Chyle Leak Research Articles

Early postoperative complications in pediatric abdominal solid tumor surgery according to Clavian-Dindo classification.

Postoperative period after abdominal solid tumor surgery is critical regarding complications. This study aimed to detect incidence and treatment of complications. Single center retrospective study including years 2010-2019 for early postoperative complications were documented and graded according to Clavian-Dindo classification. The overall complication rate was 10% and they were chylous leak (n = 8, 2%), collection in surgical field (n = 8, 2%), acute renal failure (n = 7, 1.7%), hemorrhage (n = 5, 1.3%), intestinal obstruction (n = 4, 1%), surgical site infection (n = 3, 0.7%), thromboembolism (n = 3, 0.7%) and peripheric neuronal event (n = 2, 0.5%). Distribution of complications according to Clavian-Dindo classification was as follows: 2 grade I, 23 grade II, 9 grade IIIb, 5 grade IVa and 1 grade V. While age and percentage of benign or malignant disease were not different in groups with or without complications (p = 0.11, p = 0.24), males had more complications than female patients (p = 0.008). Having more than one surgery aiming tumor resection was associated with increased postoperative complications (p = 0.002). Incidence of complications were highest after extragonadal germ cell tumor (35%) and hepatic tumors (29%). Postoperative complications of abdominal tumor surgery are diverse in children. They are related with prolonged hospital stay and need for medical or surgical interventions. Number of surgeries, organ of origin and tumor type have an influence on risk of complications.

ASO Author Reflections: Chyle Leak after Axillary Node Clearance in Breast Cancer Surgery, a Successful Management Approach from Leading Centres.

ASO Author Reflections: Chyle Leak after Axillary Node Clearance in Breast Cancer Surgery, a Successful Management Approach from Leading Centres.

Brief Report: Chylothorax and Chylous Ascites During RET Tyrosine Kinase Inhibitor Therapy

IntroductionSpontaneous chylous effusions are rare; however, they have been observed by independent investigators in patients treated with RET tyrosine kinase inhibitors (TKIs). MethodsThis multicenter, retrospective study evaluated the frequency of chylous effusions in patients treated with RET TKIs. Clinicopathologic features and management of patients with chylous effusions were evaluated. ResultsA pan-cancer cohort of 7517 patients treated with one or more multikinase inhibitor or selective RET TKI and a selective TKI cohort of 96 patients treated with selpercatinib or pralsetinib were analyzed. Chylous effusions were most common with selpercatinib (7%), followed by agerafenib (4%), cabozantinib (0.3%), and lenvatinib (0.02%); none were observed with pralsetinib. Overall, 12 patients had chylothorax, five had chylous ascites, and five had both. Time from TKI initiation to diagnosis ranged from 0.5 to 50 months. Median fluid triglyceride level was lower in chylothoraces than in chylous ascites (397 mg/dL [interquartile range: 304–4000] versus 3786 mg/dL [interquartile range: 842–6596], p = 0.035). Malignant cells were present in 13% (3 of 22) of effusions. Chyle leak was not identified by lymphangiography. After initial drainage, 76% of patients with chylothorax and 80% with chylous ascites required additional interventions. Selpercatinib dose reduction and discontinuation rates in those with chylous effusions were 47% and 0%, respectively. Median time from diagnosis to disease progression was not reached (95% confidence interval: 14.5–undefined); median time from diagnosis to TKI discontinuation was 11.4 months (95% confidence interval: 8.2–14.9). ConclusionsChylous effusions can emerge during treatment with selected RET TKIs. Recognition of this side effect is key to prevent potential misattribution of worsening effusions to progressive malignancy.

The management of chyle leak post-oesophagectomy for oesophageal carcinoma: a systematic review.

