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Management_of_Chyle_leak_following_Thoracic_duct_injury_.pptx

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Morbidity & Mortality Meeting November 2019 Wd 23/29 NHSL Dr Rohan Jayawardena Registrar in General Surgery 18/12/19
Audit • Ward 23 Admissions + Transfer in – 355 Mortality - 02 • Ward 29 Admissions + Transfer in – 322 Mortality - 02 • Clavien – Dindo Classification – Grade II
Mrs P G Lasanthi, 34yrs old female from Kahathuduwa Thyroid goiter for 4 months USS – L/S Thyroid nodule +Level III LN FNAC - ? Medullary/Hurthle cell CA S.Ca2+ S.Calcitonin NAD 24hr Urinary Metanephrines USS Abd
Total Thyroidectomy + L/S Selective Neck Dissection done • Level VI LN clearance done • L/S Level II, III, IV, Vb • 2 drains placed – Thyroid bed & Posterior Triangle • Histology – Papillary CA + 5/25 LN positive
• Post op Day 1 – No voice change No hypocalcemic features Drain = 95ml • Post op Day 3 – Drain = 315ml ? Chyle leak • Post op Day 5 – Drain = 650 ml – High output chyle leak (>500ml)
Conservative Management • Prop up – 45o • S/C Octreotide 100 mcg tds • Nutritional referral – Medium chain fatty acid diet • IV Cefuroxime 750mg tds • Lactulose • Tight dressing • Suction drain • Hydration • No hyponatremia, hypochloremia & clotting derangement
Management_of_Chyle_leak_following_Thoracic_duct_injury_.pptx
• Post op Day 8 – Drain = 300 ml • Post op Day 12 – Drain = 120 ml • Post op Day 21 – Drain = Nil • Post op Day 23 - Discharged
Root Cause Analysis T.T + L/S Functional Neck Dissection Chyle Leak (High out put) Conservative Management Chyle leak persists Chyle leak persists Surgical exploration 1)Transabdominal embolization 2)Thoracoscopic ligation 1)Low Fat Diet 2)Remove drain 3)Octreotide additional 2 days Yes No
Literature Review • Intraoperative identification Valsalva maneuver Manual abdominal compression • Conservative management Diet – MCFA + Orlistat TPN – High out put Compression dressing – controversial Octreotide • Topical agents – Sclerosing agents Fibrin glue
Literature Review cont • Surgical interventions – High out put > 5days/ no prompt response to medical Mx Re-exploration Ligation of Thoracic duct Cover with muscle flap Distal embolization – success rate 45-70 % Thoracoscopic ligation of Thoracic duct
Literature Review cont. • Retrospective study • Octreotide therapy appears superior to traditional conservative measures • Reduce hospital stay • 1st line conservative management
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Management_of_Chyle_leak_following_Thoracic_duct_injury_.pptx

  • 1. Morbidity & Mortality Meeting November 2019 Wd 23/29 NHSL Dr Rohan Jayawardena Registrar in General Surgery 18/12/19
  • 2. Audit • Ward 23 Admissions + Transfer in – 355 Mortality - 02 • Ward 29 Admissions + Transfer in – 322 Mortality - 02 • Clavien – Dindo Classification – Grade II
  • 3. Mrs P G Lasanthi, 34yrs old female from Kahathuduwa Thyroid goiter for 4 months USS – L/S Thyroid nodule +Level III LN FNAC - ? Medullary/Hurthle cell CA S.Ca2+ S.Calcitonin NAD 24hr Urinary Metanephrines USS Abd
  • 4. Total Thyroidectomy + L/S Selective Neck Dissection done • Level VI LN clearance done • L/S Level II, III, IV, Vb • 2 drains placed – Thyroid bed & Posterior Triangle • Histology – Papillary CA + 5/25 LN positive
  • 5. • Post op Day 1 – No voice change No hypocalcemic features Drain = 95ml • Post op Day 3 – Drain = 315ml ? Chyle leak • Post op Day 5 – Drain = 650 ml – High output chyle leak (>500ml)
  • 6. Conservative Management • Prop up – 45o • S/C Octreotide 100 mcg tds • Nutritional referral – Medium chain fatty acid diet • IV Cefuroxime 750mg tds • Lactulose • Tight dressing • Suction drain • Hydration • No hyponatremia, hypochloremia & clotting derangement
  • 8. • Post op Day 8 – Drain = 300 ml • Post op Day 12 – Drain = 120 ml • Post op Day 21 – Drain = Nil • Post op Day 23 - Discharged
  • 9. Root Cause Analysis T.T + L/S Functional Neck Dissection Chyle Leak (High out put) Conservative Management Chyle leak persists Chyle leak persists Surgical exploration 1)Transabdominal embolization 2)Thoracoscopic ligation 1)Low Fat Diet 2)Remove drain 3)Octreotide additional 2 days Yes No
  • 10. Literature Review • Intraoperative identification Valsalva maneuver Manual abdominal compression • Conservative management Diet – MCFA + Orlistat TPN – High out put Compression dressing – controversial Octreotide • Topical agents – Sclerosing agents Fibrin glue
  • 11. Literature Review cont • Surgical interventions – High out put > 5days/ no prompt response to medical Mx Re-exploration Ligation of Thoracic duct Cover with muscle flap Distal embolization – success rate 45-70 % Thoracoscopic ligation of Thoracic duct
  • 12. Literature Review cont. • Retrospective study • Octreotide therapy appears superior to traditional conservative measures • Reduce hospital stay • 1st line conservative management