DR GK ANANDA

 Introduction  Management
 Anatomy  Medical
 Pathophysiology  Surgical
 Complications
 Etiology
 Investigation
 1ST recorded by Cheever in 1875.

 Comprehensive review was done by Stuart in

regard to chylous fistula in 1907.

 Slaughter and Southwick ligated the thoracic

duct and cover the ligation area with scalene
muscle flap without major complication in
1955
 Arises from the lymphatic system
 Lymph from intestinal fluid
 Emulsified fat from intestinal lacteals
 Alkaline,milky, odourless fluid
 Contains
 Protein > 30g/L
 Lipid > 4 – 40g/L mostly TG
 Lymphocyte
 Electrolytes
TITLE AUTHOR YEAR PUBLICATION STUDY
DESIGN
Management of RT Gregor 2000 Otolaryngol Head and Literature review
chyle fistulization Neck (South Africa)
in association
with neck
dissection
Systemic Nussenbaum 2000 Otolaryngol Head and Retrospective
management of Neck (America)
chyle fistula
Three cases of Kiyoaki et.al. 2007 International jornal of Case report
bilateral ORL & HNS
chylothorax
developing after
neck dissection
Aetiology and Sukumaran et.al 2007 European Journal of Literature review
management of Cardio-thoracic Surgery
chylothorax in
adults
Prospective Dong -Lyel Roh 2007 Annals of Surgical Prospective study
Identification of et.al Oncology
chyle leakage in
patients
undergoing lateral
neck dissection
for metastatic
thyriod cancer
TITLE AUTHOR YEAR PUBLICATION STUDY DESIGN
When Chyle Leaks: Carol Rees Parrish 2004 Practical Systematic
Nutrition & Stacey McCray Gastroenterology Review
management
option
Somatosatin in Ali Coskun et al 2009 American journal Case report
medical of ORL
management of
chyle fistula after
neck dissection for
papillary thyroid
carcinoma

Management of Dilip Srinivas et.al 2007 BJOMS Case report

chyle leak with
tetracyline
sclerotherapy
Conservative PS Raman et.al 2007 IJOMS Case report
management of
high output
cervical chyle leak-
an encouraging
result with
octreotide
 Lymphatic system
develop independent
of cardiovascular
system
 There are 6
lymphatic sac , 2
jugular and 1 cisterna
chyli.
 The jugular lymphatic
sacs connect to the
cisterna chyli by the
development of left
and right thoracic
duct
• The thoracic duct
arches superior,
anterior and
lateral to form a
loop that
terminates into
the venous
system.
• The duct opening
is always found
within 2cm of the
internal jugular-
subclavian vein
junction.
 Chylousfistulas are known to lead to
prolonged hospitalization.

 Clinically,chylous fistulas may be

difficult to manage because of
significant electrolyte, fluid, and
protein imbalance.
 Complication rate 1 - 2.5% of neck
dissection involving level IV.

 Thiscondition has a predilection for

the left side of the neck, but up to
25% of cases involve the right side
of the neck.
 Post
operative
complication
 Radical neck
dissection
 Selective neck
dissection
 Anterior neck
dissection
• Other potential causes of Chyle Leak
– Lymphoma
– Tuberculosis
– Lymphangioleiomyomatosis
– Liver cirrhosis
– Congenital chylothorax (neonates)
– Penetrating neck trauma
– Cervical node biopsy
– Central venous cannulation
– Idiopathic
 The thoracic duct is the conduit for lymph
and dietary fat to reach the venous
bloodstream.
 The flow of chyle is around 2-4 L per day
 Consists of fat 1-3% composed of TG (70%
long chain), protein(3%), electrolytes
content is the same as plasma except of
lower calcium concentration, and
lymphocytes (T lymphocyte).
 Its daily production is dependent on the diet
and daily dietary intake.
 Chemical composition of chyle is
similar to that of tissue lymph, with
higher concentration of cholesterol,
phospholipids, and fat particles,
particularly triglyceride rich
chylomicrons and long-chain (>10
carbon atoms) esterified fats.  
  
