甲状腺癌中央区淋巴结清扫术后并发乳糜漏14例临床分析
|
摘要
目的探讨甲状腺癌中央区淋巴结清扫术后并发乳糜漏的原因、临床特点和诊治方法。方法回顾性分析2011年12月至2017年2月在中国医科大学附属第一医院甲状腺外科行甲状腺癌中央区淋巴结清扫术病人中14例术后发生乳糜漏病例的临床资料。结果乳糜漏发生率为0.5%,出现在术后的第1～2天,中位时间1.5 d;发生乳糜漏之前的引流量峰值为30～76 mL,中位数为49 mL;乳糜漏发生后,引流量进一步增多,最大值为30～135 mL,中位数为57.5 mL。乳糜漏病人淋巴结清扫区域:左侧中央区清扫3例(21.4%);右侧中央区清扫8例(57.2%),其中4例包含右侧喉返神经(rRLN)深面(rⅥb区)淋巴结清扫;双侧中央区清扫3例(21.4%,均不包含rⅥb区清扫)。淋巴结清扫数目0～14枚。发生乳糜漏后,2例经低脂饮食痊愈,7例经禁食水痊愈,剩余5例调整饮食效果不佳,辅以持续低负压吸引后痊愈。乳糜漏基本治愈时间为1～8 d,中位时间3 d。结论甲状腺癌中央区淋巴结清扫术后乳糜漏发生率较低,引流量一般较少,术后1～2天引流量异常增多及性质改变时应警惕乳糜漏的发生,及时采取调整饮食或辅以持续负压吸引可在短期内治愈。
Objective To explore the pathogeny, the clinical characteristics, diagnosis and treatment of chylous leakage after thyroid cancer surgery with central lymph node dissection(CLND). Methods The clinical data of 14 cases of chylous leakage after thyroid cancer surgery with CLND admitted in the Department of Thyroid Surgery, the First Hospital of China Medical University between December 2011 and February 2017 were analyzed retrospectively.Results The incidence of chylous leakage was 0.5%. It occurred in the median of postoperative 1.5 days(range 1 to 2). The median volume of peak drainage before chylous leakage was 49 mL(range 30 to 76). When it happened, the volume increased. The median volume of the maximum drainage after surgery was 57.5 m L(range 30 to 135). Chylous fistula occurred after left CLND in 3 cases(21.4%). Right CLND in 8 cases(57.2%), in which 4 cases had rⅥb lymph node dissection. Bilateral CLND in 3 cases(21.4%, which did not have rⅥb lymph node dissection). The number of dissected lymph node were 0 to 14. After chylous leakage happened, 2 cases were cured by low fat diet and 7 cases were cured by water fasting. The remaining 5 cases had poor effect of adjusting diet. They recovered with continuous low negative pressure drainage. The median healing time was 3 days(range 1 to 8). Conclusion The incidence of chylous leakage after thyroid cancer surgery with CLND is low. Chylous leakage should be watch out after CLND, when drainage increases abnormally or the liquid property change. It can be treated by diet adjustment and continuous suction in a very short time.
Objective To explore the pathogeny, the clinical characteristics, diagnosis and treatment of chylous leakage after thyroid cancer surgery with central lymph node dissection(CLND). Methods The clinical data of 14 cases of chylous leakage after thyroid cancer surgery with CLND admitted in the Department of Thyroid Surgery, the First Hospital of China Medical University between December 2011 and February 2017 were analyzed retrospectively.Results The incidence of chylous leakage was 0.5%. It occurred in the median of postoperative 1.5 days(range 1 to 2). The median volume of peak drainage before chylous leakage was 49 mL(range 30 to 76). When it happened, the volume increased. The median volume of the maximum drainage after surgery was 57.5 m L(range 30 to 135). Chylous fistula occurred after left CLND in 3 cases(21.4%). Right CLND in 8 cases(57.2%), in which 4 cases had rⅥb lymph node dissection. Bilateral CLND in 3 cases(21.4%, which did not have rⅥb lymph node dissection). The number of dissected lymph node were 0 to 14. After chylous leakage happened, 2 cases were cured by low fat diet and 7 cases were cured by water fasting. The remaining 5 cases had poor effect of adjusting diet. They recovered with continuous low negative pressure drainage. The median healing time was 3 days(range 1 to 8). Conclusion The incidence of chylous leakage after thyroid cancer surgery with CLND is low. Chylous leakage should be watch out after CLND, when drainage increases abnormally or the liquid property change. It can be treated by diet adjustment and continuous suction in a very short time.
