Chylothorax is even less frequent, and can exceptionally present bilaterally. Chyle fistula is defined as a leakage of lymphatic fluid from the lymphatic vessels, typically accumulating in the thoracic or abdominal cavities but occasionally manifesting as an external fistula. Minimally invasive management of chylous fistula after. Prompt identification and treatment of a chyle leak are essential. It is formed in the small intestine during digestion of fatty foods, and taken up by lymph vessels specifically known as lacteals. Chyle fistula is defined as a leakage of lymphatic fluid from the. This manuscript received at thn laryngoscort office and accepted for pub. Different management strategies have been advocated on the basis of institutional and personal experience. Pdf evolution of chylous fistula management after neck. An untreated chyle fistula is a potentially dangerous condition. Chylous ascites is defined as the accumulation of milky white lymph fluid in the peritoneal cavity. This condition has a predilection for the left side of the neck, but up to 25% of cases involve the right side of the neck. Component concentration calories 200 kcall lipids 530 gl protein 2030 gl lymphocytes 4006800mm 28 sodium 104108 mmoll potassium 3.
Chylous fistula is a rare complication of axillary lymph node dissection, with some 10 cases having been described in the literature. Such fistulae may be difficult to treat, and several techniques, both operative and nonoperative, have been advocated. The treatment of postoperative chyle fistula still. Meticulous surgical technique in the areas of the thoracic duct on the left and the lymphatic ducts.
Chyle leak following axillary lymph node clearance is a rare yet important complication. The cells in our body are surrounded by tissue fluid. Axillary chylous fistula is a complication with an incidence of less than 0. Introduction damaging or cutting a thoracic duct while operating low on the left side of the neck does not occur infrequently, even in experienced hands.
Treatment for this series could be divided into two groups. Usually, an injury of the duct manifests immediately after the operation with chylous drainage. An unexpected complication after microsurgical breast. Anatomical studies have demonstrated that in over 30% of cases the thoracic duct divides into branches and up to 4% empty into the venous system through these. Chylous fistula is a wellrecognised but rare complication of headandneck. The chyloma which forms finally ruptures the mediastinal pleura producing a pleural effusion. Journal of vascular and interventional radiology vol 31.
Chylous fistulae as a complication of neck surgery are seen in less than 2% of cases. Case report chylous fistula following axillary lymphadenectomy. Chylous fistula is an infrequent complication of head and neck surgery, with an incidence reported in % of patients undergoing major neck surgery. Prompt identification and treatment of a chyle leak are essential for optimal surgical outcome. Pfs are classified as internal if the pancreatic duct communicates with the peritoneal or pleural cavity or another hollow viscus and external if the pancreatic duct communicates with the skin. Chylous ascites refers to the accumulation of lipidrich lymph in the peritoneal cavity due to disruption of the lymphatic system secondary to traumatic injury or obstruction. In fact, transecting the duct when carrying out radical surgery low down in the neck or the mediastinum may often be necessary. Chylous pericardial effusion is an uncommon entity that is most commonly associated with postcardiac surgery, in particular aortic valve and minimally invasive cardiac surgery. Chyle leak formation is an uncommon but serious sequela of head and neck surgery when the thoracic duct is inadvertently injured, particularly with the resection of malignancy low in the neck. First described in the 17th century as complications of trauma, chyle fistulas most commonly occur secondary to lymphatic. A pancreatic fistula pf is defined as an abnormal connection between the pancreas and adjacent or distant organs, structures, or spaces. Ahmed, 23 july 2007, pages s4s9 abstract fulltext pdf 160 kb.
It was first described by morton 1 in 1961 and since then, its incidence has increased, presenting currently 1 case for every 187,000 hospitalizations, this is due to the realization of a greater number of abdominal surgeries, and also the increase the survival in cirrhotic and. A chylous fistula is a complication that can appear during the course of several abdominal diseases, such as tumors and infections, and may also be due to the effects of radiation or abdominal, thoracic or cervical surgery. Once it is recognized, treatment decisions to optimize patient care can be difficult. Neck dissection postoperative complications include hematoma, wound infection, skin flap loss, salivary fistula, facial edema, electrolyte disturbances, carotid artery rupture and chylous fistula. Chyle fistula is a rare but potentially devastating and morbid condition. A case of spontaneous chylous pericardial effusion in. Chyle extravasation can result in delayed wound healing, dehydration. Cervical chylous fistula is an uncommon complication after neck dissection, but it might lead to some serious clinical outcomes. The most usual complications are seroma, chronic lymphoedema, and sensitive alterations on the inner arm. Chylothorax is the accumulation of chyle in the pleural space. Pdf chylous fistula following axillary lymphadenectomy. Efficacy of octreotide in the treatment of chyle fistulas. Since stuart in 1907 described the first case, we have only found 21 similar cases in the literature.
Chylous fistula following axillary lymphadenectomy. A case of successful surgical treatment of a chronic thoracic duct fistula is presented. The fistula occurred in a 51yearold female following treatment of a solitary. Dear editor, we would like to share an interesting case of congestive. Chylothorax is an uncommon complication of chylous fistula and may be seen on chest radiographs as a pleural effusion.
