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Thoracoscopic management of cervical thoracic duct injuries: an alternative approach
Thoracoscopic management of cervical thoracic duct injuries: An alternative approach KIRBY J. SCOTT,
LCDR, MC, USN,
and ERIC SIMKO,
LTCOL, USAF, MC,
T horacic
duct injuries and chylous fistulas are entities that can lead to serious respiratory and nutritional complications. Management of these injuries has ranged from conservative medical management, such as minimizing dietary fat intake, to operative intervention. Operative management has included exploration of the thoracic duct via open thoracotomy, sometimes using additional agents such as fibrin glue or tetracycline sclerotherapy. This article reports a case involving a persistent chyle fistula following neck dissection that was successfully managed with thoracoscopic ligation of the thoracic duct. CASE REPORT A 55-year-old woman presented to the Otolaryngology–Head and Neck Surgery Department complaining of a 2-week history of hoarseness and symptoms consistent with intermittent aspiration. In addition, the patient had noticed a large leftsided neck mass. Physical examination demon-
From the Department of Otolaryngology–Head and Neck Surgery, Naval Medical Center. Presented as a poster at the Annual Meeting of the American Academy of Otolaryngology–Head and Neck Surgery, Denver, CO, September 9-12, 2001. The views expressed are that of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government. I am a military service member. This work was prepared as part of my official duties. Title 17 U.S.C. 105 provides that ‘Copyright protection under this title is not available for any work of the United States Government.’ Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person’s official duties. Reprint requests: LCDR Kirby J. Scott, Department of Otolaryngology, Naval Medical Center Portsmouth, 27 Effingham St, Portsmouth, VA 23708-5000; e-mail, KJScott@ mar.med.navy.mil. Otolaryngol Head Neck Surg 2003;128:755-7. Copyright © 2003 by the American Academy of Otolaryngology–Head and Neck Surgery Foundation, Inc. 0194-5998/2003/$30.00 ⫹ 0 doi:10.1016/S0194-5998(03)00253-5
Portsmouth, Virginia
strated a firm, enlarged, thyroid gland with multiple enlarged lymph nodes in the left neck; the largest measured 4 cm in the left lower neck. Flexible fiberoptic laryngoscopy revealed a paralyzed left true vocal cord. A fine needle aspiration biopsy of the neck mass and the thyroid gland revealed poorly differentiated nonpapillary carcinoma, possibly Hu¨rthle cell carcinoma of the thyroid gland. Operative intervention included total thyroidectomy, left modified radical neck dissection, and bilateral level VI lymph node dissections. An intraoperative chyle leak was noted and managed with multiple suture ligations, hemoclips, and a muscle bolster (sternocleidomastoid muscle stump). The chyle leak persisted despite strict nothingby-mouth status and a pressure dressing. Total parenteral nutrition was begun on postoperative day 4, and by postoperative day 8, drain output had increased to 800 mL/d. On postoperative day 11, thoracoscopic repair of the chyle leak resulted in the successful ligation of the thoracic duct. Pathology showed poorly differentiated papillary oncocytic (Hu¨rthle cell) carcinoma with extrathyroidal extension and multiple regional nodal metastases. The patient was treated with external beam radiation therapy postoperatively but died of widely metastatic disease 10 months later. SURGICAL TECHNIQUE The technique used in the illustrative case was as follows. A double-lumen endotracheal tube was inserted at the initiation of surgery. Instillation of 60 mL of olive oil via a nasogastric tube was undertaken before placement of the patient in the left lateral decubitus position. The right lung was deflated, and selective left lung ventilation was achieved. A small incision was made at the inferior border of the scapula at approximately the eighth interspace, at the posterior axillary line. Entrance into the chest was made just over the eighth rib. A 10-mm thoracoport was placed into the chest and a 30-degree laparoscope was placed into the chest to evaluate further port site placement. Additional ports were chosen and 755
Otolaryngology– Head and Neck Surgery May 2003
756 SCOTT and SIMKO
Fig 1. Anatomic variations of the thoracic duct.
