Medium chain triglycerides in the management of chylous fistulae following

neck dissection
I. C. Martin, L. H. Marinho,

Muxillqfacial

A. E. Brown. D. McRobbie

Unit, Queen Victoria Hospital, East Grinstead, West Sussex

SUMMARY.

The physiology of fat absorption and its relevance to chylous fistula following neck dissection is
discussed. Three patients with postoperative chylous fistulae were successfully managed conservatively using
medium chain triglycerides as a substitute for normal dietary fat.

in the management of 3 patients with postopcrativc

chylous fistulae following neck dissection.

INTRODUCTION
Persistent chylous fistula in the neck following neck
dissection is a relatively uncommon complication.
Conley (1979) reported an incidence of l-2% with
25% of cases occurring on the right. Two to four
litres a day of chyle may be produced and drain
through the fistula. This can pose particular problems
with maintaining fluid balance and nutrition in the
critical postoperative phase following major surgery
(Conley. 1979). In addition reduced immunity due to
loss of leucocytes may render the patient more susceptible to postoperative infection.
The management of chylous fistulae can be conservative or operative. Operative intervention is usually undertaken only when persistently large volumes
of fluid loss cannot adequately be replaced or when
there is a problem in maintaining adequate nutrition.
Conservative management has traditionally consisted
of a fat restricted diet. This reduces the volume of
chyle produced, thereby facilitating spontaneous closure of the fstula, however this approach leads to a
reduction in caloric intake during the period of
maximum catabolism. An alternative is to use total
parenteral nutrition, but this is not without its complications, and in some series has been shown to be of
doubtful benefit in actually reducing volumes of chyle
produced (Puntis et al., 1987).
Most dietary fat is composed of long chain triglycerides. These are absorbed by the action of intestinal lipases which break down triglycerides to their
component fatty acids and glycerol. Long chain fatty
acids are then packaged into chylomicrons which are
absorbed into the lymphatic system and drain via the
thoracic duct into the venous system. However,
medium chain fatty acids of six to ten carbon chain
length are absorbed directly into the portal system
thus by-passing the lymphatics (Fig. I).
The use of medium chain triglycerides as a substitutc for normal dietary fat has been shown to be
effective in reducing the volume of chyle produced in
chylothorax (Gershanik et al., 1974; Van Aerde et ul.,
1984; Puntis et u/., 1987; Laing & Spitz, 1989). This
paper describes the use of medium chain triglycerides

Case reports

Case 1
A 4%year-old female presented with a T2N1 MO squamous
ccl1 carcinoma of the right lateral border of the tongue. A
right functional
neck dissection and en-bloc hemiglosscctomv was performed. The defect was reconstructed using
a fasclo-cutaneous
radial forearm free flap. Whilst undergoing postoperative
adjuvant radiotherapy,
a mctastatic
node was detected in the contra-lateral
neck, and a left
functional neck dissection was therefore performed. The
patient was discharged on the 7th postoperative
day. but
returned the following day with a fluid collection in the left
neck. On aspiration
this proved to be chylc. Rcpeatcd
aspirations were therefore performed, and an oral diet with
medium chain triglyceride
(MCT) substitute was commcnccd. The MCT formulation
is shown in Table I. The
effect upon chyle production
is shown in Figure 2.

Case 2
A 40-year-old male presented with a T4NOMO squamous
cell carcinoma of the right mandibular
alveolus. He had
received external beam radiotherapy
7 years previously as
the primary treatment for a squamous cell carcinoma of
the right lateral border of the tongue. There was no evidence
of recurrent disease at this site. A right functional
neck
dissection and en-bloc hcmi-mandibulcctomy
was pcrformed. The defect was reconstructed with a composite
ossco-fascial for&m
flap. On the 12th postoperative
day
a milky discharge was noted from the drain site and
chemical analysis confirmed that this was chyle. Nasogastric
feeding with MCT was commenced. The effects upon chyle
volume and triglyceride levels arc shown in Figure 3.
Table

I - Fatty

acid composition
of Liquigcn
(Scientific
Hospital
Chain Triglyccridc
preparation.
100 ml of the
416 Kcal

Supplies) Medium
emulsion

gives

Caproic
Acid (Ch)
CaprTlic
Acid (C8)
Caprlc Acid (CIO)
Laurie Acid (C12)
236

1. I %
8 I I%
15.7%
2. I %

Medium chain triglycerides

Intestinal

237

lumen

Fig. 1 - Physiology of triglyceride absorption. Medium chain triglycerides pass directly into the portal system avoiding the lymphatics.
surface of tongue. A right radical neck dissection and enbloc resection of the tumour was pcrformcd. The defect
was reconstructed using a radial forearm fascia-cutaneous
hap. Postoperative
recovery was unremarkable
until the
8th day when a milky discharge was noted from the drain
site. The fluid was collected in a colostomy
bag and
chemical analysis confirmed the clinical impression of chylous fistula. MCT nasogastric feeding was commenced after
48 h. Figure 4 shows the effect of ,MCT on chyle volumes
and triglyceride levels.