引文
[1]Lee YS,Kim BW,Chang HS,et al.Factors predisposing to chyle leakage following thyroid cancer surgery without lateral neck dissection[J].Head Neck,2013,35(8):1149-1152.
[2]Roh JL,Yoon YH,Chan IP.Chyle Leakage in patients undergoing thyroidectomy plus central neck dissection for differentiated papillary thyroid carcinoma[J].Ann Surg Oncol,2008,15(9)2576-2580.
[3]吴干勋,蔡丽,胡俊兰,等.分化型甲状腺癌中央区清扫术后乳糜漏病例分析[J].中华耳鼻咽喉头颈外科杂志,2015,50(3)248-249.
[4]郝伟静,于洋,郑向前,等.甲状腺癌中央区淋巴结清除术后乳糜漏的防治[J].中国肿瘤临床,2016,43(2):72-75.
[5]徐震纲,刘绍严,朱一鸣.分化型甲状腺癌颈侧区淋巴结清扫专家共识(2017版)[J].中国实用外科杂志,2017,37(9):985-991.
[6]Priego JP,Collado G MV,Rojo BR,et al.Chyle fistula in right cervical area after thyroid surgery[J].Clin Transl Oncol,200810(9):593-596.
[7]黎介寿,吴孟超,黄志强.普通外科手术学[M].2版.北京:人民军医出版社,2005:4-5.
[8]Smith ME,Jani FRP.The surgical anatomy and clinical relevance of the neglected right lymphatic duct:review[J].J Laryngol Otol,2013,127(2):1-6.
[9]Randolph GW.甲状腺和甲状旁腺外科学[M].田文,姜可伟译.2版.北京:北京大学医学出版社,2016:22.
[10]刘文,程若川,苏艳军,等.甲状腺微小乳头状癌rⅥb区转移预测因素及rⅥa区、rⅥb区转移相关性研究[J].中国实用外科杂志,2017,37(9):1007-1012.
[11]Zhang DG,Gao L,Miao YW,et al.Risk factors for posterior to right recurrent laryngeal nerve lymph node metastasis in papillary thyroid carcinoma[J].Saudi Med J,2014,35(8):832-837.
[12]赵文新,颜守义,王波,等.右侧甲状腺乳头状癌喉返神经后方淋巴结清扫的临床意义[J].中华内分泌外科杂志,2016,10(4):280-283.
[13]Qu Y,Zhang H,Zhang P,et al.Risk factors and the preoperative assessment of right paraoesophageal lymph node metastasis in right lobe papillary thyroid carcinoma:A case series[J].Int J Surg,2017,42:123-127.
[14]Pinyi Z,Bin Z,Jianlong B,et al.Risk factors and clinical indication of metastasis to lymph nodes posterior to right recurrent laryngeal nerve in papillary thyroid carcinoma:a single-center study in China[J].Head Neck,2014,36(9):1335-1342.
[15]张浩.重视甲状腺乳头状癌治疗中Ⅵ区淋巴结清扫术的临床价值[J].中国实用外科杂志,2011,31(5):391-394.
[16]张浩,孙威.颈淋巴结清扫术易遗漏转移淋巴结部位及其对策[J].中国实用外科杂志,2017,37(9):965-970.
[17]田文,张浩.甲状腺外科能量器械应用专家共识(2017版)[J].中国实用外科杂志,2017,37(9):992-997.
[18]Nowak K,Wierzbicka M,Szyfter W.Chylous leakage--rare but still dangerous complication after neck surgery[J].Otolaryngol Pol,2011,65(2):128-131.
