on a cervical lymphocele containing chyle. We present a case in which a povidone-iodine solution was used successfully in percutaneous scle- rosis of a ...
CASE REPORT
Treatment of a postoperative cervical chylous lymphocele by percutaneous sclerosing with povidone-iodine Matthias H . Seelig, M D , P a u l J. Klingler, M D , and W. A n d r e w Oldenburg, M D , Jacksonville, Fla. The development of postoperative leaks of the thoracic duct after neck dissection or vascular surgery of the subclavian and vertebral artery is a well klmwn but rare complication. Usually, an injury of the duct manifests immediately after the operation with chylous drainage. Presentation as a postoperative lymphocele is rare. Operative treatment may be an option, but identification of the leak often is impossible, resulting in a high rate of failure. Percutaneous catheter drainage in combination with sclerosis with povidone-iodine has proved to be highly effective in obliterating pelvic lymphoeeles but has not been reported in patients who have undergone vascular surgery in the neck. We present a case in which a povidone-iodine solution was used successfully in percutaneous sclerosis of a cervical lymphocele after transposition of the left subclavian artery to the left common carotid artery. (J Vase Surg 1998;27:1167-70.)
Injuries to the thoracic duct after radical neck dissection are a well known complication that occur in about 2% of cases. 1 The injuries usually present immediately after the operation as a chylous fistula. The incidence of thoracic duct injurics after vascular operations of the proximal subclavian and vertebral artery is not well known, although they have been reported. 2 Dietary modifications with the use o f mediumchain triglyceridcs or total parenteral nutrition has been reported as the primary treatment to seal these leaks? but high output fistulas may require surgical intervention.i, 4 Persistent chylous fistulae have been treated successfully with topical application o f tetracycline. 5 Lymphoceles consist o f a circumscript fluid collection and lack an epithelial lining; lymphoceles in the neck are exceptionally rare, with only one case reported within the past 10 years. 6 There is no report on a cervical lymphocele containing chyle. We present a case in which a povidone-iodine solution was used successfully in percutaneous sclerosis o f a cervical lymphocele after transposition o f From the Department of Surgery, Mayo Clinic Jacksonville. Reprint requests: Matthias H. Seelig, MD, Department of Surgery, Mayo Clinic Jacksonville, 4500 San Pablo Road, Jacksonville, FL 32224. Copyright © 1998 by The Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter. 0741-5214/98/$5.00 + 0 2 4 / 4 / 9 0 2 6 2
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the left subclavian artery to the left c o m m o n carotid artery. CASE REPORT A 65-yea>old man presented with a recurrent left supraclavicular lymphocele. Three months earlier, at another institution, the patient had undergone a left subclavian and vertebral endarterectomy with transposition of the left subclavian artery to the left common carotid artery for carotid subclavian steal syndrome. During this operation, the thoracic duct was divided and ligated. The postoperative course was complicated by the development of a supraclavicular chylous lymphocele; for this reason, the patient underwent repeat exploration twice after the initial operation with ligation of a small leak in the previously ligated thoracic duct. Despite these operations, the chylous lymphocele had recurred. At presentation at our institution, the patient had no shortness of breath, dysphagia, fever, chills, or sweats. Physical examination revealed a 7 × 12 cm oblong fluctuant mass in the left supraclavicular fossa without erythema or tenderness (Fig. 1, A). The incisions were well healed. The blood pressures at the two arms were identical, and no bruit could be detected. A computed tomographic (CT) scan of the neck revealed a large, 10 × 5 cm lobulated cystic mass with a hyperdense rim in the left supraclavicular region (Fig. 2). The trachea and other vascular structures were deviated to the right. A lymphoscintigram with 99mTc-antimony colloid injected via the web sites of the feet showed little or no accumulation of the tracer in the cervical lymphocele.
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Percutaneous needle aspiration was performed, and analysis of the fluid revealed a cholesterol level of 282 mg/dl, a triglyceride level of 680 mg/dl, and a white blood cell (WBC) count of 3400 cells/mm 3, with 99% lymphocytes and 1% eosinophils. This proved the fluid to be chylous in origin. The patient underwent CT-guided percutaneous placement of an 8F soft drainage catheter with multiple side holes under local anesthesia. About 140 ml of milky fluid was removed. Cultures from the fluid collection were negative, and subsequent irrigations with 30 ml of a solution consisting of 10% povidone-iodine followed by clamping of the catheter for 30 minutes were begun twice daily on an outpatient basis. In addition, cephalexin (250 mg four times daily) was administered orally during the treatment course. Sinograms of the lymphocele were obtained by injecting 20 ml of Renografin-60 on days 1 (Fig. 3), 7, 17, and 31. In addition, serial CT scans were obtained, which showed progressive resolution of the lymphocele with no perivascular inflammatory changes. By 31 days of treatment, the drainage had ceased. The sinogram showed a significantly decreased space of 7 × 1 cm. The drainage catheter was subsequently removed with no reoccurrence of the lymphocele (Fig. 1, B). At follow-up 10 months later, the patient was well without any signs or symptoms of recurrence.
