title: Abdominal compression: a new intraoperative maneuver to detect chyle fistulas during left neck dissections that include level IV.
abstract: BACKGROUND
  Chyle fistulas may occur after left neck dissections that include level IV, due to injury of the thoracic duct or of 1 of its major branches. Despite being unusual, this complication carries substantial postoperative morbidity and even mortality. So far, no effective intraoperative maneuver has been reported to detect this fistula at the end of a neck dissection. In this cohort study, we sought to describe a simple new maneuver, intraoperative abdominal compression, which can effectively help to identify an open major lymphatic duct on level IV at the end of a neck dissection.
  
  
  METHODS
  From March 1989 to September 2010, 206 patients underwent neck dissections involving left level IV, and underwent intraoperative abdominal compression. There were 119 men and 87 women, with ages ranging from 18 to 81 years (median, 52 years). One hundred forty-four patients had squamous cell carcinomas, 54 had thyroid carcinomas, 5 had malignant melanomas, and 3 had salivary cancers. Distribution by type of left neck dissection was: selective including levels II, III, and IV (73 cases; 35.4%), selective including levels II, III, IV, and V (55 cases; 26.6%), selective including levels I, II, III, and IV (12 cases; 5.8%), modified radical (47 cases; 22.8%), and radical (19 cases; 9.2%). In all cases, at the end of the procedure, the endotracheal tube was temporarily disconnected from the ventilator. Keeping the dissected level IV area under clear visualization, an abdominal compression was performed. At this moment, any detected lymphatic leak was carefully clamped and tied with nonabsorbable sutures. After ventilating the patient, the intraoperative abdominal compression was repeated to reassure complete occlusion of the lymphatic vessel.
  
  
  RESULTS
  In 13 cases (6.3%), a chyle leak was detected after performing the intraoperative abdominal compression. All leaks except for 2 were successfully controlled after 1 attempt. In these 2 patients, a patch of muscle and fat tissue was applied with fibrin glue on the top. In 1 of these patients, another chyle leak in a different location was detected only at the second intraoperative abdominal compression, and was also effectively closed. Postoperatively, there were 2 (1%) chyle fistulas, both among these 13 cases, and all were successfully managed with clinical measures only. No fistulas occurred among the remaining 193 patients in whom intraoperative abdominal compression did not demonstrate lymphatic leak.
  
  
  CONCLUSIONS
  To our knowledge, this is the first description of a specific maneuver to actively detect a lymphatic fistula at the end of a left neck dissection involving level IV. In this study, intraoperative abdominal compression was able to detect an open lymphatic vessel in 6.3% of the cases, as well as to assure its effective sealing in the remaining 93.7% of the patients. Moreover, no life-threatening high-volume fistula was noted in this study.
authors.affiliation: Department of Head and Neck Surgery, University of São Paulo Medical School, São Paulo, Brazil. cerneamd@uol.com.br
authors.forename: Claudio R
authors.initials: CR
authors.lastname: Cernea
authors.forename: Flavio C
authors.initials: FC
authors.lastname: Hojaij
authors.forename: Dorival
authors.initials: D
authors.lastname: De Carlucci
authors.forename: Marcos R
authors.initials: MR
authors.lastname: Tavares
authors.forename: Vergilius J
authors.initials: VJ
authors.lastname: Araújo-Filho
authors.forename: Gilberto Britto E
authors.initials: GB
authors.lastname: Silva-Filho
authors.forename: Lenine G
authors.initials: LG
authors.lastname: Brandão
mesh_terms: D000005:Abdomen; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002913:Chyle; D015331:Cohort Studies; D005260:Female; D005402:Fistula / Q000175:diagnosis* / Q000209:etiology / Q000601:surgery; D006801:Humans; D008297:Male; D008875:Middle Aged; D037981:Neck Dissection / Q000009:adverse effects*; D011312:Pressure; D013897:Thoracic Duct / Q000293:injuries* / Q000601:surgery; D055815:Young Adult