Application Of Bio-glue Combined With Adjacent Muscle Flap In The Treatment Of Complex Chyle Fistula

Objective:To explore the feasibility and effective value of medical adhesive glue combined with regionalmuscle flap in the treatment of complicated chylous fistula after cervical lymph dissection,and to summarize and analyze the causes,prevention and treatment of chylous fistula.Methods:A total of 16 patients with complex chylous fistula,including 10 males and 6females,were selected from 1105 patients with oral and oropharyngeal cancer admitted from January 2014 to December 2018.Inclusion criteria:(1)clear "oily-like" clear liquid was seen in the position of the thoracic duct during surgery,and those who had conventional sutures or unilateral adjacent flap repair were not effective;(2)postoperative chylous fistula,the milky white drainage fluid was drained by negative pressure for more than 24 hours at 500 mL,and conventional methods such as compression on the clavicle,low-fat diet,total parenteral nutrition,etc.were not effective.All patients had no history of radiotherapy before surgery.All patients with complicated chylous fistula occurred on the left side;11 cases of radical cervical lymphadenectomy and 5 cases of non-radical cervical lymphadenectomy.The conservative treatment was ineffective,and the second surgical exploration revealed that the fistula of the thoracic duct was> 5 mm,and the thoracic duct could not be sutured or ligated conventionally.Application of medical bio-adhesive combined with adjacent muscle flaps in the treatment of patients with complicated chylous fistula and observation of its efficacy.Results: Among the 1105 patients undergoing cervical lymph node dissection,59(5.3%)had chylous fistula,among which 16(27%)had complex chylous fistula.five of the cases was found and confirmed to be chylous fistula during the operation.After routine ligation and suture of the thoracic duct fistula during the operation,there was still significant "oil-flower-like" chylous fluid overflow in the operative area.After treatment with medical bio-adhesive combined with orthotopic muscle flap coverage,lymphatic fluid overflow was significantly reduced.No milky drainage fluid was found after the operation.After 1 week,it was changed to a routine diet.No special abnormality wasfound in the drainage fluid.Among the 11 patients diagnosed with postoperative chylous fistula,the conservative treatment was not effective,and the secondary surgical treatment was carried out,and the medical bio-adhesive combined with orthotopic muscle flap was applied to block.After 2d,the drainage volume began to decrease,and the drainage tube was removed 5?6d.Postoperative follow-up showed that all the 16 patients were cured after surgery,with no discomfort in the operative area,good neck attachment and normal skin flap color and texture.The mean time of drainage tube removal after the second operation was 4.4d.No recurrence of chylous fistula and no local adverse reactions were found within 3 months.In one of the patients,postoperative routine supraclavicular pressure dressing resulted in obvious neck swelling,and the patient presented with symptoms of holding her breath.Urgent CT examination showed that the left parapharyngeal space-carotid artery space was wrapped with effusion and gas accumulation.Surgical exploration was performed.During the operation,it was found that the thoracic duct injury had formed a fistula,and the fistula was >5mm.Medical bio-adhesive was applied to seal the fistula,and the proximal muscle flap was used to cover the fistula.Conclusion:1.Diagnosis of chylous fistula after surgery should be treated conservatively immediately.Take bed rest and bed head raising with MCT / fat-free diet or TPN,drainage,pressure bandage,etc.Monitor fluid balance,electrolyte and protein status closely.If the effect of conservative treatment alone is not satisfactory,surgery should be considered.2.The prevention of chylous fistula should be more important than its treatment,and preventing it beforehand can reduce the patient's complications.Methods to prevent chylous fistula include: the surgeon is familiar with the anatomy of the thoracic duct,cooperates with the anesthesiologist to increase the patient's intrathoracic pressure,double ligates the unabsorbable line at the suspected lymphatic vessel,and covers the local flap with the operating bed.3.The application of medical bio-glue for precise positioning can quickly and effectively seal the neck lymphadenectomy with thoracic duct fistula,and the adjacent muscle flapto cover the wound surface,which is safe and stable.When routine treatment of complex chylous fistula is ineffective,it can ensure the surgical effect,shorten hospital stay,avoid serious complications,and provide an ideal,efficient and safe method for clinical treatment of complex chylous fistula.