.
 Theflow of chyle against gravity is
supported by the interplay of
 thoracic and abdominal pressures,
 transmission of peristaltic bowel
contractions,
 contraction of the lymphatic vessels
walls
 Venturi effect at the junction of the
thoracic duct and the subclavian vein
• 95% of ingested fats are triglycerides with long
chain fatty acids (LCT).
• These fats are re-esterified in the mucosal cells of
the bowel wall, combined with an apolipoprotein
and phospholipid and transported into the
lymphatic system as chylomicrons.
• Middle chain fatty acids (MCTs), length C12
or less, are absorbed directly into the portal
system without the formation of chylomicrons,
bypassing the lymphatics; this is important in
dietary therapy of chylous fistulas.
 Hypoproteinemia
 Hyponatremia
 Hypochloremia
 Dehydration
 Emaciation
 Lymphocytopenia and immunosupression
 Pleural effusion - chylothorax
 Wound problems - infection, suture
breakdown, hemorrhage
 Chylopharyngeal fistula
 Secondary sepsis
• Observation
– Excessive drainage, >500ml/ day for more
than 3 days
– Milky white appearance on enteral feeding
– Clear fluid on withholding enteral feeding
• Biochemical
– Triglycerides > 100mg/dL (309 vs 42mg/dL)
Jong-Lyel et.al,2007,Annals of Surgical Oncology
• Cytological
– Sudan III stains chylomicrons
(No quantitative criteria have been established)
 Nussenbaum et.al (2000) reviewed the
management protocol based on 10 studies
done previously and based on personal
experience.
 Outline of management
 Prevention
 Nutritional modification
 Medical management
 Surgical management
 The most common location of major
lymphatic vessel injury is at level IV.
 Posterior approach of radical neck
dissection – the lymphatic tissue
lateral to the carotid artery is the
last to be removed.
 If it’s not in the oncologic resection,
do not attempt to find the thoracic
duct.
After
completing the
neck dissection
make it a point
to place the
patient in
Trendelenburg
’s position and
observe the
wound while
applying a
prolonged
positive
pressure breath.
 All chyle leaked discovered
intraoperatively should be identified
and ligated with non-absorable
suture material [3/0 or 4/0]
 The needle should not pass directly
through the duct – it’s fragile and
have the tendency to leak.
 Over sewing the duct continuously
with the fascia attached to the duct
stump using black silk.
 If a chylous fistula was treated intra-
operatively, medical management
strategies should be initiated post-
operatively without delay.
"All deaths are hateful
to miserable mortals ,
But the most pitiable
death of all is to
starve"
HOMER ODYSSEY XII
 Goals of therapy

 Reduce chyle fluid production

 Replace fluid and electrolytes
 Maintain replete nutritional status and
prevent malnutrition
Nutrition intervention
 Fat free diet (< 0.5g fat per serving)