Chyle leak is an uncommon yet potentially fatal complication of oesophagectomy for oesophageal cancer. The management of chyle leak is a debated, controversial topic and to date there is no standardised approach or validated algorithm for its management. This review aims to summarise current treatment algorithms for chyle leak post-oesophagectomy and their outcomes. A systematic search of Embase, MEDLINE, UpToDate and Cochrane was conducted to identify studies reporting on the management of chyle leak following oesophagectomy for oesophageal cancer. Data on interventional success rate and mortality are reported. Twenty-one studies met the inclusion criteria including over 23,254 oesophagectomies and identifying 838 chyle leaks (incidence <3.6%). The majority of cases were initially managed conservatively (95.3%), with a failure rate of 50.4%. Immediate surgical or radiological management resolved chylothorax in the majority of cases (97.3%), however the numbers were small. Death occurred in 54 cases (6.6%), all of whom underwent conservative management initially. Owing to the heterogeneity of treatment algorithms, timings and indications for interventions, the optimal strategy for managing chyle leak remains unclear. This review has identified an unmet need for prospective multicentre studies assessing the efficacy of predefined algorithms.

Percutaneous Lipiodol Lymphangiogram in Chylous Leakage Successful Embolisation Post Mastectomy: A Case Report

Complication of chyle leakage is rare post mastectomy, ranging from 0.36 – 0.84%. This case report discuses a rare case of chylous leakage post mastectomy in a 79-year-old female. The complication was suspected when the draining colour of axillary drainage change from serous fluid to milky colour, diagnosis then confirmed clinically and biochemically as chyle. The patient was initially managed conservatively, but this was not successful and was referred to an interventional radiology for lymphangiogram and embolization. Percutaneous lipiodol embolization was performed with immediate success.

Pancreatoduodenectomy in obese patients: surgery for nonmalignant tumors might be deferred.

Obesity has traditionally been considered a cause of increased surgical complexity and poor outcomes following pancreatoduodenectomy (PD). This study aimed at evaluating the role of obesity in terms of mortality and failure to rescue (FTR), with a particular focus on nonmalignant tumors. All patients undergoing elective PD over 10 consecutive years were analyzed. Patients were stratified according to their BMI and categorized into two groups. Predictors of mortality and FTR were assessed through logistic regression. Out of 1865 patients included, 151 were obese (8.1%). Overall mortality and FTR were 3.1% and 14.1%, respectively. In obese patients, mortality was 6.0% and FTR 26.5%, significantly higher compared to nonobese (p<0.05). In the multivariable analysis, obesity, age > 70 years, and ASA-PS score were independent predictors of mortality and FTR. Postoperative pancreatic fistula (35.8% vs. 25.8%), postpancreatectomy acute pancreatitis (24.5% vs. 12.5%), and chyle leak (6.0% vs. 3.2%) were more frequent among obese patients. In the subgroup of patients with nonmalignant tumors (n=443), obesity was the only independent predictor of FTR. PD performed in obese patients was associated with higher surgical morbidity and mortality. When dealing with nonmalignant tumors, deferring surgery in obese patients should be strongly considered.

A Retrospective Study of Lymph Node Dissection for Renal Cell Carcinoma

We retrospectively analyzed the effect of lymph node dissection (LND) in patients with renal cell carcinoma (RCC). Of 151 patients who underwent nephrectomy for RCC, 86 underwent LND. No distant metastasis (M0) was present in 71 patients, although distant metastasis (M1) was present in 15. Three (4.2%) and eight (53%) patients in the M0 and M1 groups, respectively, were clinical N-stage positive. Two (2.8%) and three (20%) patients in the M0 and M1 groups, respectively, were pathological N-stage positive. Both pathological N stage-positive patients in the M0 group were pathologically diagnosed with microphthalmia transcription family translocation RCC. The clinical and pathological positive node areas exhibited concordance in all three pathological N stage-positive patients in the M1 group. Chylous leakage occurred in 16 (19%) patients in the LND group (p＜0.05). Extended LND was a statistically significant risk factor for chylous leakage in the multivariate analysis. Only limited cases should undergo LND, owing to the low frequency of positive pathological lymph node metastasis, and high complication rate.

Chylothorax and chylous ascites during RET tyrosine kinase inhibitor therapy.

