thoracic duct injury in neck dissection
TRANSCRIPT
![Page 1: Thoracic duct injury in neck dissection](https://reader035.vdocuments.us/reader035/viewer/2022062400/589fabe21a28abc04e8b6ded/html5/thumbnails/1.jpg)
THORACIC DUCT INJURY IN NECK DISSECTIONDR AJAY MANICKAMFELLOW , DEPT OF HEAD AND NECK SURGICAL ONCOLOGYTATA MEDICAL CENTRE, KOLKATA
![Page 2: Thoracic duct injury in neck dissection](https://reader035.vdocuments.us/reader035/viewer/2022062400/589fabe21a28abc04e8b6ded/html5/thumbnails/2.jpg)
THE THORACIC DUCT•Body’s largest Lymphatic conduit•Draining upwards about 75% of
lymphatic fluid - nearly 2-4 L Lymphatic fluid/day•Cisterna Chyli – Lt Jugulovenous angle.•40-60%
![Page 3: Thoracic duct injury in neck dissection](https://reader035.vdocuments.us/reader035/viewer/2022062400/589fabe21a28abc04e8b6ded/html5/thumbnails/3.jpg)
Normal Anatomy• Cisterna chyli (T12-L2)• Rt – Lt (T5-T6)
![Page 4: Thoracic duct injury in neck dissection](https://reader035.vdocuments.us/reader035/viewer/2022062400/589fabe21a28abc04e8b6ded/html5/thumbnails/4.jpg)
Clinically Relevant variations
![Page 5: Thoracic duct injury in neck dissection](https://reader035.vdocuments.us/reader035/viewer/2022062400/589fabe21a28abc04e8b6ded/html5/thumbnails/5.jpg)
Thoracic duct Embryology• Lymphatic system – 6th week of life – Haemangioblastic stem
cells.• Lymph node formation – 9th week of life• Concurrent regression of previously formed plexus. • One duct remains – drains lymphatics of lower body, Lt Head,
Lt Arm – LT Jugular Subclavian axis. • Lower 2/3rd thoracic duct – Rt embryonic duct• Upper 1/3rd thoracic duct – Lt embryonic duct
![Page 6: Thoracic duct injury in neck dissection](https://reader035.vdocuments.us/reader035/viewer/2022062400/589fabe21a28abc04e8b6ded/html5/thumbnails/6.jpg)
Thoracic duct disruption and Injury• 1) Direct Trauma and Laceration of the Thoracic Duct• 2) Occlusion of the Thoracic duct with concurrent leaky
collaterals.
![Page 7: Thoracic duct injury in neck dissection](https://reader035.vdocuments.us/reader035/viewer/2022062400/589fabe21a28abc04e8b6ded/html5/thumbnails/7.jpg)
Intra operative assesment• Chyle flow/ second – couple of drops• Cernea et al – Manual Abdominal Compression
Maneuver allowed visualization of thoracic duct leak at the end of nec dissection involving level 4. • Pharyngo esohageal resection and reconstruction, post
op salivary leaks may mimic chyle leak. • Oral methylene blue administration
15 mins – stain in neck – salivaChyle – 1-4hours later
![Page 8: Thoracic duct injury in neck dissection](https://reader035.vdocuments.us/reader035/viewer/2022062400/589fabe21a28abc04e8b6ded/html5/thumbnails/8.jpg)
Chylous fistula management after neck dissection• Incidence – 0.62% - 6.2% ( Corrado C Campisi et al)• Incidence was more with B/L Neck dissection• No specific universal international treatment guidelines
Non surgical management
Surgical management
![Page 9: Thoracic duct injury in neck dissection](https://reader035.vdocuments.us/reader035/viewer/2022062400/589fabe21a28abc04e8b6ded/html5/thumbnails/9.jpg)
Non surgical management•Nutritional approaches• Somatostatin analogs - octreotide•Negative pressure wound therapy
![Page 10: Thoracic duct injury in neck dissection](https://reader035.vdocuments.us/reader035/viewer/2022062400/589fabe21a28abc04e8b6ded/html5/thumbnails/10.jpg)
Nutritional approaches• Aim – Decrease the production and flow of
Lymph – Preventing malnutrition (1900-2000 kcal/day & 100gm protein in diet/ according to body wt)• LFD ( Low Fat Diet) / FFD ( Fat Free Diet)• Enteral nutrition with specialized formula• Parenteral support without oral intake
![Page 11: Thoracic duct injury in neck dissection](https://reader035.vdocuments.us/reader035/viewer/2022062400/589fabe21a28abc04e8b6ded/html5/thumbnails/11.jpg)
Problems • How much fat is acceptable to promote closure??• Essential fatty acids, multivitamins, minerals –
nutritional status - may need to be added • MCT ( Medium chain Triglycerides) - transported
via portal vein.• But studies also show – increased output
drainage – with MCT
![Page 12: Thoracic duct injury in neck dissection](https://reader035.vdocuments.us/reader035/viewer/2022062400/589fabe21a28abc04e8b6ded/html5/thumbnails/12.jpg)
Literature suggestions (Stager et al, Jensen et al, Benedix et al)• Output - <0.5L/day – low fat, semi elemental
formula• Output - >0.5L/day – elemental formula• Output - >1L/day – TPN > LFD• Intravenous lipid emulsions – IVLE – source of
calories / EFA – bypass chyle flow – not contribute to chyle flow
![Page 13: Thoracic duct injury in neck dissection](https://reader035.vdocuments.us/reader035/viewer/2022062400/589fabe21a28abc04e8b6ded/html5/thumbnails/13.jpg)
Somatostatin analogs (Coskun et al, Barilli e al)
•Octreotide – act on endorine and paracrine pathway•Minimize excretion of lymphatic products
![Page 14: Thoracic duct injury in neck dissection](https://reader035.vdocuments.us/reader035/viewer/2022062400/589fabe21a28abc04e8b6ded/html5/thumbnails/14.jpg)
Negative pressure wound therapy(Kadota et al)•Low pressure 50mmHg – to avoid an unwanted increase in drainage. •Mainly used in low output fistulas complex poor healing wounds.