[19]Lorenz K,Abuazab M,Sekulla C,et al.Management of lymph fistulas in thyroid surgery.[J].Langenbecks Arch Surg,2010395(7):911-917.
[20]孙团起,吴毅.甲状腺手术乳糜漏发生原因及防治[J].中国实用外科杂志,2012,32(5):372-374.
[2]Roh JL,Yoon YH,Chan IP.Chyle Leakage in patients undergoing thyroidectomy plus central neck dissection for differentiated papillary thyroid carcinoma[J].Ann Surg Oncol,2008,15(9)2576-2580.
[3]吴干勋,蔡丽,胡俊兰,等.分化型甲状腺癌中央区清扫术后乳糜漏病例分析[J].中华耳鼻咽喉头颈外科杂志,2015,50(3)248-249.
[4]郝伟静,于洋,郑向前,等.甲状腺癌中央区淋巴结清除术后乳糜漏的防治[J].中国肿瘤临床,2016,43(2):72-75.
[5]徐震纲,刘绍严,朱一鸣.分化型甲状腺癌颈侧区淋巴结清扫专家共识(2017版)[J].中国实用外科杂志,2017,37(9):985-991.
[6]Priego JP,Collado G MV,Rojo BR,et al.Chyle fistula in right cervical area after thyroid surgery[J].Clin Transl Oncol,200810(9):593-596.
[7]黎介寿,吴孟超,黄志强.普通外科手术学[M].2版.北京:人民军医出版社,2005:4-5.
[8]Smith ME,Jani FRP.The surgical anatomy and clinical relevance of the neglected right lymphatic duct:review[J].J Laryngol Otol,2013,127(2):1-6.
[9]Randolph GW.甲状腺和甲状旁腺外科学[M].田文,姜可伟译.2版.北京:北京大学医学出版社,2016:22.
[10]刘文,程若川,苏艳军,等.甲状腺微小乳头状癌rⅥb区转移预测因素及rⅥa区、rⅥb区转移相关性研究[J].中国实用外科杂志,2017,37(9):1007-1012.
[11]Zhang DG,Gao L,Miao YW,et al.Risk factors for posterior to right recurrent laryngeal nerve lymph node metastasis in papillary thyroid carcinoma[J].Saudi Med J,2014,35(8):832-837.
[12]赵文新,颜守义,王波,等.右侧甲状腺乳头状癌喉返神经后方淋巴结清扫的临床意义[J].中华内分泌外科杂志,2016,10(4):280-283.
[13]Qu Y,Zhang H,Zhang P,et al.Risk factors and the preoperative assessment of right paraoesophageal lymph node metastasis in right lobe papillary thyroid carcinoma:A case series[J].Int J Surg,2017,42:123-127.
[14]Pinyi Z,Bin Z,Jianlong B,et al.Risk factors and clinical indication of metastasis to lymph nodes posterior to right recurrent laryngeal nerve in papillary thyroid carcinoma:a single-center study in China[J].Head Neck,2014,36(9):1335-1342.
[15]张浩.重视甲状腺乳头状癌治疗中Ⅵ区淋巴结清扫术的临床价值[J].中国实用外科杂志,2011,31(5):391-394.
[16]张浩,孙威.颈淋巴结清扫术易遗漏转移淋巴结部位及其对策[J].中国实用外科杂志,2017,37(9):965-970.
[17]田文,张浩.甲状腺外科能量器械应用专家共识(2017版)[J].中国实用外科杂志,2017,37(9):992-997.
[18]Nowak K,Wierzbicka M,Szyfter W.Chylous leakage--rare but still dangerous complication after neck surgery[J].Otolaryngol Pol,2011,65(2):128-131.
[19]Lorenz K,Abuazab M,Sekulla C,et al.Management of lymph fistulas in thyroid surgery.[J].Langenbecks Arch Surg,2010395(7):911-917.
[20]孙团起,吴毅.甲状腺手术乳糜漏发生原因及防治[J].中国实用外科杂志,2012,32(5):372-374.