandaging was better than that of group A, with statistical significance. Conclusion:Gelatin sponge packing can not reduce the occurrence of chyle leakage, but can delay the occurrence time of chyle leakage and reduce the amount of chyle leakage. It has a certain clinical value in the active treatment of chyle leakage.