 Fat free diet supplemented with MCT

 TPN
 MCT
 Available in as MCT oil or in specialised
oral/enteral supplement
 Diarrhoea & GI distress
 May also contain small amount of LCF
 High level of MCT may cause increase in
chyle output
Daily requirement 60-70g/day
• Ramos and Faintuch (1986) reported in their study
a total of 18 patients with thoracic duct fistula had
high output fistulas, 1200/d avg.
• Eleven cases were treated with TPN and 7 cases
given fat-free, nonelemental NG diet. Closure of
the fistula occurred in 10 of 11 (TPN) and 3 of 7
(enteral diet) with mean time to closure 10.1 days
and 13.7 days, respectively; patients were treated
for 18 days and then returned to OR if chyle flow
did not abate.
• They found that fistula volume reduced sooner and
more with TPN.
• They concluded that oral feeding worked in some
but not as consistently as TPN.
 Patients who are only on fat free/MCT
diet as the only fat source for any
duration of time will have to
supplement essential fatty acids
(EFA)
 EFA cannot be produced endogenously
and must be taken in form of diet.
 Linoliec acid
 ἀ-linolenic acid
 Other important unsaturated fatty acids can be
made from these EFA.
 Arachidonic acid is synthesized from linolenic acid
and is the precursor molecule for prostaglandins,
leukotriens and thromboxane molecule
 EFA deficiency can occur within 5 days of fat free
diet.
 Eczema
 Impaired wound healing
 Thrombocytopenia
 Adequate protein intake
 Chyle contains significant amounts of protein
(22–60 g/L)
 Recommendations for protein intake should
account for such losses if an external drain is
present or with repeated chylous fluid “taps”
 Adequate intake may be a challenge for
patients on a fat free oral diet
 Essential fatty acid deficiency (EFAD)
 2%–4% of total calories from EFA required to
avoid EFAD
 May occur within 1-3 weeks of a fat free diet
 Diagnosis: triene to tetraene ratio of >0.4 &/or
physical signs of EFAD (see section on MCT oil
for more details)
 IV fat emulsion may be required if a patient is
unable to tolerate any oral/enteral fat or if it is
unwise to try adding oral/enteral fat
 MCT oil does not provide significant EFA
 Fat soluble vitamins
 Fat soluble vitamins are also carried by the lymphatic system
 A multivitamin with minerals is generally recommended for
patients on a restricted oral or enteral regimen
 Water soluble forms of vitamins A, D, E, and K may be better
utilized

Practical Gastroenterology,2004
University of Virginia Health System Nutrition Support Traineeship Syllabus
 Intervention
that promote
spontaneous fistula closure
 Pressure dressing
 Aspiration
 Closed drainage
 Open wound packing

Nussenbaum et.al
 The use of somatostatin (octreotide),
PS Raman et.al (2007), Ali Coskun
et.al (2009).
 Somatostatin is a peptide
 Neurohormone
 Paracrine
• Somatostatin biological action are diverse
• It inhibits
– Thyroid stimulating hormone
– Growth hormone
– Vasoactive intestinal peptide (VIP)
– Gastrin
– Motilin
– Insulin
– Glucagon
– Intestinal secretion
– Bile flow
 It decreases the intestinal
absorption of fats, therefore
TG concentration in the
thoracic duct is lowered.

 Somatostatin  DECREASES THE

 reduces gastric, pancreatic
and intestinal secretion.
THORACIC DUCT
 It inhibit the motor activity of LYMPH FLOW RATE
the intestine
 slows the process of intestinal
absorption
 reduces splanhnic blood flow
 decreases hepatic venous
pressure
 Tetracyline sclerotherapy ( Doxycyline )
 Induces inflammatory reaction
 Place into wound bed by
▪ Percutaneous injection
▪ Instillation through the drain tube
Intra-operatively surgicel
impregnated with tetracyline –placed
on known and ligated thoracic duct
 Advantages
 Chylous fistula resolved
 No reoperation
 Shorter hospital stay
 Disadvantages
 Impairment of skin flap
 Re-exploration is difficult if sclerotherapy fails
 Phrenic nerve paralysis
▪ Neurotoxicity of doxycyline
 Gregor et.al (2000) has outline a protocol
 Intraoperative care to prevent chyle leak
 If leak is present, immediate intervention with
fibrin sealant or collagen felt or Vicryl mesh- if
unsuccessful / severe cases muscle flap
(omohyoid flap,Zheng Jiang et.al 2007).
 MCT if postoperative suspicion of chyle leak.
 No reduction in drain production, Peptison tube
feeding should be initiated.
 TPN for 30 days before surgical intervention
IF EVERYHING
ELSE FAILS
 Surgical management when daily chyle leak
exceeds 1L for a period more >5 days.
 Locate leak
 Lymphangiography
 Injection of 1% Evans blue dye in the thigh
 Administration of a fat source with methylene blue to
highlight the leaking site.
 Operative Strategy
 Direct ligation of thoracic duct
 Fibrin with myofascial flap
▪ Scalenus
▪ Pectoralis
▪ Omohyoid
 Mass ligation of supradiaphargmatic
thoracic duct
THANK YOU
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