口腔癌颈淋巴清扫术后并发乳糜胸3例及文献复习

Chylothorax following neck dissection for oral cancer:a report of 3 cases and literatures review

目的探讨口腔癌颈淋巴清扫术后并发乳糜胸的临床表现、诊断方法及治疗策略。方法分析2020年1月至2021年5月于中南大学湘雅医院口腔医学中心行口腔癌颈淋巴清扫扫术后并发乳糜胸的3例患者的临床资料,并通过复习文献,总结该并发疾病的危险因素、临床表现、诊断方法、治疗策略及预后。结果3例患者均为男性口腔癌患者,年龄42~63岁,临床表现为颈淋巴清扫术后2~5 d出现进行性呼吸困难,胸部X线片、B超和(或)CT显示双侧胸腔积液,胸腔穿刺液送检乳糜试验阳性后确诊。其中左侧乳糜胸1例(左侧颈淋巴清扫),双侧乳糜胸2例(分别为左侧颈淋巴清扫和双侧颈淋巴清扫)。3例患者均在术中对胸导管进行过缝扎处理,2例术后还伴有严重的颈部乳糜漏,局部加压效果不佳,行再次手术结扎胸导管。3例患者的乳糜胸均采用营养支持、机械辅助通气、胸腔穿刺引流等保守治疗后,乳糜量逐渐减少,7~15 d后拔除胸部引流管,顺利出院。文献复习结果表明,口腔癌颈淋巴清扫术后患者出现进行性呼吸困难时,临床医师应对患者进行胸片、超声影像、CT及乳糜试验等辅助检查手段,当明确诊断为乳糜胸后,可选用营养支持、生长抑素、机械性辅助通气、胸腔穿刺引流等保守治疗,必要时进行开胸结扎胸导管手术治疗。结论乳糜胸是口腔癌颈淋巴清扫术后较为少见的并发症,以双侧胸腔同时发生为主,亦可只发生于颈淋巴清扫术侧胸腔,左侧颈淋巴清扫是并发乳糜胸的危险因素。临床表现多为颈淋巴清扫术后进行性呼吸困难,详细的体查、胸部X线片、B超和(或)CT可发现胸腔积液,穿刺抽出乳白色或淡黄色乳糜样液体且乳糜实验阳性后可确诊。采用胸腔穿刺引流,呼吸支持等保守治疗多可获得痊愈。

Objective To investigate the clinical manifestations,diagnostics,and treatment of chylothorax following neck dissection for oral cancer.Methods The clinical data of 3 patients with chylothorax after neck dissection for oral cancer from January 2020 to May 2021 in the Stomatological Center of Xiangya Hospital,Central South University,were retrospectively analyzed in detail,and the relevant literature was reviewed.The risk factors,clinical manifestations,diagnostics,treatment,and prognosis of chylothorax were summarized.Results The 3 patients were all male patients with oral cancer aged 4263 years.Their clinical manifestations were progressive dyspnea 25 days after cervical lymphadenectomy.Chest Xray,Bultrasound,and/or CT showed unilateral or bilateral pleural effusion,and the diagnosis was confirmed after a positive chylous test of pleural puncture fluid.There was 1 case with left chylothorax(1 case after left neck dissection)and 2 cases with bilateral chylothorax(1 case after left neck dissection,1 case after bilateral neck dissection).Severe neck chylous leakage occurred in 2 patients;local compression did not work,and the thoracic ducts were ligated.All patients were treated with nutritional support,assisted mechanical ventilation,tube thoracostomy drainage,and other conservative treatments.The chylothorax volume of each patient was gradually reduced,and the chest drainage tube was removed 7 to 15 days later.All patients recovered successfully.The literature review results showed that when patients with oral cancer after neck dissection experienced progressive dyspnea,related auxiliary examination methods such as chest Xray,Bultrasound,CT,and chyle tests should be used by clinicians.When a patient is diagnosed with chylothorax,they should be treated with nutritional support,mechanical ventilation,somatostatin,thoracic puncture drainage,other conservative treatments,and even thoracotomy and ligation of the thoracic duct surgery when necessary.Conclusion Chylothorax is a relatively rare complication after neck dissection for oral cancer.It mainly occurs bilaterally or only in the ipsilateral pleural cavity on the surgical side of neck dissection.Left neck dissection is a risk factor.The clinical manifestations are mostly progressive dyspnea after neck dissection.Detailed physical examination,chest Xray,B ultrasound,and/or CT could detect pleural effusion,and chylothorax could be diagnosed when milky white or pale yellow chylous liquid is aspirated and the chylous test is positive.Most patients can be cured with tube thoracostomy drainage,respiratory support,and other conservative treatments.