9080 Background: Spontaneous, atraumatic chylous effusions are rare. Investigators have observed a higher than anticipated incidence of chylothorax and chylous ascites in patients (pts) treated with RET tyrosine kinase inhibitors (TKIs). A systematic analysis of the occurrence of chylous effusions during RET TKI therapy and management strategies was thus performed. Methods: In this multicenter, retrospective study, the frequency of biochemically confirmed chylothorax or chylous ascites in pts treated with multikinase inhibitors (MKIs) with anti-RET activity or selective RET TKIs was determined. Clinicopathologic features and management of pts with chylous effusions were assessed. Results: A pan-cancer cohort of 7517 pts treated with at least 1 of 17 MKIs and selective RET TKIs and an independent cohort of 96 pts treated with the selective RET TKIs, selpercatinib or pralsetinib, were identified. Across cohorts, chylous effusions were identified in 22 pts and were most common with selpercatinib (7%; 15/217), followed by the MKIs agerafenib (4%; 1/24), cabozantinib (0.3%; 3/918), and lenvatinib (0.3%; 3/1185). Chylous effusions were not noted in 28 pts treated with pralsetinib. The distribution of malignancies included lung adenocarcinoma (54%) medullary thyroid carcinoma (23%), renal cell carcinoma (19%), and desmoplastic small round cell tumor (4%). Of the 22 pts, 12 had chylothorax, 5 had chylous ascites, and 5 had both. The cumulative incidence of chylous effusions from TKI initiation at 12 months was 3.09%. Median fluid triglyceride level was lower in chylothorax than in chylous ascites [397 mg/dL (IQR 282-4000) vs. 3786 mg/dL (IQR 676-6596), p = 0.035]. Median pleural fluid triglyceride level was higher with selpercatinib compared to MKIs [4,000 mg/dL (IQR 356-4425) vs. 287 mg/dL (IQR 216-395); p = 0.017]. Malignant cells were identified in the effusions from 12% (2/17) and 10% (1/10) of pts with chylothoraces and chylous ascites, respectively. Median time to disease progression from radiographic index and biochemical index across the full cohort was 1.5 years (IQR: 0.6-2.4) and 1.0 year (IQR: 0.1-1.2), respectively. Anatomic chyle leak was not identified in 6 pts who underwent lymphangiography. After initial drainage, additional drainage procedures were required in all cases with chylothorax and 50% of cases with chylous ascites. Chylous effusions prompted TKI dose reduction in 47% (7/15) of pts treated with selpercatinib and 14% (1/7) treated with MKI; none discontinued TKI due to chylous effusions. Conclusions: Chylous effusions can emerge on treatment with certain MKIs or selective RET TKIs. Recognition of this potential side effect is key to prevent misattribution of worsening effusions to progressive malignancy and to motivate a better understanding of its biology and management.

Systematic review on the use and management of drainages in pancreatic surgery

Abstract Objective The use of drains in pancreatic surgery, both in distal pancreatectomy (DP) and partial pancreaticoduodenectomy (PD) is controversial. The aim of this meta-analysis was to assess the potential benefit of drainage use in pancreatic surgery on postoperative outcomes. Methods A systematic literature search was performed in MEDLINE, Web of Science and CENTRAL. All RCTs investigating the use and management of any drainage in patients undergoing pancreatectomy were included. Data on mortality, postoperative complications and length of hospital stay (LOS) were analysed. A random-effects model for Mantel-Haenzsel and inverse variance analysis was used. Cochrane RoB 2.0 tool and GRADE approach was used for assessment of risk of bias and certainty of evidence. Results Ten RCTs investigating drainage vs no drainage, timing of drainage removal or type of drainage in PD such as DP with a total of 2004 patients were included. Drainage vs no drainage: Three RCTs (two with PD and DP, one with PD only). Neither mortality (OR 1.57, 95%-CI: 0.62 to 3.93 p=0.34) nor overall complications (OR 0.88, 95%-CI: 0.71 to 1.08, p=0.21) differed between both groups (certainty of evidence: low). However, one trial was stopped prematurely because of higher 90-day mortality in the no drainage group. Early vs late drainage removal: Four RCTs (two with PD and DP, two with PD only). Early drain removal resulted in both a significant reduction of chyle leak (OR 0.22, 95%-CI: 0.06 to 0.59, p&amp;lt;0.01) as well as a shortening of LOS (mean difference -2.64 days, 95%CI: -4.63 to -0.65, p&amp;lt;0.01). For both outcomes the certainty of evidence was moderate. Mortality, postoperative pancreatic fistula and hemorrhage showed no difference between early vs late drainage removal (certainty of evidence: low). Active vs passive drainage: Three RCTs (one with PD and DP, two with PD only). None of the studies found any significant difference in outcome with regard to the type of drainage. Conclusion There is no evidence that drainages after pancreatic surgery should be standard of care. However, there is also no evidence that placing a drain leads to worse outcomes. If a drainage is used it should be removed early to avoid chyle leak and accelerate hospital discharge.

