Brett Tracy and Guy J Petruzzelli*
Department of Surgery, Memorial University Medical Center and Mercer University School of Medicine, 4700 Waters Ave Savannah, Georgia
Received: 15 May, 2017; Accepted: 02 August, 2017; Published: 03 August, 2017
Guy J Petruzzelli, MD, PhD, FACS, Department of Surgery, Memorial University Medical Center and Mercer University School of Medicine, 4700 Waters Ave, Savannah, Georgia, 31404, E-mail:
Tracy B, Petruzzelli GJ (2017) Management of Intra-operative Chyle Leak during Neck Dissection: Recognition and Control. Arch Otolaryngol Rhinol 3(3): 083-086. DOI: 10.17352/2455-1759.000053
© 2017 Tracy B, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Chyle fistula (CF) is a rare complication of neck dissection. The extravasation of chyle can result in potentially devastating metabolic, nutritional and immunologic sequellae.
We report the efficacy a protocol for treatment of intraoperative (CF).
Hospital length of stay, time to oral alimentation, and type of diet were analyzed.
There were 19 patients with thoracic duct injury development following neck dissection (0.08%) The mean age was 62 years and the majority were male with squamous cell carcinoma of the oral cavity. The TDI’s were identified on the left side in 16 patients and on the right side in 3 patients. In all cases TDI were identified intraoperatively, packed with micro-fibrillar collagen and oversewn with monofilamemnt nylon. In one patient required re-exploration and placement of a muscle flap. The mean number of days NPO was 2.5 (range 1 to 13 days, SD ± 2.8). The mean LOS was 4 days (range 2 to 14 days, SD ± 2.7). Only patient number 5 and 12 required MCT administration for 14 and 12 days and no patients required parenteral nutrition.
Prompt recognition and definitive intraoperative management of TDI can result in reduced post-operative complications and early return to acceptable oral alimentation.
Chyle fistula is a rare but serious complication following neck dissection with an incidence ranging from 1% to 2.5% . This uncontrolled extravasation of chyle arise from damage to the thoracic duct, which transports triglycerides and cholesterol from intestinal lymphatics into the venous system . Beginning at the cisterna chyli, the thoracic duct ascends though the aortic hiatus of the diaphragm. It enters the neck to form a loop that courses between the internal jugular vein and anterior scalene muscle , where it terminates into the venous system. Due to the integral role of this lymphatic structure in fluid balance, metabolism, and immunity, unresolved chyle leaks can cause extreme morbidity secondary to the loss of fluids, electrolytes, and other proteinaceous nutrients. These losses can lead to severe dehydration, electrolyte disturbances, and lymphopenia ultimately delaying wound healing, causing skin-flap necrosis and infection, and substantially prolonging the duration of hospitalization .
The management of chyle fistula is multi-faceted and contingent upon timing of the recognition of thoracic duct injury (TDI). If identified during surgery, operative management by over-sewing and ligating the TDI is indicated. However, if unrecognized during the index operation, a chyle leak will usually manifest after resuming enteral feeding through the appearance of milky fluid from neck drainage contents. Findings on physical examination include a ballotable subcutaneous mass the medial neck or supraclavicular fossa, and associated induration, edema, and erythema of the overlying skin [4,5]. Management of a chyle leak includes dietary modification consisting of total parenteral nutrition (TPN) or the implementation of a medium-chain triglyceride (MTC) diet as to bypass the remnant thoracic duct and prevent intestinal peristalsis and lymph flow. Adjunctive treatments include the administration of octreotide to decrease triglyceride absorption and inhibit splanchnic circulation , elevation of the head of the bed, and application of compressive dressings [7-10]. Delayed surgical management is indicated for cases in which medical treatment has failed to decrease the amount of chyle drainage by half, or for high-output fistulas (>1000 ml/day for 5-7 days), or when there are serious complications such as chylothorax with respiratory insufficiency and severe malnutrition/electrolyte disturbances . In these instances, the neck is re-explored and thoracic duct is ligated.
Herein we describe an approach to the treatment of thoracic duct injuries, focusing on early intraoperative recognition and immediate repair. The aim of this study is to demonstrate the efficacy of Avitene, a microfibrillar collagen hemostat, and post-operative adherence to a low fat, low carbohydrate diet as an adjunct to the standard intraoperative management of a chyle fistula.
Materials and Methods
Between 1995 and 2015, 1736 patients underwent 2381 neck dissections or node biopsies by the senior author (GJP). After eliminating sentinel node biopsies (96) and Zone 1,2 3 selective neck dissections (1100), there were 1185 necks at risk for TDI having undergone either comprehensive neck (161), modified neck (995), zones 4 node dissection (1) or Zone 6-para-tracheal node (28) dissections. Of the 1185 at risk necks, a total of 19 thoracic duct injuries were identified intraoperatively (Figure 1). Data was collected from a password protected database of deidentified patient surgical records maintained by the senior author.
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