placed slightly inferior, at the ninth interspace on the anterior axillary line as well as two ports slightly more posterior, to aid with the dissection of the esophagus and retraction of the lung. After all ports were placed, the inferior portion of the right lung was grasped and the inferior pulmonary ligament was divided. The right lung was then further deflated and retracted superomedially to improve exposure of the esophagus. The diaphragmatic hiatus was identified, the esophagus was identified, and a Penrose drain was placed around the esophagus laparoscopically for retraction. Posteriorly, the pleura of the esophagus was incised
just medial to the azygous vein and lateral to the aorta. A singular tubular appearing structure with a branch point was encountered (Fig 1). This tube was identified as the thoracic duct, and 2 clips were applied. A portion of the duct was removed and confirmed by pathologic examination to be the thoracic duct. Ligation of the duct was undertaken, and smaller ductal structures were clipped once proximally and once distally before cleaning the space between the azygous vein and the aorta. Minimal dissection was carried out after inspection of the area to the left of the aorta. Evaluation of the ligated duct revealed no chyle at the site of
Otolaryngology– Head and Neck Surgery Volume 128 Number 5
the diaphragmatic hiatus. A No. 32 French chest tube was placed through the ninth anterior interspace trocar and directed anteriorly and superiorly. The lung was allowed to reinflate, and the remainder of the ports were withdrawn. Postoperatively, the wound drainage ceased immediately. The chest tube was removed on the first postoperative day, and the patient was discharged on postoperative day 6. DISCUSSION The surgical procedures available for managing patients with prolonged chylous leak include thoracotomy with ligation of the thoracic duct, pleuroperitoneal shunting, pleurodesis with talc or tetracycline, and thoracoscopy with ligation of the thoracic duct.1,2 Thoracic duct ligation via right open thoracotomy remains the traditional operative procedure for managing chylous drainage refractory to medical management. Thoracoscopic ligation offers the advantages of successful duct ligation without the morbidity associated with thoracotomy. Limited incisions, decreased postoperative pain and recovery time, and lower morbidity make a thoracoscopic approach an attractive alternative to open thoracotomy.3 Suggested guidelines dictate that surgical measures should be considered and conservative measures abandoned when the average daily loss of chyle exceeds 500 mL for a 5-day period, chyle flow has not diminished after 14 days, or serious nutritional complications are likely.4,5 After a trial of medical management with pressure dressings,
SCOTT and SIMKO 757
closed wound drainage, medium-chain triglyceride nutritional modification, and evaluation of the chylous fluid, operative intervention should be considered. If 24-hour drainage exceeds 600 to 1000 mL without response medical management should be abandoned and surgical intervention strongly considered. In conclusion, a thorough knowledge of the anatomy, physiology, and variations of the thoracic duct, as well as early recognition and appropriate management of chyle fistulas, will be more likely to result in less morbidity. With the added ease and lower morbidity of thoracoscopic ligation of the thoracic duct, thoracoscopic management should be strongly considered as a safe, costeffective, and expedient solution to a difficult surgical problem. The authors thank Jean L. Bonnette for her assistance with the figure. REFERENCES
1. Spiro JD, Spiro RH, Strong EW. The management of chyle fistula. Laryngoscope 1990;100:771-4. 2. De Gier HHW, Baim AJM, Bruining PF, et al. Systematic approach to the treatment of chylous leakage after neck dissection. Head Neck 1996;18:347-51. 3. Kent RB, Pinson TW. Thoracoscopic ligation of the thoracic duct. Surg Endosc 1993;7:52-3. 4. Nussenbaum B, Liu JH, Sinard RJ. Systematic management of chyle fistula: the Southwestern experience and review of the literature. Otolaryngol Head Neck Surg 2000;122:31-8. 5. Crosthwaite GL, Joypaul BV, Cuschieri A. Thoracoscopic management of thoracic duct injury. J R Coll Surg Edinb 1995;40:303-4.