End-to-side circular stapled versus side-to-side linear stapled intrathoracic esophagogastric anastomosis following minimally invasive Ivor-Lewis esophagectomy: comparison of short-term outcomes.

The search for the optimal procedure for creation of a safe gastroesophageal intrathoracic anastomosis with a lower risk of leakage in totally minimally invasive Ivor-Lewis esophagectomy (TMIIL) is ongoing. In the present study, we compared the outcomes of end-to-side (with circular stapler [CS]) and side-to-side (with linear stapler [LS]) techniques for intrathoracic anastomosis during TMIIL performed in 2 European high-volume centers for upper gastrointestinal surgery. A propensity score method was used to compare the CS and LS groups. We retrospectively evaluated patients with lower esophageal cancer or Siewert type 1 or 2 esophagogastric junction carcinoma who underwent a planned TMIIL esophagectomy, performed from January 2017 to September 2020. The anastomosis was created by a semi-mechanical technique using a LS in one center and by a mechanical technique using a CS in the other center. General features, operative techniques, pathology data, and short-term outcomes were analyzed. Statistical evaluations were performed on the whole cohort, stratifying the analyses by risk strata factors identified with the propensity scores, and on a subgroup of patients matched by propensity score. The primary endpoint of the study was the rate of anastomotic leakage in the two groups. Secondary endpoints included rates of anastomotic stricture and overall postoperative complications. Considering the whole population, 256 patients were included; of those, 220 received the anastomosis with a circular stapler (CS group), and 36 received the anastomosis with a linear stapler (LS group). No significant differences by group in terms of sex, age, American Society of Anesthesiologists physical status classification, and type of neoplasm were showed. The rate of anastomotic leakage did not differ in the two groups (9.6% CS vs. 5.6% LS, p = 0.438), as well as the rate of anastomotic stricture in the 3-month follow-up (0.9% CS vs. 2.8% LS, p = 0.367). The rate of chyle leakage and of pulmonary, cardiac, and infective complications was not significantly different in the groups. After propensity score matching, 72 patients were included in the analysis. The 2 obtained propensity score matched groups did not differ for any of the clinical and pathologic variables considered for the analysis, resulting in well-balanced cohorts. The results obtained on the whole population were confirmed in the matched groups. The results of our study suggest that both techniques for esophagogastric anastomosis during TMIIL are feasible, safe, and effective, with comparable rates of postoperative anastomotic leakage and stricture.

Therapeutic lymphography for persistent chyle leak after pancreatic surgery

Chyle leak is a common complication following pancreatic surgery. After failure of conservative treatment, lymphography is one of the last therapeutic options. The objective of this study was to evaluate whether lymphography represents an effective treatment for severe chyle leak (International study Group on Pancreatic Surgery, grade C) after pancreatic surgery. Patients with grade C chyle leak after pancreatic surgery who received transpedal or transnodal therapeutic lymphography between 2010 and 2020 were identified from a prospectively maintained database. Clinical success of the lymphography was evaluated according to percent decrease of drainage output after lymphography (>50% decrease=partial success; >85% decrease=complete success). Of the 48 patients undergoing lymphography, 23 had a clinically successful lymphography: 14 (29%) showed partial and 9 (19%) complete success. In 25 cases (52%) lymphography did not lead to a significant reduction of chyle leak. Successful lymphography was associated with earlier drain removal and hospital discharge [complete clinical success: 7.1 days (±4.1); partial clinical success: 12 days (±9.1), clinical failure: 19 days (±19) after lymphography; p=0.006]. No serious adverse events were observed. Therapeutic lymphography is a feasible, safe, and effective option for treating grade C chyle leak after pancreatic surgery.

