A Novel Method of Management of High Output Chyle Leak Following Neck Dissection: Indocyanine Green Fluorescence-guided Robotic Transthoracic Thoracic Duct Ligation: A Case Series

Abstract

High-output Chyle leak is a dreadful complication following neck dissection, posing challenges in management due to the morbidity associated with prolonged leakage. This case series describes the efficacy of a novel Indocyanine Green (ICG) Fluorescence-guided Robotic Transthoracic thoracic duct ligation technique in intractable high-output chyle leaks following neck dissection. Three patients with persistent high-output chyle leaks following neck dissection underwent robot-assisted thoracic duct ligation. Preoperative evaluation, surgical technique, postoperative care, outcomes and follow-up were recorded. All patients experienced successful resolution of chyle leaks with no intraoperative complications. Postoperative recovery was uneventful, and no recurrences were observed during the follow-up period. ICG-guided robotic transthoracic thoracic duct ligation is a safe and effective method for managing persistent high-output chyle leaks following neck dissection, offering a minimally invasive technique with favourable outcomes.

Introduction

Thoracic duct injury in the neck following neck dissection, although rare (2–8%), but poses various management challenges [1–3]. It can happen following left-sided neck dissection, which is frequently identified at the time of surgery. Intraoperative recognition and management will prevent postoperative dreadful morbidity. Primary causes of iatragenic thoracic duct damage is its anatomical variation. The adult thoracic duct typically measures between 36 and 45 cm in length, with an average diameter of 5 mm. Its diameter decreases from the abdomen to the thorax, then increases again in the cervical region, reaching up to 1 cm in diameter as it drains into the venous system. Thoracic duct distention in the neck and its delicate wall are the other reasons for its injury in the neck. High output chyle leak is defines as > 500 ml/day. Although conservative management is attempted initially, may ultimately require surgical interventions requiring thoracic duct ligation in high output leaks [2, 4, 5]. Traditional methods, including midchain fatty acid dietary modification, octreotide injection, and surgical techniques, often yield variable success rates [5–7]. Robotic transthoracic thoracic duct ligation offers a novel, minimally invasive approach [8]. This case series describes the management of high-output chyle leak following neck dissection, managed by novel minimally invasive Indocyanine Green Fluorescence (ICG)-guided robotic thoracic duct ligation in three patients. An initial management algorithm for chyle leaks will guide the surgeon and prevent increased morbidity.

Methods

Three patients aged 35–59 years, with persistent high output chyle leaks, post left-sided modified radical neck dissection not responding to conservative management, were included.

S.No	Age/sex	Primary diagnosis	Procedure underwent
1.	23/F	Papillary carcinoma thyroid	Total thyroidectomy with bilateral neck dissection
2.	50/M	Carcinoma left buccal mucosa T3N1M0	Wide local excision and left modified radical neck dissection
3.	59/M	Carcinoma left buccal mucosa T3N1M0	Wide local excision and left modified radical neck dissection

All patients underwent blood investigations, including complete blood count, serum glucose, total protein, triglycerides, albumin. Chest radiographs were done to rule out chylothorax/pleural effusion. Neck drain output was serially monitored in all patients and contents were analysed for LDH levels.

Surgical Technique

Robotic transthoracic thoracic duct ligation was performed using the Da Vinci Xi Surgical System (Intuitive Surgical Inc. (ISI), Sunnyvale, CA, USA).

Key steps included:

1. ICG Injection: To enhance thoracic duct identification during surgery, a two-step administration of ICG is employed. The first dose of ICG 0.5 mg/kg, is injected into the subcutaneous plane at 8 PM on the day before surgery. This initial administration allows the dye to disperse and bind effectively to the lymphatic system, facilitating the visualization of the thoracic duct and associated lymphatic structures intraoperatively.

   On the day of surgery, after the patient has been anesthetized, a second dose of 0.5 mg/kg of ICG is administered. This time, the injection is made into the superficial inguinal nodes under the guidance of ultrasound. This precise method ensures that the ICG dye enters the lymphatic system efficiently and enhances the fluorescence of the thoracic duct.

2. Patient Positioning and Endotracheal Intubation: For this surgical procedure, the patient is positioned in the prone position, which involves lying face down on the operating table. This positioning provides optimal access and visualization of the the thoracic duct within thoracic cavity.

