Complications

Postoperative complications after neck surgery have a significant impact on morbidity and health care cost, leading to prolonged hospitalizations, further operations, permanent sequelae, and sometimes, fatal outcome. Aging, poor nutritional status, and chronic diseases of the respiratory, cardiovascular, and other systems (due to alcohol and tobacco abuse) are common factors in most patients with tumors of the upper aerodigestive tract. Salvage surgery after radiation therapy has also been related to higher incidence of complications.

In procedures not requiring opening of the aerodigestive tract, functional neck dissection is considered a clean surgical procedure, and perioperative antibiotics are not beneficial in preventing infection. Antibiotic prophylaxis is important to decrease the infection rate in some surgical procedures, although it is not the key to the problem in isolated neck dissection. Different antibiotic combinations that cover aerobic and anaerobic bacteria are reported depending on the individual preferences. Dose, time of administration, and type of antibiotic depend on personal preferences and are different at each institution.

Infection should be suspected in a patient with spiking fever, chills, malaise, odor, and swelling or edema of the skin flaps. A small separate incision, or the opening of a limited window in the skin incision, is usually sufficient to drain a serohematoma and prevent further elevation of the flaps with the risk of necrosis and exposure of the great vessels.

Wound Dehiscence

Wound dehiscence is related to inadequate planning of the incision or to infection. Proper placement of the incision should be planned with the patient sitting in the upright position. The location of the incision and its length should be sufficient to allow adequate exposure to minimize the need for vigorous wound retraction intraoperatively. The skin flaps should be carefully protected from retractors or cautery. We usually fix wet towels to the skin flaps to protect the skin throughout the operation and to avoid direct traction over the skin edge. Crosshatch marks should be avoided to improve the cosmetic results and to avoid additional scarring. Methylene blue or surgical pen marks allow proper realignment of long incisions during skin closure without the risk of additional scars.

Chylous Fistula

Chylous leakage is an uncommon complication, with a reported incidence of 1 to 2.5%. It is much more frequent on the left side of the neck. When the thoracic duct is to be ligated during surgery, it should be surrounded by muscle, fascia, or adipose tissue to avoid sectioning its thin wall with the ligature. After ligation, the lower part of the left side of the neck must be carefully inspected for chyle pooling. Asking the anesthesiologist to increase the intrathoracic pressure and placing the patient in the Trendelenburg position are helpful in the intraoperative identification of chyle leak in the area of the thoracic duct. It is important to note that in most patients developing postoperative chyle fistula, this was previously identified and apparently controlled intraoperatively.

In the postoperative period, chylous fistula is recognized by the appearance of a milky fluid in the drains. This is usually evident within the first 5 days after surgery. The chylous origin of the fluid can be confirmed by measuring the content of triglycerides, usually over 100 mg/dL. When chylous leak is suspected, dietary modifications can be prescribed. Low fat diet, either enteral or parenteral, is usually recommended because medium-chain triglycerides are absorbed directly into the portal venous circulation, avoiding the thoracic duct. Elevation of the head, repeated aspiration, and pressure dressing are also recommended. However, it is important to note that preservation of the sternocleidomastoid muscle in functional and selective neck dissection constitutes an important obstacle for successful compression. Insertion of a pressure packing impregnated with irritant solution, like Betadine, into the area of the thoracic duct has also been recommended as a nonsurgical method to stop chylous leak. The daily volume of the leak has been reported to range from 80 to 4500 mL. When more than 500 mL of chyle drain per day, nonsurgical stop is unlikely.

If no response is found upon conservative treatment, the lower part of the neck should be surgically explored. Before surgery is attempted it may be helpful to put the patient on a high lipid enteral diet to give chyle a thick and milky consistency, which will improve the intraoperative identification of the leak.

Vascular Complications

Bleeding

Bleeding is not a frequent complication after neck dissection, but when it happens, it is important to determine whether the hemorrhage is due to a small superficial vessel or to a more important deep vessel. Superficial bleeding is usually bright red, it does not bulge the skin flaps, and it tends to stop with gentle external compression or by placing a stitch around the bleeding point. Generalized oozing of blood can produce up to 500 mL in a few hours. On the other hand, ballooning of the skin flaps or filling the drain system containers with more than 250 mL of blood in less than 30 minutes indicates a more serious hemorrhage.