Management_of_Chyle_leak_following_Thoracic_duct_injury_.pptx

A clinical case with the management

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.Ca 2+ 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 – 45 o 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

7. 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

8. 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

9. 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

10. 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

11. Literature Review cont. Retrospective study Octreotide therapy appears superior to traditional conservative measures Reduce hospital stay 1 st line conservative management

12. Thank you