Van Natta Timothy L, Nguyen Alexander T, Benharash Peyman, French Samuel W
Department of Surgery, Harbor-UCLA Medical Center, Torrance, California 90509, USA.
JSLS. 2009 Jul-Sep;13(3):430-2.
Chylous fistulas can occur after neck surgery. Both nonoperative measures and direct fistula ligation may lead to fistula resolution. However, a refractory fistula requires upstream thoracic duct ligation. This can be accomplished minimally invasively. Success depends on lymphatic flow interruption where the duct enters the thorax. We report on the utility of frozen section confirmation in achieving this goal.
Persistent chylous fistulas occurred in 2 patients after left cervical operations. In the first patient, attempted direct fistula ligation and sclerosant application failed. Fasting, parenteral nutrition, and somatostatin-analog provided no benefit. For the second patient, nonoperative treatment was also ineffective. Prior radiation therapy and multiple cervical operations militated against attempted direct fistula ligation. Both patients underwent thoracoscopic thoracic duct interruption.
In both cases, a duct candidate was identified between the aorta and azygos vein. Frozen section analysis of tissue resected between endoclips verified it as thoracic duct. Fistula resolution ensued promptly in both instances.
This report lends further credence to the efficacy of minimally invasive thoracic duct ligation in treating postoperative cervical chylous fistulas. Frozen section confirmation of thoracic duct tissue is useful. It allows one facile with thoracoscopy, but less familiar with thoracic duct ligation, to confidently terminate the operation.
颈部手术后可发生乳糜瘘。非手术措施和直接瘘管结扎均可使瘘管愈合。然而，难治性瘘管需要进行上游胸导管结扎。这可以通过微创方式完成。成功取决于在胸导管进入胸腔处中断淋巴液流动。我们报告了冰冻切片确认在实现这一目标中的作用。
2例患者在左颈部手术后发生持续性乳糜瘘。第一例患者，尝试直接瘘管结扎和应用硬化剂均失败。禁食、肠外营养和生长抑素类似物均无效果。第二例患者，非手术治疗也无效。既往放疗和多次颈部手术使尝试直接瘘管结扎不可行。2例患者均接受了胸腔镜下胸导管阻断术。
在两例患者中，均在主动脉和奇静脉之间识别出一条可能的导管。对夹闭端之间切除的组织进行冰冻切片分析，证实其为胸导管。两例患者的瘘管均迅速愈合。
本报告进一步证实了微创胸导管结扎术治疗术后颈部乳糜瘘的有效性。胸导管组织的冰冻切片确认很有用。它使熟悉胸腔镜但不太熟悉胸导管结扎的人能够自信地结束手术。