116: INFLUENCE OF BODY COMPOSITE MEASURES ON CHYLE LEAK AFTER OESOPHAGECTOMY

Abstract Background and aim Chyle leak is an infrequent but potentially serious complication of oesophagectomy. Sarcopenia is an increasingly recognised prognostic factor in oesophageal cancer surgery. The aim of this study was to identify the influence of body composition and related factors on chyle leak following oesophagectomy. Methods Patients who developed chyle leak after oesophagectomy between January 2006–December 2020 were identified retrospectively from a prospectively collected and maintained dataset. A control group of patients undergoing oesophagectomy during the same time period was also collected. Relationships between chyle leak and demographics, operative factors and body composition measures were investigated as primary outcomes. Risk factors for severe chyle leak, defined as need for reintervention or greater than 1 litre of output per day, were evaluated as a secondary outcome. Results There were 26 patients who developed a chyle leak following an oesophagectomy. On univariate analysis, preoperative body mass index (BMI) (P = 0.001), subcutaneous fat index (P = 0.001) and total fat index (P = 0.004) were significantly associated with chyle leak. On multivariate analysis, a lower preoperative subcutaneous fat index was a significant independent predictor of chyle leak (P = 0.001). Sarcopenia was not found to be a significant predictor of developing chyle leaks. No significant predictors of severe chyle leak were identified. Conclusion A reduced preoperative body fat composition is a risk factor for chyle leak after oesophagectomy. Sarcopenia doesn’t predict either the occurrence or severity of chyle leak. This emphasises the importance of physiological and nutritional optimisation before oesophagectomy.

Laparoscopic Complete Mesocolic Excision with Central Vascular Ligation (CME + CVL) for Right-Sided Colon Cancer: A New "Superior Mesenteric Artery First" Approach.

It remains a technical challenge to perform "superior mesenteric artery (SMA) first" approach for laparoscopic right hemicolectomy with complete mesocolon excision (CME) as the vascular anatomy of the right colon varies a lot, which may cause difficulty in early location of SMA and the risk of vascular damage during central vascular ligation (CVL). The purpose of this study was to describe a new "SMA first" approach for laparoscopic CME with CVL in right hemicolectomy with Treitz's ligamentand ileocolic vascular pedicle as the anatomical landmarks for early identificationof and exposure of SMA. This procedure was performed on 21 patients with right colon cancer between March 2020 and August 2021. To start, the transverse mesocolon was retracted to expose the ligamentof Treitz, and the pedicle of ileocolic vessels was anteriorly grasped. Next, the peritoneum near the right border of the ligamentof Treitz was divided along the left side of SMA until the peritoneum below the ileocolic vessels. Next, the mesenteric lymphatic adipose tissue outside of the sheath of SMA was dissected from medial to lateral. Then, laparoscopic right hemicolectomy with complete mesocolic excision (CME) was performed. Patients' preoperative baseline characteristics and intraoperative and postoperative complications were examined. The median operative time was 180 min, and the median intraoperative blood loss was 50 ml (interquartile range 40-90). Chylous leakage occurred in four patients, and all the patients resolved with percutaneous drainage. The total harvested lymph nodes was 21.0 (range 16-27). The median times to first flatus and liquid diet intake were both 3.0 days. The median number of postoperative hospital days was 10.0 days. No severe postoperative complications, such as abdominal infection, anastomotic leakage, or bleeding, were observed. This new "SMA first" approach is safe and technically feasible for laparoscopic CME with CVL in right hemicolectomy.

Chylous Peritonitis and Chylothorax Presenting with Acute Abdomen after Heavy Lifting

Acute abdominal pain with signs and symptoms of peritonitis due to sudden extravasation of chyle into the peritoneal cavity is a rare condition often mistaken for other disorders. Diagnosis is rarely definite preoperatively. Acute chylous peritonitis is generally idiopathic and diagnosed with laparoscopy or laparotomy. Intra-abdominal lavage and drainage are often used as treatment methods. We report a case of spontaneous chylous peritonitis due to elevated intra-abdominal pressure, which was diagnosed intraoperatively by observation of chylous fluid leakage from the retroperitoneum. The patient was treated with peritoneal lavage and drainage with primary suture ligation at the level of leakage.

