Massive Chylous Leakage After Endoscopic Thyroidectomy with Central Lymph Node Dissection: A Case Report

Introduction

Chylous leakage (CL) is a serious complication of thyroidectomy accompanied by neck dissection, with an incidence of 4.5% to 8.3% [1,2] following lateral cervical lymph node dissection and 0.6% to 1.4% [3,4] following central lymph node dissection through the cervical incision approach. Massive CL can lead to electrolyte imbalances, hypoproteinemia, infections, and even death. It significantly reduces patients’ postoperative quality of life and prolongs hospital stays. Currently, endoscopic thyroid surgery has been widely used in the treatment of thyroid carcinoma. As lateral cervical lymph node dissection is not often performed endoscopically, CL is very rare after endoscopic central lymph node dissection. Here, we report a case of massive CL following endoscopic thyroidectomy with central lymph node dissection, which failed to be controlled by conservative management and was successfully reoperated endoscopically using the original ports.

Case Report

A 37-year-old woman presented with a thyroid nodule during a physical examination and sought further treatment at our hospital. Ultrasound imaging revealed a nodule measuring 5×4.7 mm in the left lobe of the thyroid and multiple lymph nodes enlarged in the left central compartment, with the largest node measuring approximately 1.5 cm in diameter. The fine-needle aspiration biopsy confirmed the diagnosis of papillary thyroid carcinoma. After discussing the treatment options with the patient, she opted for endoscopic thyroidectomy (left thyroidectomy and isthmectomy) with central lymph node dissection via bilateral areola approach. During the surgery, an enlarged lymph node was detected in the left central compartment, positioned medially to the left common carotid artery, approximately at the level of the second tracheal cartilage. No CL was detected after lung inflation, and the surgery was completed after inserting a negative pressure drainage tube. On the first postoperative day, a volume of 270 mL of milky fluid was drained (Figure 1). The diagnosis of CL was made based on white turbid drainage [5,6], and local application of Pseudomonas aeruginosa injection [7], a kind of adhesive that is made from dead bacteria of P. aeruginosa, was applied. Meanwhile, various conservative management strategies were utilized, including fasting, parenteral nutrition, maintenance of electrolyte balance, and continuous infusion of somatostatin (3 mg/12 h). On the second postoperative day, a volume of 1092 mL of milky fluid was drained, and conservative treatments were continued for the patient. On the third postoperative day, the drainage output remained around 1490 mL and continued to exhibit a milky appearance. Due to the patient’s poor response to conservative management and the increasing drainage volume [6,8], it was decided that surgical intervention was necessary. The necessity of the surgery and the surgical plan were thoroughly discussed with the patient, and the patient expressed understanding and signed the informed consent form. During the surgical exploration on the third postoperative day, it was observed that the surgical site was filled with lymphatic fluid, which continued to drain from the central area (Figure 2). The fluid was suctioned using an aspirator, and the site of the leak was identified on the medial side of the left common carotid artery, at the level of the second tracheal cartilage (Figure 3). The residual end of the lymphatic vessel was then clamped with a biological clip (Medtronic, Lapro-Clip™ 8886848813), and no further leakage of lymphatic fluid was observed (Figure 4). After pressing the abdomen and inflating the lungs, there was no lymphatic fluid observed. The observation was continued for 10 min, and the surgery was concluded by inserting a latex drainage tube through the left areolar incision.

On the first day after reoperation, 70 mL of slightly milky fluid was drained. The patient was prescribed a low-fat diet, received a continuous infusion of somatostatin (3 mg/12 h), and subsequently, the drainage volume gradually decreased. The drainage was removed 4 days after the second operation, and the patient was discharged on the fifth day following the second operation. During the follow-up, no abnormalities were observed.

Discussion

To the best of our knowledge, this is the first reported case of a patient experiencing significant CL following endoscopic thyroidectomy with central lymph node dissection, and subsequently undergoing reoperation through the initial surgical approach to ligate the lymphatic vessels. CL is a serious complication following lymph node dissection for thyroid carcinoma, especially after lateral neck dissection. Although CL is rare after endoscopic thyroidectomy, it should still be taken seriously if the patient experiences a significant amount of postoperative drainage that appears creamy or milky [6].

CL is primarily associated with injury to the thoracic duct or right lymphatic duct. While direct injury to the thoracic duct during central lymph node dissection is rare, CL can still occur due to variations in the thoracic duct [3,9]. Additionally, significant CL can occur during central lymph node dissection, potentially attributed to injury in some large lymphatic vessels. These damaged lymphatic vessels can be temporarily sealed by electrocautery or ultrasonic scalpel coagulation and can reopen after surgery, potentially leading to the development of CL [4]. In this case, while surgically removing central lymph nodes, the surgeon identified an enlarged lymph node on the medial side of the left common carotid artery, at the level of the second tracheal cartilage. This location coincided with the occurrence of CL as well. The enlarged lymph node may have connected to lymphatic vessels, which reopened after the surgery, resulting in CL. Due to the suboptimal effectiveness of ultrasonic scalpel in sealing lymphatic vessels in this case, further investigation is required to determine whether the use of ultrasonic scalpel to seal lymphatic vessels without suturing can pose hidden risks for CL.

Postoperative management of CL includes both conservative management and surgical intervention. Conservative management mainly involves dietary management and nutritional support [10], negative pressure suction [11], localized compression bandaging, administration of somatostatin and its analogs [12–15], and application of local adhesives. Furthermore, ultrasound-guided intranodal lymphangiography with lipiodol is gaining attention as a minimally invasive diagnostic and potential therapeutic approach for CL [16]. In our center, when encountering significant postoperative drainage volume increase or sudden flow rate elevation, our initial approach is local compression. Wound compression therapy as a conservative treatment often works satisfactorily. If local compression is ineffective, other conservative treatment options will be used. Surgical intervention is generally recommended in the following situations: (1) persistence of a high drainage volume (>1000 mL/day, or some recommend >500 mL/day for 3 consecutive days) with no significant reduction despite conservative management [6,8]; in particular, timely surgical intervention is warranted for the patient with a drainage volume exceeding 2000 mL/day [17]; (2) severe malnutrition and electrolyte imbalance [9]; and (3) other serious complications. The surgical indications above for CL are predominantly derived from cases following lateral neck dissection. In the present case, the postoperative drainage fluid was milky white and could not be effectively controlled by conservative management. The diagnosis of CL was made based on white turbid drainage and high daily drainage volume. Therefore, we deemed a second surgery necessary. To minimize patient trauma, we planned to perform surgical exploration using the original surgical approach. If the CL cannot be treated intraoperatively, conversion to traditional open surgery can be necessary. Furthermore, thoracoscopic ligation of the thoracic duct is a viable option [18]. Following a comprehensive discussion, the patient consented and signed the informed consent form. During the surgical exploration, it was noted that the surgical site was filled with lymphatic fluid. Luckily, the fluid was aspirated, and the site of the leakage was subsequently identified. The residual end of the lymphatic vessel was clamped with a biological clip, and no further leakage was observed. Fortunately, the patient was successfully treated through the original surgical port sites.

Conclusions

Managing significant CL poses a challenge for surgeons. This complication is rare following endoscopic thyroidectomy with central lymph node dissection, and there remains a lack of sufficient experience in effectively preventing and treating such occurrences. We aim to raise awareness of this complication through our case report.