LCDR, MC, USN,
and ERIC SIMKO,
LTCOL, USAF, MC,
T horacic
duct injuries and chylous fistulas are entities that can lead to serious respiratory and nutritional complications. Management of these injuries has ranged from conservative medical management, such as minimizing dietary fat intake, to operative intervention. Operative management has included exploration of the thoracic duct via open thoracotomy, sometimes using additional agents such as fibrin glue or tetracycline sclerotherapy. This article reports a case involving a persistent chyle fistula following neck dissection that was successfully managed with thoracoscopic ligation of the thoracic duct. CASE REPORT A 55-year-old woman presented to the Otolaryngology–Head and Neck Surgery Department complaining of a 2-week history of hoarseness and symptoms consistent with intermittent aspiration. In addition, the patient had noticed a large leftsided neck mass. Physical examination demon-
From the Department of Otolaryngology–Head and Neck Surgery, Naval Medical Center. Presented as a poster at the Annual Meeting of the American Academy of Otolaryngology–Head and Neck Surgery, Denver, CO, September 9-12, 2001. The views expressed are that of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government. I am a military service member. This work was prepared as part of my official duties. Title 17 U.S.C. 105 provides that ‘Copyright protection under this title is not available for any work of the United States Government.’ Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person’s official duties. Reprint requests: LCDR Kirby J. Scott, Department of Otolaryngology, Naval Medical Center Portsmouth, 27 Effingham St, Portsmouth, VA 23708-5000; e-mail, KJScott@ mar.med.navy.mil. Otolaryngol Head Neck Surg 2003;128:755-7. Copyright © 2003 by the American Academy of Otolaryngology–Head and Neck Surgery Foundation, Inc. 0194-5998/2003/$30.00 ⫹ 0 doi:10.1016/S0194-5998(03)00253-5
Portsmouth, Virginia
strated a firm, enlarged, thyroid gland with multiple enlarged lymph nodes in the left neck; the largest measured 4 cm in the left lower neck. Flexible fiberoptic laryngoscopy revealed a paralyzed left true vocal cord. A fine needle aspiration biopsy of the neck mass and the thyroid gland revealed poorly differentiated nonpapillary carcinoma, possibly Hu¨rthle cell carcinoma of the thyroid gland. Operative intervention included total thyroidectomy, left modified radical neck dissection, and bilateral level VI lymph node dissections. An intraoperative chyle leak was noted and managed with multiple suture ligations, hemoclips, and a muscle bolster (sternocleidomastoid muscle stump). The chyle leak persisted despite strict nothingby-mouth status and a pressure dressing. Total parenteral nutrition was begun on postoperative day 4, and by postoperative day 8, drain output had increased to 800 mL/d. On postoperative day 11, thoracoscopic repair of the chyle leak resulted in the successful ligation of the thoracic duct. Pathology showed poorly differentiated papillary oncocytic (Hu¨rthle cell) carcinoma with extrathyroidal extension and multiple regional nodal metastases. The patient was treated with external beam radiation therapy postoperatively but died of widely metastatic disease 10 months later. SURGICAL TECHNIQUE The technique used in the illustrative case was as follows. A double-lumen endotracheal tube was inserted at the initiation of surgery. Instillation of 60 mL of olive oil via a nasogastric tube was undertaken before placement of the patient in the left lateral decubitus position. The right lung was deflated, and selective left lung ventilation was achieved. A small incision was made at the inferior border of the scapula at approximately the eighth interspace, at the posterior axillary line. Entrance into the chest was made just over the eighth rib. A 10-mm thoracoport was placed into the chest and a 30-degree laparoscope was placed into the chest to evaluate further port site placement. Additional ports were chosen and 755
Otolaryngology– Head and Neck Surgery May 2003
756 SCOTT and SIMKO
Fig 1. Anatomic variations of the thoracic duct.