Influence of body composition measures on chyle leak after oesophagectomy.

BackgroundChyle leak (CL) is an infrequent but potentially serious complication of oesophagectomy. Sarcopenia is an increasingly recognised prognostic factor in oesophageal cancer surgery. The aim of this study was to identify the influence of body composition measures on CL following oesophagectomy.MethodsPatients who developed CL after oesophagectomy between January 2006–December 2020 were identified retrospectively from a prospectively maintained dataset. A control group of patients undergoing oesophagectomy, who did not experience chyle leak during the same time period, was also collected. Relationships between CL and demographics, operative factors and body composition measures were investigated as primary outcomes. Risk factors for severe CL were evaluated as a secondary outcome.ResultsThere were 26 patients who developed a CL following an oesophagectomy. On univariate analysis, preoperative body mass index (BMI) (P=0.001), subcutaneous fat index (P=0.001) and total fat index (P=0.004) were significantly associated with CL. On multivariate analysis, a lower preoperative subcutaneous fat index was a significant independent predictor of CL (P=0.003). Sarcopenia, as an overall measure, was not found to be a significant predictor of developing CLs. No significant predictors of severe CL were identified.ConclusionsA reduced preoperative BMI and body fat composition are risk factors for CL after oesophagectomy. Sarcopenia does not predict either the occurrence or severity of CL. This presents potentially modifiable risk factors for CL after oesophagectomy and emphasises the importance of physiological and nutritional optimisation before oesophagectomy.

Chylothorax After Orthotopic Heart Transplant - A Rare Complication

<h3>Introduction</h3> A high output chylothorax is a therapeutic challenge and a cause of major morbidity due to persistent drainage of lymph, resulting in immune suppression, malnutrition and electrolyte abnormalities. Postop. chylothorax is rare (0.42% after general thoracic surgery). Chylothorax after thoracic organ transplant is very rare and mostly reported after lung transplant (1.38%) while after heart transplant it is extremely rare with only a handful of case reports. <h3>Case Report</h3> A 53yr old lady with Arrhythmogenic right ventricular dysfunction underwent orthotopic heart transplantation. She had multiple past ablations for VT and paroxysmal AF for which she was on Amiodarone. She also had a CRT device which was explanted at the time of transplant. Hypothyroidism& renal dysfunction were the other significant problems. Her transplant was complicated by primary graft dysfunction and bleeding from the right lower lobe of lung. Bronchoscopy did not reveal any cause. She was weaned off support and mobilised by the end of the 1st week. Immunosuppression and infection prophylaxis were as per institutional protocol. The chylothorax presented as large pericardial effusion and right pleural effusion on screening Echo and CXR done on postop day 7. This was confirmed on CT scan. Sub xiphoid drainage of pericardial effusion and intercostal drainage was done. The fluid was confirmed to be chyle with a triglyceride level of 8 mmol/l. The fluid was sterile. Low fat diet was started, in spite of which there was persistent drainage more than 500 ml /day. She was put on a more aggressive fat free, fruit only diet and s/c octreotide 100mcg 8 hrly. Drain output was closely monitored and surgery deferred considering the risks. Close monitoring of the nutritional status and dietary input was done. Slow but progressive decline in drainage permitted drain removal in three weeks. The dietary restrictions were eased over 3 to 4 months with no recurrence of leak. <h3>Summary</h3> Chylothorax is rare after heart transplantation. Prompt diagnosis and treatment are of paramount importance. Chyle leak is a challenge in these immunosuppressed patients given the concern for infection and the requirements of rigorous dietary modification. The risks of surgery have to be balanced against nutritional depletion and deconditioning. Close monitoring and multidisciplinary input is required for a successful outcome by conservative treatment.