   A single lumen endotracheal tube is used to secure the patient’s airway and ensure adequate ventilation throughout the surgery. A right thoracic approach is utilized for the procedure. This involves making small incisions for the port on the right side of the thorax to access the thoracic cavity. The right thoracic approach is often preferred due to the anatomical location of the duct and its accessibility from the right side allowing the surgeon to maneuver robotic instruments and visualize the thoracic duct more effectively.

3. Port Placement: Three robotic ports are strategically placed at the 5th, 7th, and 9th intercostal spaces to facilitate the surgical procedure (Fig. 1). Additionally, an assistant port is positioned in the 8th intercostal space to provide access for necessary instruments and assistance during the operation. This arrangement allows for optimal maneuverability and access to the surgical site while minimizing patient discomfort and potential complications.

4. Thoracic Duct Identification: In the infracarinal region, the thoracic duct is typically situated between the descending thoracic aorta and the esophagus. The use of ICG fluorescence significantly enhances the identification process. When injected, ICG binds to proteins and becomes fluorescent under near-infrared light, making it easier to visualize the thoracic duct and any aberrant lymphatic ducts (Fig. 2). This technique improves the accuracy and efficiency of identifying the thoracic duct during surgical procedures, reducing the risk of inadvertent injury and improving patient outcomes.

5. Ligation: The thoracic duct is ligated along with surrounding tissue using large size Weck Hem-o-Lok (Teleflex) polymer locking ligation clip, which has small teeth on its inner edge to prevent slipping (Figs. 3 and 4).

6. Postoperative Care: After surgery, it is crucial to closely monitor the patient for any signs of chyle output. Post operatively, the volume and characteristics of drainout is monitored to detect chyle leakage early. Maintaining the patient’s nutritional status is a key aspect of postoperative care, especially in cases involving the thoracic duct as chyle is rich in fats, proteins, and other essential nutrients, and its loss can lead to significant nutritional deficits. Regular assessments of the patient’s nutritional status, and weight monitoring, help and ensure patients adequate nutrition.

   Patients are vigilantly monitored for any signs of infection or other postoperative complications. The surgical site is inspected regularly for signs of infection. Any fever, increased pain, may signal an infection or other complications requiring immediate attention. Postoperative chest X-ray is taken to ensure proper lung function and detect any fluid accumulation.

Fig. 1.

Port position for robotic thoracic duct ligation. Two robotic trocars were placed in the scapular line for the camera and Maryland forceps. One robotic trocar was placed medial to the scapula for scissors. An assistant trocar was placed between the scapular and posterior axillary lines to place intercostal tube drainage at the end of surgery

Fig. 2.

Thoracic duct seen as a fluorescent structure using Indocyanine green (ICG) lymphangiography

Fig. 3.

Thoracic duct ligated with clips

Fig. 4.

Fibrofatty tissue (Arrow) between the aorta and the azygous vein that might contain accessory lymphatics suture ligated and clipped. The thoracic duct can be identified separately (arrowhead)

Results

Patient Demographics

Patient demographics included a mean age of 23 to 59 years, with a distribution of two males and one female. The primary diagnosis for all patients was head and neck malignancies.

Surgical Outcomes

The mean operative time for the surgical procedure was 15 min, demonstrating efficient surgical techniques. There were no intraoperative complications reported. Postoperatively, all patients experienced complete resolution of chyle leak, underscoring the efficacy of the surgical intervention in addressing this condition. This outcome reflects successful management of thoracic duct abnormalities and effective closure techniques. Patients’ recovery post-surgery was uneventful, with no significant complications noted during the immediate postoperative period. The average hospital stay for patients undergoing this procedure was 3 days. There were no reported postoperative infections or complications among the patients. Additionally, nutritional parameters normalized within 2 weeks post-surgery, reflecting successful dietary management and supportive care.