![Page 15: Thoracic duct injury in neck dissection](https://reader035.vdocuments.us/reader035/viewer/2022062400/589fabe21a28abc04e8b6ded/html5/thumbnails/15.jpg)
SURGICAL MANAGEMENT• Output greater than 1 L - high output• Larygectomized pt with leak more than 5 days –
surgery needed (Stager et al)• Cerfolio et al recommends – ‘fatty meal test’ – if
output remains low from chyle leak for 2 days after the meal, tube can be removed. If the output increases or persists after the fatty meal – surgical intervention
![Page 16: Thoracic duct injury in neck dissection](https://reader035.vdocuments.us/reader035/viewer/2022062400/589fabe21a28abc04e8b6ded/html5/thumbnails/16.jpg)
Thoracic duct ligation (Ilczyszyn et al)•Open thoracotomy/ Thoracoscopic
approach• Rt sided approach – occlusion of
thoracic duct by mass ligation of tissue above the supra diaphragmatic hiatus between the azygos vein and the aorta.
![Page 17: Thoracic duct injury in neck dissection](https://reader035.vdocuments.us/reader035/viewer/2022062400/589fabe21a28abc04e8b6ded/html5/thumbnails/17.jpg)
Therapeutic Lymphography• Alenjandre Lafront et al – Therapeutic
aplication using a contrast solution of lidocaine and 5ml of methylene blue dye and lipiodol to occlude lymphatic leaks.• Lipiodol – irrigating and inflammatory
effect at the leakage site.
![Page 18: Thoracic duct injury in neck dissection](https://reader035.vdocuments.us/reader035/viewer/2022062400/589fabe21a28abc04e8b6ded/html5/thumbnails/18.jpg)
Locoregional flaps (Cernea et al)
•Myofascial flaps – pectoralis major / clavicular head of the sternocleidomastoid muscle.
![Page 19: Thoracic duct injury in neck dissection](https://reader035.vdocuments.us/reader035/viewer/2022062400/589fabe21a28abc04e8b6ded/html5/thumbnails/19.jpg)
Lymphatic venous anastomosis•Healthy appearing lymphatic found at the site of surgical incision are selected and directly introduced into the cut end of a recipient vein (external/internal jugular vein) by a U stitch
![Page 20: Thoracic duct injury in neck dissection](https://reader035.vdocuments.us/reader035/viewer/2022062400/589fabe21a28abc04e8b6ded/html5/thumbnails/20.jpg)
Thoracic duct embolization - Pedal Lymphangiography• Magnetic resonance ductography - embolization planning• T2 weighed images are obtained in axial and coronal images. • Location of cisterna chyli and configuration of thoracic duct
![Page 21: Thoracic duct injury in neck dissection](https://reader035.vdocuments.us/reader035/viewer/2022062400/589fabe21a28abc04e8b6ded/html5/thumbnails/21.jpg)
Intra nodal lymphangiography
![Page 22: Thoracic duct injury in neck dissection](https://reader035.vdocuments.us/reader035/viewer/2022062400/589fabe21a28abc04e8b6ded/html5/thumbnails/22.jpg)
Success rates•79%• Success rates higher with traumatic
cases
![Page 23: Thoracic duct injury in neck dissection](https://reader035.vdocuments.us/reader035/viewer/2022062400/589fabe21a28abc04e8b6ded/html5/thumbnails/23.jpg)
(N Butyl – 2 – cyanoacrylate) Tissue glue in thoracic duct injury during Neck dissection• Area dried with guaze , chloramphenicol 1%
eye ointment was applied to Internal Jugular vein, carotid artery and vagus nerve • Maximum of 1 ml solution was applied over
the suspected area using sterile applicator. (Blythe et al British Journal of OMFS)
![Page 24: Thoracic duct injury in neck dissection](https://reader035.vdocuments.us/reader035/viewer/2022062400/589fabe21a28abc04e8b6ded/html5/thumbnails/24.jpg)
Conclusion • Conservative measures • Management depends on individual case• Functional repair of the thoracic duct injury
should be preferred solution rather than an approach that oblitertes the thoracic duct – lymphatic – chylous pathway, as this can cause unwanted consequences – redistribution of flow - distal complications
![Page 25: Thoracic duct injury in neck dissection](https://reader035.vdocuments.us/reader035/viewer/2022062400/589fabe21a28abc04e8b6ded/html5/thumbnails/25.jpg)
References
![Page 26: Thoracic duct injury in neck dissection](https://reader035.vdocuments.us/reader035/viewer/2022062400/589fabe21a28abc04e8b6ded/html5/thumbnails/26.jpg)