After failure to control the chylous effusion with conservative medical treatment, the patient underwent videoassisted thoracic surgery through the left chest for thoracic duct ligation and pericardial fenestration. What should be avoided, however, is the failure to. Pdf chyle leak following axillary lymph node clearance is a rare yet important complication. Novel management of intractable cervical chylous fistula. Chylothorax is associated with significant morbidity and mortality if left untreated. Fistula is an abnormal tubelike passage between two points within the body or with one point on the skin surface. Lalonde, 23 july 2007, pages s1s3 fulltext pdf 102 kb critical issues public health challenges in measuring obstetric fistula c. Although most cervical chylous fistulas can heal in a few days with standard treatments, some can be intractable. Lymphoscintigraphy examination indicated that a chylous fistula was present in the plane of the tracheal carina. Open access a report of congestive myelopathy as a result. Others evaluate the drainage fluid for characteristics such as triglyceride content, alkaline ph, and presence of fat, when chyle leaks. Worldwide, abdominal malignancy, cirrhosis, and tuberculosis are the commonest causes of ca in adults, the latter being most prevalent in developing countries, whereas congenital abnormalities of the lymphatic system and.
Renal artery to inferior vena cava arteriovenous fistula after retrieval of an 8yearold fractured optease inferior vena cava filter. Postoperative chylous fistulas occur as a complication in 12 percent of. Evolution of chylous fistula management after neck. Acquired lymphatic disruption from surgery or trauma, leads to dilation of the retroperitoneal lymphatics with subsequent drainage of lymph into the abdomen through a lymphoperitoneal fistula. Mogensen ms, rdap, ldn, cnsc team leader dietitian specialist, department of nutrition, brigham and women s hospital, boston, ma. Journal articles obstetric fistula research project. Chylous fistula following radical neck dissection is a disturbing and potentially serious complication.
Operative treatment may be an option, but identification of the leak. Obstructed labour is one of the leading causes of maternal mortality in developing countries and. Sinard, md otolaryngologyhead and neck surgery 2000 122. Management of chylous fistulas myers en, dinerman ws. Plastic surgical treatment of a chronic thoracic duct.
Chest radiographs in patients with chylous fistula can demonstrate a softdensity opacity at the root of the neck. The thoracic duct is the primary structure that returns lymph and chyle from the entire left and right lower half of the body. Lymphatic fistula is one of the possible complication of neck dissection and may be very challenging to manage because of the anatomical complexities such as proximity to major vessels and variations. Chylous ascites after abdominal aortic surgery, clinical. Its lymphatic fluid contains protein, white blood cells wbcs, electrolytes, fatsoluble vitamins, trace elements, and glucose absorbed from the interstitial fluid, to be. First described in the 17th century as complications of trauma, chyle fistulas most commonly occur secondary to lymphatic disease or malignancy or following abdominal, neck, or thoracic operations.
A milky appearance of the drainage fluid is often the initial clue. In addition, chyle contains between 2000 and 20,000 wbcsmm 3, most of which are lymphocytes. Chyle from the greek word chylos, juice is a milky bodily fluid consisting of lymph and emulsified fats, or free fatty acids ffas. Management of chyle leaks following pancreatic resection. It serves as a medium for substances to move in an out of cells and the blood vessels. Chylous fistula is often located in the lower left portion of the neck, so this characteristic location helps raise the suspicion of this complication. Chyle can be identified by the appearance of a milky clouded fluid in drains and its accumulation can cause redness and swelling of the surrounding. Postradiation therapy, infection, mediastinal neoplasm, lymphoma and a small group of idiopathic, spontaneous chylous pericardial effusion have also been reported as the causes. Severe cervical chyle fistula after radical neck dissection. Chylous fistula is a rare complication of esophagectomy that is reported to occur in 24% of cases. Case report a 56yearold patient was admitted to our hospital with a malignant tumor of the left floor of the mouth t3nomx. The lipids in the chyle are colloidally suspended in chylomicrons clinical significance. One simple method several authors advocate is to restrict enteral fat intake. Lymphangiography, chylothorax, chylous ascites, lymphatic fistula introduction lymphatic leakage is a rare but severe complication that can occur after various surgical procedures, such as pancreaticoduodenectomy, abdominothoracic esophagectomy, inguinal lymph node resection, and nephrouretectomy 1.
The treatment of postoperative chyle fistula still remains. Chylothorax can be due to several etiologies, among which malignancy and surgical trauma are the commonest table 1. Most chylous fistulae after radical neck dissection are successfully treated conservatively. Thoracic duct fistula is a rare but potentially serious complication of head and neck surgery. A remarkable clinical feature of chylothorax is the long latent interval which may exist between the time of injury and the onset of chylous pleural effusion. Lymphangiography to treat postoperative lymphatic leakage. The development of postoperative leaks of the thoracic duct after neck dissection or vascular surgery of the subclavian and vertebral artery is a well known but rare complication. Presentation as a postoperative lymphocele is rare. Chylous fistulas are known to lead to prolonged hospitalization. Postoperative cervical chyle fistula after neck dissection is a complication with potentially serious morbidity. Repair of chylous fistula in the neck by local muscular flaps. Clinically, chylous fistulas may be difficult to manage because of significant electrolyte, fluid, and protein imbalance. Chylous fistula of the neck free download as powerpoint presentation.
Although chyle fistulae can be diagnosed through examination of the drained fluid, a chylous fig. Management of chyle leak after head and neck surgery. Chyle fistula is defined as a leakage of lymphatic fluid from the lymphatic vessels, typically accumulating in the thoracic or abdominal cavities, but occasionally manifesting as an external fistula. Treatment of chyle fistulas is determined by the following see treatment. Mediastinal chyloma a roentgenographic sign of chylous fistula. Treatment of a postoperative cervical chylous lymphocele. Initial presentation of patient with leftsided cervi.
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