Dr.Raad Al- Saffar,C.A.B.S - PowerPoint Presentation

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Dr.Raad Al-Saffar,C.A.B.S consultant laparoscopic and thyroid surgeonDr.Tarik Al-Shimmery, F.I.C.M.S. senior vascular surgeonDr.Humam Alaa ,MBChB,senior resident of general surgery.

Chylous

fistula after total thyroidectomy and radical lymph node dissection for anaplastic thyroid carcinoma

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40 years old female patient , she is a known case of anaplastic thyroid cancer which diagnosed one month ago after she had a neck swelling and addmitted for surgery . At first operation ( done by another surgeon) who did only biopsy and left tumor in situ.The histopathology result was anaplastic thyroid carcinoma.Imaging investigations were done for reassesment.

Case summary

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She had been addmitted for total thyroidectomy and neck dissection after preparation .General anesthesia with endotracheal tube was given.Supine position and hyperextention of the neck with mild degree head elevation.Collar incision extended bilaterally parallel to anterior border of sternomastoid muscle up to angle of the mandible.Upper and lower skin flaps were done. Operative notes

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Total thyroidectomy done with radical left lymph node neck dissection and selective right lymph node dissection: done by Dr. Raad Al-Saffar (thyroid surgeon) and Dr. Tarik Al-Shimmery(vascular surgeon)Removing of all areolar tissues and lymph nodes at levels 2 ,3 , 4, 5 and 6.Operative procedure

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The vocal cords were normal on immediate postoperative examination.blood transfuion , aitibiotics and analgesia were given.Day 1 was uneventfull the drain content was serosanguineous discharge about 100 cc. per day.The patient discharged home at day 3 with drain of serous content of about 150 cc. per day.

After 5 days drain was removed with few

milleliters

of serous fluid.

At day 6 patient develop

shotness

of breath and neck swelling.

On examination there is

subcutaneos

fluid collection.

She

addmitted

and the drain inserted under local aneasthesia at site of previous drain. The discharge was thick and milky, first drainage about 300 ml.

Post operative follow up

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So the diagnosis was chylous leak …..The discharge was increased with oral feeding so we started trial of fat free diet and discharge amount decreased to 200 ml per day …..After that she was discharged home with drain and advised to come back 3 days later ….Five days later she was addmitted because of continues and increased leak with generalized

weakness and mild fever.

Braod

spectrum antibiotics was given with analgesia.

T

he leak was about 600 ml/24

hrs

and we started TPN with

intralipid

(MCT) and

vamin

as well as

somatostatin

subcutaneous injection.

 

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The discharge decreased gradually and stopped after 7 days of conservative treatment and drain was removed.The patient referred to the oncology center for chemoradiation.

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CHYLOUS FISTULA OF THE NECK

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Alkaline,milky, odourless fluid2-4L produced everyday1 liter of chyle contain :200 kcal20-30 g of protein5-30 g of fat

What is

Chyle

?

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Complication rate 1 - 2.5% of neck dissection involving level IV.predilection for the left side of the neck, but up to 25% of cases involve the right side of the neck.FREQUENCY

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Post operative complicationRadical neck dissectionSelective neck dissectionAnterior neck surgeryPenetrating traumaLymph node biopsyCervical rib excisionETIOLOGY

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95% of ingested fats are triglycerides with long chain fatty acids (LCT). These fats are re-esterified in the mucosal cells of the bowel wall, combined with an apolipoprotein and phospholipid and transported into the lymphatic system as chylomicrons.Middle chain fatty acids (MCTs), length C12 or less, are absorbed directly into the portal system without the formation of chylomicrons, bypassing the lymphatics; this is important in dietary therapy of chylous fistulas.

FAT METABOLISM

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The thoracic duct is the conduit for lymph and dietary fat to reach the venous bloodstream. The flow of chyle is around 2-4 L per day

Consists of fat 1-3% composed of TG (70% long chain), protein(3%), electrolytes content is the same as plasma except of lower calcium concentration, and lymphocytes (T lymphocyte).

Its daily production is dependent on the diet and daily dietary intake

.

PATHOPHYSIOLOGY

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HypoproteinemiaHyponatremiaHypochloremiaDehydrationEmaciation Lymphocytopenia and

immunosupression

Pleural effusion -

chylothorax

Wound problems - infection, suture breakdown, hemorrhage

Peripheral

edema

Secondary sepsis

The challenges in patient with

chyle

leak

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Outline of management Nutritional modificationMedical managementSurgical managementMANAGEMENT OF CHYLE FISTULA

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Goals of therapyReduce chyle fluid productionReplace fluid and electrolytesMaintain replete nutritional status and prevent malnutritionNutritional Management

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Nutrition interventionFat free diet supplemented with MCTTPNAdequate protein intakeChyle contains significant amounts of protein (22–60 g/L)

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It decreases the intestinal absorption of fats, therefore TG concentration in the thoracic duct is lowered.Somatostatin reduces gastric, pancreatic and intestinal secretion.

It inhibit the motor activity of the intestine

slows the process of intestinal absorption

reduces splanchnic blood flow

decreases hepatic venous pressure

Somatostatin

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Local procedures– reexploration of wound site after fat rich diet.And suturing with non absorbable suture or clips and local flap.Vicryl mesh overlay has been described.Thoracoscopic ligation of TD. Right sided approachSURGICAL MANAGEMENT

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Question & Answerfrom(Rush)

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A 61-year-old man with T3N2cM0 SCC of the supraglottic larynx undergoes total laryngectomy with left radical neck dissection / right modified radical neck dissection and primary pharyngeal closure without any intraoperative complications. Tube feeding is started on postoperative day 2. On day 3 the patient

is noted to have increasingly high output of

yellow/cloudy

fluid from the left neck drain recorded to be 400

mL over

the past 24 hours

.

The hemoglobin concentration

and white

blood cell count are stable.

The

patient is afebrile

with no

signs of infection at the surgical site. What is the next most appropriate step in management?A. Immediate reexploration and closure of the pharyngealFistula.B. Thoracotomy with clamping of the thoracic duct.

C. Closed wound drainage, pressure dressings, and

tube

feeding consisting of medium-chain

triglycerides.

D. Continuation of the current postoperative

management.

E. Removal of the left neck drain with a pressure dressing

applied to the

wound.

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This patient has a chylous fistula. The initiation of tube feeding provided lipids to the lymphatic system, which increased the volume of chyle flow. Pharyngeal fistulas do not generally develop this early in the postoperative course and do not usually

have such extremely high drain output

.

However, it

is always

something to consider after a pharyngeal repair

.

Chylous

fistulas

typically occur in the left side of the neck during

radical neck

dissections when dissecting low in the level IV/V region. The incidence is about 1% to 2%. If recognized at the time of surgery, they should be repaired immediately with ligature. If they occur in delayed

fashion, such as in this patient, they

can usually be initially managed conservatively, as stated in choice C.

comment

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The rationale for using medium-chain triglycerides is that they are absorbed directly through the portal circulation and not the lymphatic system. Another nutritional alternative in more severe cases is the use of total parenteral nutrition. In regard to deciding on surgical management, a general guideline accepted by many physicians is greater than 600 mL of output over a 24-hour period. Reexploration with control of the leak can be very difficult given the delicate nature of lymphatic tissue.

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A N S W E R : C