Abstract
Ligation of bilateral IJV causes interruption of major part of venous drainage from Dural venous sinuses that causes complications such as gross facial edema, increased intracranial pressure, brain compression, coma and even death increasing the morbidity and mortality post-operatively. This case report illustrates a case of normalcy noted in post-operative period in a patient after ligation of bilateral IJV in left lower alveolus cancer.
Keywords: Left lower alveolus carcinoma, Radical neck dissection, Bilateral IJV ligation, Post-operative normalcy, Patency of vertebral veins
Introduction
The neck dissection has remained a pivotal aspect of head and neck cancer management for over a century. Popularized by Hayes Martin in 1951 [1], radical neck dissection (RND) has been the standard treatment for visible or probable cervical metastases for many years. Crile first described neck dissection as a part of managing head and neck cancers in 1906 [2]. RND has been described as enbloc removal of lymph nodes, fibro-fatty tissue and lymph- bearing fascia along with removal of essential structures such as IJV, SCM, SAN [3]. Bilateral IJV ligation interrupts major venous blood return from central nervous system [4] and this may lead to facial oedema, rise in intracranial pressure with secondary systemic hypertension (CUSHING’S REFLEX) [5], chylous leak, occulo-sympathetic paresis or syndrome (blepharoptosis, enophthalmos, miosis), cellulitis in tissues surrounding operative site, impaired neurological function, brain compression, coma, death [6].
This case report portrays a post-operative normalcy phase in a patient with left lower alveolus cancer after intra-operative bilateral ligation of IJV during neck dissection.
Case Report
55-year-old male patient presented to the hospital setting with a non-healing ulcer over his left lower alveolus involving skin with exposed mandibular body and myiasis and diagnosed as squamous cell carcinoma on further investigation. Lesion was approaching midline anteriorly, posteriorly up-to retromolar trigone region, involving the superior and inferior gingivo-buccal sulcus. Involved mandible had bony erosions that extended up to midline. Multiple nodes were palpable at level IA, IB bilaterally for which left RND and right MRND- III was planned. RND was performed for left neck. Intra-operatively IJV on right side was collapsed and was inadvertently transected during surgery. No reverse flow was noted from superior stump of the vessel. Inferior stump was ligated. (Fig. 1 and 2) Right Common facial vein was ligated. Right Lingual vein was preserved. After the procedure mild face oedema was noted on the right temporal region that gradually subsided to normal in the next 12 h (Figs. 3 and 4). No complications related to the bilateral IJV ligation were noticed thereafter. MRI Brain was done post-operatively to rule out any anomalies that might have contributed to the formation of a secondary venous channels here MRI brain revealed no abnormalities. Further a contrast enhanced computed tomography (CECT) head and thorax with arterial, venous and triple phase was done which revealed that upper stump of IJV above the ligation was smaller in caliber and prominence of right external jugular vein (EJV). Clinically anteriorly, due to salivary collection and the patient's inability to deglute inadequately orocutaneous fistula (OCF) was formed and managed conservatively. On subsequent follow-ups patient did not report with any of the complications associated with bilateral IJV ligation (Fig. 5).
Fig. 1.
Intra-operative image depicting modified radical neck dissection-II on right side with inferior end of IJV ligated and superior end showing no evident blood flow
Fig. 2.
Intra-operative image of composite resection with left radical neck dissection
Fig. 3.
Clinically post-operative normalcy reported
Fig. 4.
Post- operative CECT with Venous phase showing increased calibre of vertebral Vein and EJV of right side
Fig. 5.
Post-operative 3 months follow-up
Discussion
Regional lymphatics status is an important prognostic factor in individuals with head and neck cancer. Bilateral IJV ligation management is still a debatable subject [3]. Contralateral metastatic spread may occur after regional node becomes substantially involved causing a definite contralateral lymphatic spread over midline or by crossing afferent lymphatics or a specific anatomical region with an ambiguous midline [6]. According to an article, simultaneous neck dissection is a procedure that is sufficiently entrenched as safe to consider it for specific indications such as, metastatic tumors present bilaterally on neck, avoiding cutting through the cancer tissue or disease might become inoperable on either side if surgery is postponed, without jeopardising the patient. To limit post-operative morbidity and mortality and avoid significant and dreadful repercussions, some institutions choose to remove both IJV when necessary, in two phases by maintaining a two-week gap between IJV ligations.
Crile asserted that the brain's venous drainage could be carried over by the vertebral and other deep veins and so IJV must be sacrificed by en-bloc dissection. Additionally, he advocated for simultaneous bilateral neck dissection when necessary, documenting one case of bilateral IJV excision. The patient can survive bilateral IJV ablation when there is enough collateral venous circulation, as depicted by several investigations [7]. When deciding whether to ligate the jugular vein, a jugular vein occlusion test may provide us crucial information about the patient. Baston vertebral veins make up for this collateral return. The vertebral system of veins effectively drains the brain, intracranial, extra-cranial tissue, and the front and lateral aspects of the neck. According to Baston and Gius, the vertebral vein travels extra-spinally between the vertebrae and the erector spinal muscle group as well as between the dura and the vertebrae as a plexiform network, predominantly in a longitudinal direction. A healthy brain may withstand bilateral jugular vein ligation after radical neck dissection attributable to the opening of these hidden channels. These channels can be located in the neck muscles and in the epidural region of the foramen magnum. This vertebral venous plexus drains into the right and left subclavian veins by a single channel at the cervicothoracic junction. The cervical draining channels are formed by the vertebral vein, together with tributaries from the internal vertebral plexus, anterior vertebral vein, and deep cervical veins, averting any post-operative sequelae following bilateral IJV ligation
Conclusion
It is crucial to protect the vertebral veins of Boston and maintain the patency of the EJV in cases when simultaneous bilateral IJV ligation is being executed, as well as to reduce morbidity and perhaps death and achieve post-operative results that are near normal. Technically speaking, it is rapid and safe to preserve the EJV during bilateral neck dissections, and clinical and radiological tests have demonstrated its patency [8]. Simultaneous IJV ligation should be carried out when the EJV is preserved in order to reduce post-operative problems. Therefore, in view of this case report and on noticing the normalcy in post-operative period after ligation of bilateral IJV, CECT in venous phase revealed patency of right Boston’s vertebral venous plexus contributing towards normalcy and forming major draining collaterals for cerebral venous return
Declarations
Conflict of interest
The authors that they have no conflict of interest.
Informed Consent
Informed consent was taken from the patient.
Footnotes
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