DISCUSSION Injuries to the thoracic duct after radical neck dissection or subclavian bypass surgery occur with an incidence rate o f about 2%. 1 Due to the high anatomic variability o f the course o f the thoracic duct, lacerations may easily occur. The thoracic duct can enter the lowest portion o f the jugular vein, the subclavian vein, or at the confluence o f the two veins. Multiple terminations o f the duct are noted in 11% to 45% o f cases, 7 which may empty into the same or different veins, and the cephalic extent o f the duct may be as high as 5 cm above the clavicle. Due to the variable terminations o f the thoracic duct, injuries to the thoracic duct may bc easily overlooked. This anatomic variability may be the reason for the persistence o f the ehylous lymphoccle in our patient despite two repeated operations with ligation o f the thoracic duct. The presence o f a leak in the thoracic duct can bc determined through evaluation o f the drained fluid. A milldike appearance to the fluid and a triglyccride level o f greater than 100 m g / d l is highly suggestive o f a chylous fistula. In addition, chyle contains between 2000 and 20,000 W B C s / m m 3, most o f which are lymphocytes. 8 Such were the findings in our patient. Although chyle fistulae can be diagnosed through examination o f the drained fluid, a chylous
Fig. 1. Initial presentation of patient with left-sided cervical lymphocele (A). Result after removal of the catheter (B).
lymphocele is more difficult to diagnose. A chylous lymphocele, however, should be suspected when a patient develops a postoperative left-sided mass after neck dissection. On physical examination, a fluctuating mass with overlying edema and erythema may be identified. Ultrasound, CT, and magnetic resonance imaging may help to confirm the diagnosis, and duplex ultrasound may exclude any involvement o f the cervical vessels. Aspiration o f the fluid is necessary to differentiate a simple, typical sn'aw-colored lymphocele from a chylous collection. In the case o f a cervical lymphocele, the presence o f a cyst or an aneurysm o f the thoracic duct must be considered.9,1° Lymphoscinfigraphy may show pooling o f the radioactive tracer in the location of the mass, but data on the value o f this method in detecting a chylous fistula are lacking. The most i m p o r t a n t issue when dealing with chyle fistulas and lymphoceles is to prevent their occurrence. Operations in this area o f the neck
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Fig. 2. Cervical contrast-enhanced CT scan identifies a left-sided 5 x 10 cm lobulated cystic mass with deviation of the trachea.
require a thorough knowledge of the normal anatomy of the thoracic duct and its multiple variants. If an injury is suspected, lowering the patient's head and use of the Valsalva maneuver have been proposed to identify the leak. In addition, lupe magnification or the use of the operating microscope has been proposed) ] The thoracic duct can usually be ligated without any complications because multiple collateral vessels are present. 12 In the case of postoperative chylous fistula after neck surgery, most clinicians recommend an initial trial of conservative management, which consists of bed rest with head elevation, continuation of closed drainage, and dietary modification consisting of total parcnteral nutrition or enteral feeding with medium-chain triglycerides as the only fat source. In addition, external pressure may be used. Severe initial leaks of greater than 2 liters per day may require early operative intervention. Patients with a daily fistula drainage of more than 600 ml are likely to fail a conservative approach and should be considered for operation as well. 1 The operation should be performed before granulation tissue has obscured norreal structures. Operative treatment includes duct ligation and open wound management. The use of local anesthesia is appropriate in most instances. Milk or cream administered preoperatively may facil-