Volumetml)
100

80

60

40

DISCUSSION
20

0
0

10
Post-op.

15
days

20

25

Fig. 2 - Case I. Chyle drainage ceased 10 days after substitution of

MCT for dietary fat given orally.

-.- MCT

Volume(mlj

1000

800

- I

TriglycerideImmoliL!

Triglyceride
-

The rationale for nutritional intervention in abnormal

chyle drainage is to prevent malnutrition
and to
diminish chyle production and flow. The major constituents of dietary lipid are long chain triglycerides,
most of which, once absorbed, are transported by the
lymphatic system. The basal rate of lymph flow
(1.38 ml/Kg/Hr) can increase tenfold following a fatty
meal. A diet in which the fat content is comprised
solely of medium chain triglycerides leads to low flow
of achylous lymph. The precise mechanism by which
MCT reduces chyle volume is unclear, however it
would seem reasonable to speculate that this could

600

300

VolumeCmlj
-

--.

-.

Triglyceridebnmol/LI
-60

.r--1

MC, I
250

Volume

Triglycetide

50

I40

30

-0

10

15
Post-op. days

20

25

30.

3 - Case 2. Triglyceride levels fell rapidly following the

institution of nasogastric feeding with MCT. Chyle drainage
ceased I4 days following the commencement of this regime

20

Fig.

10

,L0

Case 3
A 24-year-old patient presented with a T2N2MO squamous
cell carcinoma of the right floor of mouth and ventral

__.~.__
5

.\_
10

-A.-

15
20
Post-op. days

\;I?-(,
25

30

35

4 - Case 3. Triglyceride levels fell immediately following the

institution of the MCT regime. The chylous leak had resolved
completely I5 days later.
Fig.

238

British

Journal

of Oral

and Maxillofacial

Sureerv

be explained by the reduction in chylomicron production resulting from MCT bypassing the lymphatic
pathway and being directly absorbed into the portal
system. We are unable to explain the transient increase
in Triglyceride level which occurred immediately following the introduction
of MCT in case 2 but this
might suggest that MCT has a direct inhibitory effect
upon chyle production. MCT maintains adequate
caloric intake whilst at the same time creating favourable conditions for the spontaneous closure of a
chylous fistula.
In all three patients the listula had closed within 2
weeks of commencing the feeding regime in which
MCT was used to replace dietary fat rcquiremcnts.
Whilst little information
is available regarding the
length of time taken for fistulae to close spontaneously without any dietary intervention, Crumley
and Smith (1976) reported a series of 12 cases in
which chyle drainage persisted for up to 28 days
when surgical intervention was not undertaken.
The use of MCT together with protein, metabolic
mineral mixture, folic acid and multivitamin
supplements, proved to be a satisfactory conservative
approach to the difficult problem of postoperative
chylous listula.
References
Co&y.

J. J. (I 979). Compiicntions
of Head und Nerk
pp. 30-3 I Philadelphia:
W. B. Saunders.

Surgery.

Crumley.
R. L. & Smith. J. D. (1976). Postoperative
chylous hstula
prevention
and management.
Ixvpga.scope.
86,804.
Gershanik.
J. J.. Jonsonn,
H. T., Rio@.
D. A. & Packer. R. M.
(1974). Dietary
management
of neonatal chylothorax.
Pediurrics,
53,400.
Laing, J. H. E. & Spitz. L. (1989). Chylothorax
and delayed
paraparesis
in an infant following
improper
use of a front seal
belt. Brilish Journal of Surgery, 76, 129.
Puntis, J. W. L.. Roberts,
K. D. & Handy,
D. (1987). IIow should
chylolhorax
bc managed? Archives of Discuses in Childhood.
62, 593.
Van Aerde, J.. Campbell,
A. N.. Smyth. J. A., Lloyd, D. &
Bryan. H. (1984). Spontaneous
chylothorax
in newborns.
American
Journal of Discuses of Childhood,
138,96 I,

The Authors
1. C. Martin
FDSRCS,
ARCS
Senior Registrar
in Maxillofacial
Surgery
L. H. Marinho
Xl%, FFDRCSI
Visiting Registrar
in Maxihofacial
Surgery
A. E. Brown FDSRCS,
ERCS
Consultant
Maxillofaacial
Surgeon
D. McRohhie
BPharm,
MRPharmS
Clinical Services Pharmacist
Queen Victoria
Hospital
East Grinstead
West Sussex RH I9 3DZ
Correspondence
and requests for offprints
to Mr 1. C. Martin,
Consultant
Maxillofacial
Surgeon, Sunderland
District
General
IIospital.
Kayll Road, Sunderland
SR4 7TP
Paper received
I June
Accepted
I4 December

I992
1992