Campisi Corrado C, Boccardo Francesco, Piazza Cesare, Campisi Corradino
Unit of Plastic and Reconstructive Surgery, Department of Surgery, IRCCS University Hospital San Martino - IST National Institute for Cancer Research, Genova, Italy.
Curr Opin Otolaryngol Head Neck Surg. 2013 Apr;21(2):150-6. doi: 10.1097/MOO.0b013e32835e9d97.
The present review is focused on the management of lymphatic, chylous, and thoracic duct lesions following head and neck surgery, with particular attention to these complications after neck dissection. Postoperative scenarios may include chylous fistula, chylothorax, chylomediastinum, chylopericardium, lymphocele, persistent lymphorrhea, and secondary lymphedema.
There is a paucity of literature on the treatment of lymphatic, chylous, and thoracic duct injuries following head and neck surgery; however, this review suggests that the most appropriate treatment should include both conservative and surgical approaches. Nonsurgical options consist of low-fat diet with medium-chain triglycerides, total parenteral nutrition, careful monitoring of fluid and electrolytes, drainage of the leakage, somatostatin analogs such as octreotide, and negative-pressure wound therapy. On the other hand, surgical management includes therapeutic percutaneous lymphography-guided thoracic duct cannulation and embolization, thoracic duct ligation, excision and imbrication of leaking lymphatics, chylous fistula surgical/microsurgical repair, fistula closure by locoregional flaps, video-assisted thoracoscopic surgery, thoracotomy, pleurodesis and decortication, pericardial 'window', and pleura-venous/pleura-peritoneal shunts. In addition, single or, preferably, multiple lymphovenous anastomoses may be taken into account.
The various possible clinical presentations of such challenging lymphatic, chylous, and thoracic duct injuries require an appropriate multidisciplinary approach by experienced teams. Primary prevention of these complications can be achieved through adequate surgical planning to minimize lesions, including structured and thorough patient assessment, and centralization of resources and teams.
本综述聚焦于头颈部手术后淋巴管、乳糜管及胸导管损伤的处理，尤其关注颈部清扫术后的这些并发症。术后情况可能包括乳糜瘘、乳糜胸、乳糜纵隔、乳糜心包、淋巴囊肿、持续性淋巴漏及继发性淋巴水肿。
关于头颈部手术后淋巴管、乳糜管及胸导管损伤治疗的文献较少；然而，本综述表明最合适的治疗应包括保守和手术方法。非手术选择包括含中链甘油三酯的低脂饮食、全胃肠外营养、仔细监测液体和电解质、漏液引流、生长抑素类似物如奥曲肽以及负压伤口治疗。另一方面，手术管理包括经皮淋巴管造影引导下的胸导管插管及栓塞治疗、胸导管结扎、渗漏淋巴管的切除及重叠缝合、乳糜瘘的手术/显微手术修复、局部皮瓣封闭瘘口、电视辅助胸腔镜手术、开胸手术、胸膜固定术及纤维板剥脱术、心包“开窗”以及胸膜-静脉/胸膜-腹膜分流术。此外，可考虑进行单次或，最好是多次淋巴静脉吻合术。
此类具有挑战性的淋巴管、乳糜管及胸导管损伤的各种可能临床表现需要经验丰富的团队采取适当的多学科方法。通过充分的手术规划以尽量减少损伤，包括对患者进行系统全面的评估以及资源和团队的集中化，可实现对这些并发症的一级预防。