Redo surgery for neurogenic thoracic outlet syndrome is useful

ObjectivesSurgery for neurogenic thoracic outlet syndrome (NTOS) has shown good outcome in numerous case series. However, 5% to 30% of patients will have persistent or recurrent symptoms, caused by incomplete first rib resection, reattachment of residual scalene muscle, fibrous scarring around the brachial plexus, or a wrong NTOS diagnosis. In patients with a sound diagnosis of recurrent or persisting NTOS, not responding to conservative measures, a secondary procedure can be considered. We report the results of redo thoracic outlet decompression surgery through the supraclavicular approach (SC-REDO-TOD) for persistent or recurrent NTOS. MethodsA retrospective review of a prospective database was performed. Every patient referred from September 2016 until January 2020 was eligible for inclusion. In an SC-REDO-TOD, we perform complete (cartilage-cartilage) resection of the first rib, any bony and fibrous anomalies, complete anterior and middle scalenectomy, and complete neurolysis of the brachial plexus (complete anatomical decompression of the brachial plexus). Clinical outcomes were assessed by questionnaires including the Disability of Arm, Shoulder and Hand (DASH), Cervico-Brachial Symptoms Questionnaire (CBSQ), and TOS (thoracic outlet syndrome) Disability scale. ResultsIn total, 45 patients had a SC-REDO-TOD. The median duration of hospital admission after SC-REDO-TOD was 1.41 days (interquartile range, 1.00 day). In total, 30 (66.66%) of 45 patients had recurrent NTOS, and 15 (33.33%) of 45 patients had persisting NTOS. Postoperative complications were seen in eight patients (18.18%). One patient had postoperative complications with permanent impairment (Horner syndrome). Seven patients had postoperative complications with full recovery (three patients had a chylous leakage that was treated with a median-chain triglycerides diet for 6 weeks, three patients had transient phrenic nerve palsy with full recovery <6 weeks, and one patient had a discrete Horner syndrome that resolved in 6 weeks). The median time of follow-up was 19.50 months (interquartile range, 14.00 months) and the response rate to the questionnaires was 91.11% at 6 months and 64.44% at 12 months. We found a positive and statistically significant difference for DASH score, CBSQ score, and TOS Disability Scale score comparing scores for all patients. (DASH score: P < .001; CBSQ score: P < .001; TOS Disability Scale: P < .001). Patients with first rib remnants showed a significant better response (lower DASH, CBSQ and TOS Disability Scale scores) compared with patients without first rib remnants (DASH score: P = .004; CBSQ score: P ≤ .014; TOS Disability Scale: P = .009). ConclusionsSC-REDO-TOD after a previous NTOS surgery shows good results with a low risk of permanent impairment. Patients with NTOS with first rib remnants after primary surgery seem to benefit the most from SC-REDO-TOD surgery.

30-Day Morbidity and Bleeding Rates Associated with Transoral Robotic Surgery for HPV Associated Oropharyngeal Squamous Cell Carcinoma: A Retrospective Analysis of Two Prospective Adjuvant Radiotherapy Deescalation Trials (MC1273 & MC1675)

