Management of Chyle Fistula Utilizing Thoracoscopic Ligation of the Thoracic Duct

Abstract

Objectives: To document the treatment of refractory chyle leaks using thoracoscopic thoracic duct ligation and provide systematic guidelines to manage chyle leaks. Methods: The medical records of 2 patients with chyle leaks are reviewed, followed by a review of the literature on chyle leaks and their thoracoscopic management. Conclusions: Initial treatment of chyle fistula is aimed at conservative medical management. Persistent high-output fistulas (>500 cm³) should be considered for neck reexploration as conservative management is likely to fail. Thoracoscopic thoracic duct ligation provides a safe and efficient means of treating chyle leaks refractory to repeated surgical and medical intervention. It should also be considered as a primary surgical intervention for patients with: (1) chyle output exceeding 500 cm³/day where prior intraoperative attempts at ligation have failed, (2) severe metabolic and nutritional complications, (3) coexisting chylothorax with respiratory compromise, and (4) low-output fistulas (<500 cm³/day) of long duration (>14 days).

Factors predisposing to chyle leakage following thyroid cancer surgery without lateral neck dissection

“…9,11 The second approach is videothoracoscopic surgery, which allows visualization of the thoracic duct in the supradiaphragmatic area, where it can be ligated en bloc with periaortic tissue and the azygos vein, either with clips, a stapler, or a harmonic scalpel. 12 Another alternative is percutaneous lymphangiography-guided cannulation with embolization of the leakage duct. 13 None of our patients required surgical interventions to control chyle leakages, with all 14 patients controlled conservatively, by methods including pressure dressings, shifting to a fat-free diet, and repeated aspirations.…”

Introduction of lymphangiography and percutaneous embolization of the thoracic duct in a stepwise approach to the management of chylous fistulas

“…10,12 However, in the international literature only a few cases have been reported in relation to chronic chyle fistulas after neck surgery. Although the thoracoscopic method seems attractive as an alternative for open thoracic surgery and intrathoracic ligation of the duct, the advantages of video-assisted thoracic surgery procedures over open thoracic surgery are modest and the many intrathoracic anatomic variations and duplications may interfere with straightforward localizing and clipping of the duct(s).…”

“…4,10,12 Conservative management by medium chain triglyceride diet or total parenteral nutrition with continuous vacuum drainage resolves the problem in roughly half of the patients. If conservative management fails, surgical reintervention protocols have been advocated, but effective management of chylous fistulas remains difficult.…”

Lymphatic fistulae after neck dissection: The fibrin sealant treatment

“…Several treatment modalities were described in literature for this matter. Among them are vacuum suction drainage [1,5], pressure dressing [3,4], low long-chain triglycerides fat diet (low-fat diet) [4,6], surgical treatment with thoracic duct ligation [7][8][9], omohyoid muscle flap [10] or sternocleidomastoid muscle flap [8]. Somatostatin analog treatment [8], octreotide, etilefrine and local tetracycline sclerotherapy also were tried [4].…”