itate identification of the leak. In the case reported by Chantarasak and Green, successful treatment of the postoperative chylous lymphocele with an obvious connection to the thoracic duct was achieved through dissection of the cyst and transfixation and ligation of the connection. 6 In severe cases, the application of fibrin sealant in conjunction with pectoralis major muscle flap has been described. 13 Very rarely, ligation of the thoracic duct in the thoracic cavity may be necessary. 14 For intractable chyle fistulae, sclerothcrapy with tetracycline has been used successfully.~ However, a case of phrcnic nerve palsy after doxycycline therapy for a chylous fistula was reported. 1 Our patient had unsuccessfully undergone repeat exploration twice before he presented to our institution, making success at an additional operation more than questionable. We decided to use a percutancous approach with povidone-iodine as a sclerosing agent. Povidone-iodine has been successfully administered percutaneously in lymphoceles after kidney transplantation and pelvic surgery, with success rates ranging between 81% and i00%.I6,17 The sclerosing effect of povidone-iodine is supposed to be a result of an inflammatory process caused by the elemental iodine that is released d m ~ g instillation. There is a potential of increased iodine uptake,
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but as long as the contact time is limited, an adverse effect is not to be expected. However, a history of hypersensitivity to iodine should be considered a contraindication for transcatheter sclerosing therapy. The advantage of transcatheter sclerosing therapy is that further surgery may be avoided and the treatment can be performed on an outpatient basis with cooperative patients. Spiro et a l ) treated cervical chylous lymphoceles after radical neck dissection by reoperation followed by open pacldng. In their experience, the cervical lymphoceles resolved for the most part within 28 days. This is not dissimilar to our case, in which the lymphoceles resolved with nonoperative outpatient management within 31 days. In conclusion, this report is the first to demonstrate the safe and successful resolution of an otherwise intractable postoperative cervical chylous lymphocele by means of transcatheter sclerosing with a povidone-iodine solution. REFERENCES
1. Spiro JD, Spiro RH, Strong EW. The management of chyle fistula. Laryngoscope 1990;100:771-4. 2. Berguer tL Vertebrobasilar ischemia: indications, techniques, and results of surgical repair. In: Rutherford RB, editor. Vascular surgery, Vol. II. 4th ed. Philadelphia: WB Saunders; 1995. p. 1574-88. 3. Lucente FE, Diktaban T, Lawson W, Biller HF. Chyle fistula management. Otolaryngol Head Neck Surg 1981;89:575-8. 4. Crumley RL, Smith JL. Postoperative chylous fistula prevention and management. Laryngoscope 1976;86:804-13. 5. Kassel RN, Havas TE, Gullane PJ. The use of topical tetracycline in the management of persistent chylous fistulae. J Otolaryngol 1987;16:174-8. 6. Chantarasak DN, Green MF. Delayed lymphocele following neck dissection. Br J Plastic Surg 1989;42:339-40. 7. Greenfield J, Gottlieb MI. Variations in the terminal portion of the human thoracic duct. Arch Surg 1956;73:955-9. 8. Bozzetti F, Arullani A, Baticci F, Terno G, Ammatuna M, Capello G. Management of lymphatic fistulas by total parenteral nutrition. J Parent Nutr 1982;6:526-7. 9. Wax MK, Treloar ME. Thoracic duct cyst: an unusual supraclavicular mass. Head Neck 1992;14:502-5. 10. Livermore GH, Kryzer TC, Patow CA. Aneurysm of the thoracic duct presenting as an asymptomatic left supraclavicular mass. Otolaryngol Head Neck Surg 1993;109:530-3. 11. Thawley SE. Chylous fistula prevention and management. Laryngoscope 1980;90:522-5. 12. Har-E1 G, Lucente FE. Lymphatic drainage system after left radical neck dissection. Ann Otol Rhinol Laryngol 1994;103:46-8. 13. De Gier HH, Balm AJ, Bruning PF, Gregor RT, Hilgers FJ. Systematic approach to the treatment ofchylous leakage after neck dissection. Head Neck 1996;18:347-51. 14. Rollon A, Salazar C~ Mayorga F, Marin R~ Infante E Severe
Fig. 3. Sinogram o f the left-sided cervical lymphocele. There is no evidence o f extravasation or retrograde flow into a vascular structure.
cervical chyle fistula after radical neck dissection. Int J Oral Maxillofac Surg 1996;25;363-5. 15. Kassel RN, Havas TE, Gullane PJ. The use oftopicai tetracycline in the management of persistent chylous fistulae. J Otolaryngol 1987;16:174-8. 16. I(irse DJ, Suen J, Stern SL Phrenic nerve paralysis after doxycycline sclerotherapy for chylous fistula. Otolaryngol Head Neck Surg 1997;116:680-3. 17. Rivera M, Marc4n R, Burgaos J, Arranz M, Rodriguez R, Teruel JL, et al. Treatment ofposttransplant lymphocele with povidone-iodine sclerosis: long-term follow-up. Nephron 1996;74:324-7. Submitted Dec. 23, I997; accepted Mar. i0, 1998.