Follow-Up

Patients were followed up for an average duration of 12 months post-surgery. This extended follow-up period allows for comprehensive monitoring of long-term outcomes and ensures ongoing patient care and support. Throughout the follow-up period, there were no instances of chyle leak recurrence among the patients. The surgical outcomes underscore the success and reliability of the procedure in achieving complete resolution of chyle leaks with minimal operative time, short hospital stays, and excellent postoperative recovery. The absence of complications and recurrence during follow-up further reinforces the procedure’s efficacy and patient satisfaction in managing high output leak effectively.

Discussion

The thoracic duct plays a crucial role in the lymphatic system, responsible for transporting approximately 75% of the body’s lymph volume. Postoperative chyle leaks can lead to significant hemodynamic instability and nutritional deficiencies due to the loss of protein-rich lymphatic fluid. Conservative management approaches, such as parenteral nutrition or a fat-free diet, often prove fails with high-output chyle leaks [9]. Surgical ligation of the thoracic duct via a cervical approach, although attempted, is technically challenging and associated with a high failure rate in the immediate postoperative period adding onto its complication [5].

Robotic transthoracic thoracic duct ligation with ICG guidance emerges as a promising solution for managing highout chyle leaks that are refractory to conservative measures. This minimally invasive approach offers several advantages over traditional methods. The identification of the thoracic duct during surgery is greatly facilitated by ICG fluorescence, a technique that enhances visualization under near-infrared light. Unlike traditional subcutaneous injections, administering ICG into the groin nodes under sonographic guidance has shown more consistent outcomes, ensuring reliable fluorescence and precise localization of the thoracic duct [10].

Vecchiato et al. (2020) demonstrated the efficacy of this approach in a study involving 19 patients undergoing minimally invasive esophagectomy. They achieved successful identification of the thoracic duct in all cases, with ICG fluorescence appearing within an average of 52.7 min post-injection. This method’s precision and minimally invasive nature contribute significantly to its effectiveness and patient safety, contrasting with the higher morbidity associated with traditional thoracic duct ligation [10].

The use of ICG fluorescence not only enhances the visualization of the thoracic duct but also aids in identifying aberrant lymphatic ducts, thereby reducing the risk of procedural failure. This technological advancement allows surgeons to perform more accurate and targeted interventions, ensuring comprehensive management of chyle leaks with improved outcomes. Moreover, the reduced operative morbidity and faster recovery associated with robotic transthoracic thoracic duct ligation underscore its potential as a preferred approach in challenging cases of postoperative highoutput chyle leaks.

In conclusion, the integration of ICG fluorescence-guided robotic transthoracic thoracic duct ligation represents a significant advancement in the surgical management of refractory chyle leaks. This approach not only enhances surgical precision but also minimizes postoperative complications, offering patients a safer and more effective treatment option compared to traditional methods.

Advantages

Minimally Invasive as it has reduced postoperative pain and quicker recovery. It has high precision because of enhanced visualisation and dexterity with robotic assistance. High success rate (100%) in resolving persistent chyle leaks. Furthermore, this novel technique avoids the re-exploration of already existing neck wound, hence reducing post operative morbidity and significantly shortening the wound healing time and hence, the hospital stay.

Limitations

The adoption of robotic techniques in surgery often entails higher associated costs, however, in medical centers where these facilities are available, robotic surgery has proven to be a safe and reliable technique.Another significant consideration is the learning curve associated with robotic surgery. Performing operations using robotic systems requires specialized training and experience for surgical teams. Despite the initial challenges posed by the learning curve, centers that invest in comprehensive training programs often see significant benefits in patient outcomes and procedural efficiency over time.

In conclusion, while the adoption of robotic surgery may involve higher upfront costs and a steep learning curve, centers with dedicated training and ongoing support mechanisms can leverage this technology to deliver advanced surgical care safely and effectively.

Conclusion

Robotic transthoracic thoracic duct ligation is an innovative and effective technique for the management of chyle leaks following neck dissection. This case series demonstrates its safety, efficacy, and potential to improve patient outcomes in this challenging clinical scenario. Further studies with larger cohorts are warranted to validate these findings.

Funding

None declared.

Data Availability

All authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. The data is available to anyone for review upon request.

Declarations

Ethical Approval

our institution does not require ethical approval for reporting individual cases or case series.

Informed Consent

Written informed consent was obtained from the patient(s) for their anonymized information to be published in this article.

Conflict of Interest

The authors have no conflict of interests.