Percutaneous treatment of thoracic duct injuries

Background  

Major thoracic or neck surgery or penetrating trauma can cause injury to the thoracic duct and development of a chylothorax. Chylothorax results in metabolic and immunologic disorders that can be life threatening, with a mortality rate reaching 50%. The management of chyle leaks is dependent on the etiology and daily output. Interventions are used to treat only leaks unresponsive to medical management or those with an output exceeding 1,000 ml/day.     

Complications of thyroid surgery

Background: The morbidity of thyroid surgery is low. Despite this, some authors advocate a subtotal thyroidectomy instead of a total thyroidectomy, to avoid the higher morbidity associated with a total thyroidectomy. Methods: We retrospectively evaluated the complications of thyroid surgery in Leiden between January 1, 1982 and October 1, 1990. Three hundred forty-one patients—261 women and 80 men—had 356 operations; 15 patients were operated on twice; there were 152 total hemithyroidectomies, 3 subtotal hemithyroidectomies, 33 total thyroidectomies, 122 bilateral subtotal hemithyroidectomies, 12 combinations of total and subtotal hemithyroidectomies, and 34 other operations. Results: Calculated for the nerves at risk (n=489), the percentage of permanent recurrent nerve lesions was 3.1 (in the 5 most recent years it was 1.2%). There was no significant difference between total or subtotal (hemi)thyroidectomies. Initial symptomatic hypocalcemia necessitating supplementation was encountered 42 times (12.5%). The occurrence of permanent symptomatic hypocalcemia (6%) was not significantly different between total and subtotal (hemi)thyroidectomies (p=0.06). The duration of surgery was 137.8 min for bilateral subtotal thyroidectomies and 182.9 min for bilateral total thyroidectomies (p<0.0001). There was no difference in blood loss between total and subtotal (hemi)thyroidectomies. Conclusions: Because total thyroidectomy carries a risk of complications similar to that for subtotal thyroidectomy, it is not logical to avoid total resections. If the number of total resections were increased, it is anticipated that fewer reoperations, which involve a relatively high morbidity rate, would have to be performed.Results of this work were presented at the 46th Annual Cancer Symposium of The Society of Surgical Oncology, Los Angeles, March 18–21, 1993.     

Complications of thyroid surgery

Thyroid surgery has a history of significant changes in the technique and the incidence of complications. Since then continuous developments in surgical techniques and better understanding of thyroid anatomy and pathology have increased the safety of thyroid surgery and reduced the incidence of complications. Nowadays, the rate of postoperative mortality is extremely low. Nevertheless, the incidence of postoperative complications varies in literature from 7.4% to 53% of the operations performed. The most common and potentially life-threatening complications in thyroid gland surgery are vocal cord palsy and hypocalcemia. Herein we discuss the common complications in thyroid gland surgery and their proper management.     

Complications in thyroid surgery

Thyroidectomy is one of the most frequently performed surgical procedure worldwide, even if the risks of lethal postoperative complications prevented its evolution and diffusion until the beginning of the XX century. At that time, T. Kocher described his meticulous technique, reporting excellent results in terms of mortality and morbidity. At present, mortality for this procedure approaches 0% and overall complication rate is less than 3%. Nonetheless, major complications of thyroidectomy (i.e. compressive hematoma, recurrent laryngeal nerve palsy and hypoparathyroidism) are still fearful complications and account for a significant percentage of medico-legal claims. Patients volume and surgical skill play an important role in reducing the risk of complications. Accurate knowledge of anatomy and pathophysiology, complications incidence and pathogenesis and a careful surgical performance are essential. In this review, post-thyroidectomy complications basing on literature analysis and personal experience are described. The main anatomical, technical and pathophysiological factors that help preventing post-thyroidectomy complications are analyzed, taking into proper account new technologies and the minimally invasive surgical procedures that influenced thyroid surgery during the last decade.     

Major surgery in thoracic injuries

Chest injuries have a high and steadily increasing incidence in western countries, but only some of the most common problems they create require an emergency thoracotomy or surgical video thoracoscopy. Flail chest, persistent pneumothorax, massive haemothorax, mediastinal emphysema, cardiac tamponade and intrathoracic foreign bodies can be identified as major surgical problems. Some of such patients (i.e. those with flail chest or foreign bodies) would be immediately candidates for major intervention. Other require fast but diagnostic procedures, because the choice of a therapy is dependent upon a precise identification of the damage. Injuries of trachea and primary bronchi, oesophagus, diaphragma, vena cava, great lung vessels, heart and aorta may represent important surgical emergencies; some leading rapidly to death. Fortunately, major surgical procedures are not really frequent in the management of thoracic traumas. Only 42 (3.5%) of nearly 2,000 patients with non-penetrating thoracic injuries had a thoracotomy or an surgical video thoracoscopy. The figure is far different for penetrating wounds; in fact 12 patients (41%) of 29 underwent mayor surgery.     