<h3>Purpose/Objective(s)</h3> MC1273 and MC1675 were phase II and III clinical trials examining deescalated adjuvant chemoradiation after margin negative resection for HPV(+)OPSCC. We examine 30-day morbidity and mortality associated with primary transoral robotic (TORS) surgical resection in patients enrolled in these trials. We hypothesize that TORS was associated with low surgical morbidity. <h3>Materials/Methods</h3> Enrollment criteria and the DART regimen utilized in MC1273/MC1675 have been reported. Patients were accrued from 2013-2020. For this analysis, patients undergoing any TORS procedure were included. Prospective study data and retrospective chart review were utilized to identify events. The severity of postoperative transoral bleeding was graded using the Hinni transoral surgery bleeding scale (Grade 0 – none, Grade 1: expected postoperative blood-tinged mucous, Grade 2: resolved without operative intervention, Grade 3: venous bleed requiring cautery, Grade 4: arterial bleed requiring ligation or embolization, Grade 5: life-threatening bleed, Grade 6: death). Continuous variables using mean (SD) and categorical variables were summarized using frequency (%). <h3>Results</h3> 218 patients were included in this retrospective analysis. The mean (SD) age of the cohort was 58.9 (8.2), and 193 (88%) were male. The majority (n=146, 67%) were never smokers. TNM 8^th Edition AJCC staging for patients was as follows: pT1: 80 (37%), pT2: 108 (50%), pT3: 24 (11%), pT4: 6 (3%), pN0: 1 (<1%), pN1: 186 (85%), pN2: 31 (14%). All patients had negative margins, underwent concurrent neck dissection, and the majority (n=196, 90%) had prophylactic ligation of external carotid artery branches in the ipsilateral neck. The mean (SD) length of hospital stay was 3 (4) days. A total of 7 (3.2%) patients required tracheostomy placement at the time of surgery, and all were decannulated within 26 (median: 5, range: 2-26) days of surgery. NGT placement occurred in 98 (45%) patients, with 92% (n=90) removed within 30 days of surgery. Two (1%) patients underwent PEG placement prior to or within 30 days of surgery. There were 32 (15%) returns to the emergency department (ED) within 30 days. 10 (5%) patients required readmission. 7 (3.2%) patients experienced ≥ Grade 3 bleeding (Grade 3: 6; Grade 4: 1), with no Grade 5/6 bleeds. Other postoperative complications included 1 cardiac event (0.5%), 5 chyle leaks (2.3%), 1 pulmonary embolus (0.5%), 1 deep venous thrombosis (0.5%), 2 surgical site infections (0.9%), 1 seroma (0.5%), and 2 hematomas (0.9%). There were no treatment related deaths. <h3>Conclusion</h3> TORS for HPV(+)OPSCC in carefully selected patients undergoing a deescalation protocol at a high volume center was associated with low morbidity and zero mortality. ED return rates of 15%, readmission rates of 5%, and intervention rates of 3% for postoperative bleeds are all comparable to rates after routine pediatric tonsillectomy.

Understanding Lymphatic Anatomy and Abnormalities at Imaging.

Lymphatic abnormalities encompass a wide range of disorders spanning solitary common cystic lymphatic malformations (LMs) to entities involving multiple organ systems such as lymphangioleiomyomatosis. Many of these disorders are rare, yet some, such as secondary lymphedema from the treatment of malignancy (radiation therapy and/or lymph node dissection), affect millions of patients worldwide. Owing to complex and variable anatomy, the lymphatics are not as well understood as other organ systems. Further complicating this is the variability in the description of lymphatic disease processes and their nomenclature in the medical literature. In recent years, medical imaging has begun to facilitate a deeper understanding of the physiology and pathologic processes that involve the lymphatic system. Radiology is playing an important and growing role in the diagnosis and treatment of many lymphatic conditions. The authors describe both normal and common variant lymphatic anatomy. Various imaging modalities including nuclear medicine lymphoscintigraphy, conventional lymphangiography, and MR lymphangiography used in the diagnosis and treatment of lymphatic disorders are highlighted. The authors discuss imaging many of the common and uncommon lymphatic disorders, including primary LMs described by the International Society for the Study of Vascular Anomalies 2018 classification system (microcystic, mixed, and macrocystic LMs; primary lymphedema). Secondary central lymphatic disorders are also detailed, including secondary lymphedema and chylous leaks, as well as lymphatic disorders not otherwise easily classified. The authors aim to provide the reader with an overview of the anatomy, pathology, imaging findings, and treatment of a wide variety of lymphatic conditions. ©RSNA, 2022.

Successful treatment of congenital chylothorax using povidone iodine in trisomy 21 newborn

Congenital chylothorax is known as abnormal leakage and accumulation of chyle in the pleural space. As one of the minimally invasive treatments, chemical pleurodesis has been more frequently used in treating pediatric chylothorax in recent years. We report through this observation the clinical case of a newborn male with Down’s syndrome born at 38 weeks of amenorrhea admitted to our unit for a respiratory distress after his birth. On exploration we concluded right unilateral congenital chylothorax. Treatment consisted in an evacuation of pleural fluid with a chemical pleurodesis based on povidone iodine with good clinical and radiological outcome. Keywords: congenital chylothorax; chemical pleurodesis; down’s syndrome; povidone iodine.