Chyle Fistula Management

Abstract

Chyle fistula is a potentially devastating phenomenon that results from violation of the thoracic duct or right lymphatic duct in the neck, most commonly during radical neck dissection. It may impair nutrition, compromise and delay wound healing, and prolong hospitalization. In view of the morbidity produced by chyle leak discovered postoperatively and the lack of success of its management by aggressive surgical techniques, we have employed a different protocol for the past six years. It is based on careful intraoperative inspection of the neck for possibly chyle fistula, minimal but specific surgical handling of the damaged duct, and a postoperative nutritional program designed to reduce chyle formation and facilitate spontaneous closure. The nutritional element involves the use of medium chain triglycerides (MCT) that are easily ingested, rapidly absorbed, and readily metabolized directly into the portal venous system, bypassing the thoracic duct lymphatic system. During a four-year period, 1976 to 1980, 574 radical neck dissections were performed with only six chyle fistulas being detected postoperatively. All have been successfully treated by the protocol with no patients requiring reexploration. There have been no deaths owing to chyle fistula and no complications or side effects from the use of medium chain triglycerides.

Chyle Fistula after Neck Dissection for an Unusual Breast Cancer Recurrence

“…The CF was resistant to conservative treatment and somatostatin analogue administration even though the output was under 500 ml daily. This situation contradicts the literature [3,4]. Having observed these 2 rare entities in 1 patient inspired us to present the case.…”

Crushed Muscle Tissue Graft: A Efficient Repair Technique for Intraoperative Chylous Fistulas

“…14,15 The complications like delayed wound healing due to skin flap elevation later delaying the required adjuvant radiotherapy can lead onto fatal morbidity later on. 4 Apart from complications like electrolyte imbalances, protein loss, and lymphocytopenia due to long-term chylous leakage major complications like myocutaneous flap failures, carotid blowout and rarely chylothorax have been reported. [16][17][18] Cisterna chyli collects the lymph and chyle below the diaphragm and ascends through the thorax in the posterior mediastinum between the aorta and the azygos vein as the thoracic duct.…”

“…[1][2][3][4] The various modifications of neck dissections are aimed at blocking tumor cell migration and metastasis into the lymphatic drainage system. 5 Careful preservation of vital structures like carotid artery, vagus nerve, thoracic duct, and phrenic nerve takes the top priority in neck dissections.…”

“…4 Chylothorax is a rare complication where the and metabolic conditions should be closely monitored. 5 Casler and Brietzke advocated free fat graft from the submental area while Nouwen et al tried abdominal fat with varying results.…”

Management of Chyle Fistula Utilizing Thoracoscopic Ligation of the Thoracic Duct

“…In 1975, Mallen and Kudryk [14] advocated the use of medium-chain triglycerides in addition to local wound care in the treatment of chylothorax and chyle fistula. Furthermore, Lucente et al [15] demonstrated that dietary intervention with medium-chain triglycerides and tients were begun on medium-chain triglycerides and changed to TPN for refractory fistulas. Four of 6 patients switched to TPN did not require further operative intervention.…”