placed slightly inferior, at the ninth interspace on the anterior axillary line as well as two ports slightly more posterior, to aid with the dissection of the esophagus and retraction of the lung. After all ports were placed, the inferior portion of the right lung was grasped and the inferior pulmonary ligament was divided. The right lung was then further deflated and retracted superomedially to improve exposure of the esophagus. The diaphragmatic hiatus was identified, the esophagus was identified, and a Penrose drain was placed around the esophagus laparoscopically for retraction. Posteriorly, the pleura of the esophagus was incised
just medial to the azygous vein and lateral to the aorta. A singular tubular appearing structure with a branch point was encountered (Fig 1). This tube was identified as the thoracic duct, and 2 clips were applied. A portion of the duct was removed and confirmed by pathologic examination to be the thoracic duct. Ligation of the duct was undertaken, and smaller ductal structures were clipped once proximally and once distally before cleaning the space between the azygous vein and the aorta. Minimal dissection was carried out after inspection of the area to the left of the aorta. Evaluation of the ligated duct revealed no chyle at the site of
Otolaryngology– Head and Neck Surgery Volume 128 Number 5
the diaphragmatic hiatus. A No. 32 French chest tube was placed through the ninth anterior interspace trocar and directed anteriorly and superiorly. The lung was allowed to reinflate, and the remainder of the ports were withdrawn. Postoperatively, the wound drainage ceased immediately. The chest tube was removed on the first postoperative day, and the patient was discharged on postoperative day 6. DISCUSSION The surgical procedures available for managing patients with prolonged chylous leak include thoracotomy with ligation of the thoracic duct, pleuroperitoneal shunting, pleurodesis with talc or tetracycline, and thoracoscopy with ligation of the thoracic duct.1,2 Thoracic duct ligation via right open thoracotomy remains the traditional operative procedure for managing chylous drainage refractory to medical management. Thoracoscopic ligation offers the advantages of successful duct ligation without the morbidity associated with thoracotomy. Limited incisions, decreased postoperative pain and recovery time, and lower morbidity make a thoracoscopic approach an attractive alternative to open thoracotomy.3 Suggested guidelines dictate that surgical measures should be considered and conservative measures abandoned when the average daily loss of chyle exceeds 500 mL for a 5-day period, chyle flow has not diminished after 14 days, or serious nutritional complications are likely.4,5 After a trial of medical management with pressure dressings,
SCOTT and SIMKO 757
closed wound drainage, medium-chain triglyceride nutritional modification, and evaluation of the chylous fluid, operative intervention should be considered. If 24-hour drainage exceeds 600 to 1000 mL without response medical management should be abandoned and surgical intervention strongly considered. In conclusion, a thorough knowledge of the anatomy, physiology, and variations of the thoracic duct, as well as early recognition and appropriate management of chyle fistulas, will be more likely to result in less morbidity. With the added ease and lower morbidity of thoracoscopic ligation of the thoracic duct, thoracoscopic management should be strongly considered as a safe, costeffective, and expedient solution to a difficult surgical problem. The authors thank Jean L. Bonnette for her assistance with the figure. REFERENCES
1. Spiro JD, Spiro RH, Strong EW. The management of chyle fistula. Laryngoscope 1990;100:771-4. 2. De Gier HHW, Baim AJM, Bruining PF, et al. Systematic approach to the treatment of chylous leakage after neck dissection. Head Neck 1996;18:347-51. 3. Kent RB, Pinson TW. Thoracoscopic ligation of the thoracic duct. Surg Endosc 1993;7:52-3. 4. Nussenbaum B, Liu JH, Sinard RJ. Systematic management of chyle fistula: the Southwestern experience and review of the literature. Otolaryngol Head Neck Surg 2000;122:31-8. 5. Crosthwaite GL, Joypaul BV, Cuschieri A. Thoracoscopic management of thoracic duct injury. J R Coll Surg Edinb 1995;40:303-4.