Octreotide in the treatment of thoracic duct injuries

Anecdotal reports support the use of octreotide in the treatment of traumatic thoracic duct injuries and chylothorax, but no prospective studies have proved its efficacy. We evaluated the effects of octreotide in treating thoracic duct transection in a canine model. Eight mongrel dogs (27.8+/-5.1 kg) were fed one pint of 10.5 per cent milkfat 2 hours before operation. Through a left supraclavicular neck incision, the thoracic duct was identified and transected, producing free flow of chyle. A quarter-inch drain was tunneled subcutaneously from the wound and attached to closed suction. After wound closure dogs were randomized to a control group (n = 4) receiving sham injections of saline subcutaneously three times per day, or a treatment group (n = 4) given 3 microg/kg octreotide three times per day. Postoperatively all dogs were fed a standard low-fat (5-7%) crude fat diet. Drain output was measured each day, and on odd-numbered postoperative days the drainage was analyzed for cholesterol, triglycerides, albumin, and total protein. Fistula closure was defined as drainage <10 ml/24-hour period. Treated dogs achieved fistula closure significantly faster than controls: 3.5+/-1.3 days versus 7.8+/-1.0 days (P = 0.0037). Whereas equivalent amounts of drainage occurred on the day of surgery and on postoperative day one in both groups, by postoperative day 2 the treatment group had significantly less drainage over 24 hours: 63+/-69 ml versus 195+/-79 ml (P = 0.046); this significant difference persisted through postoperative day 5 when drainage began to decrease in the control group. No significant differences between groups were seen in levels of cholesterol, triglycerides, albumin, or protein in the drainage at any time point. We conclude that octreotide is effective in treating thoracic duct injury, leading to an early decrease in drainage and early fistula closure. The mechanism for this effect remains to be clarified.     

Management of thoracic duct injuries after oesophagectomy.

BACKGROUND: Thoracic duct laceration is a rare but potentially life-threatening complication of oesophagectomy. The management of such an injury is uncertain in respect of the relative merits of conservative and surgical treatment. METHODS: The literature was reviewed by searching Medline databases from 1966 to the present time. The majority of the evidence presented is level 3, as no randomized or controlled data are available. RESULTS: Prolonged conservative treatment of thoracic duct injury is associated with a mortality rate of 50-82 per cent. The results of early surgical ligation of the duct are more encouraging, with a mortality rate of 10-16 per cent. Elective ligation of the duct reduces the incidence of postoperative chylothorax. CONCLUSION: The thoracic duct should be ligated during oesophagectomy. A high index of suspicion for duct injury must be maintained in all patients after operation. A policy of very early thoracic duct ligation at 48 h from diagnosis is proposed for duct injury if aggressive conservative management fails.     

Life threatening presentation of thoracic duct injury post thyroid surgery; a case report

BackgroundInjury to thoracic duct is a rare potential complication of time-honored conventional thyroidectomy. Nevertheless, it can be a cause of significant morbidity, and sometimes life-threatening.Patient findingsA 78-year-old female patient with a previous surgical history of thyroid lobectomy for nodular disease presented with primary hyperparathyroidism, and a nodule in the remaining thyroid lobe. The patient underwent completion thyroidectomy and parathyroidectomy. Less than 24 h post operatively, the patient developed progressive shortness of breath and neck swelling requiring immediate intubation and re-exploration. A large amount of chyle was drained and an injured thoracic duct was identified and ligated.SummaryIn experienced hands thyroid surgery is safe. Nevertheless, factors such as the type of pathology and its extent, the level of surgery, and re-operative surgery increase the risk of postoperative complications. Immediate surgical exploration is necessary when patients present with neck swelling and respiratory distress. In our case, a high output chyle leak in a confined space was life threatening.ConclusionTimely re-exploration following thyroid surgery and thorough knowledge of the anatomy of neck structures is crucial in sparing patients potential morbidity and/or mortality.     

Complications of surgery for thoracic outlet syndrome

Having read through the previous litany of potential disasters and complications, one could ask the obvious question, "Why would anyone want to do this kind of surgery?" The answer is that most people elect not to! Nevertheless, for those who decide to venture into this field, there is the tremendous reward of being able to help patients who would otherwise continue to live with extremely disabling and disheartening symptoms. A sound knowledge of the regional anatomy and tutelage by those knowledgeable in particular areas of surgery that may not have been a part of the individual surgeon's prior training is essential. The author was fortunate to have the help of a very accomplished and generous vascular surgeon, Dr. William Abbott of the Massachusetts General Hospital for many months when I began on what I have considered a fascinating and intellectually rewarding odyssey.     

Case report of a cervical thoracic duct cyst

After a number of anatomical considerations regarding the thoracic duct and the diseases that may affect it, the authors report that, in the literature, such cystic lesions of an iatrogenic nature are extremely rare in the cervical area. After discussing the diagnostic methods for a correct preoperative diagnosis, they address the surgical technique they used for removal of the lesion.     

Damage control surgery for thoracic injuries

Damage control of thoracic injuries begins frequently with an emergency department thoracotomy via an anterolateral incision. Bleeding and air leaks are quickly temporised. As opposed to abdominal damage control where most injuries can be temporised, most thoracic injuries require initial definitive repair. Thus, the goal of thoracic damage control is to perform the least definitive repair using the fastest and easiest techniques to shorten the operative time as much as possible. There are some injuries that can be temporised and require re-operation once physiologic normality has been achieved.