DR GK ANANDA

Introduction Anatomy Pathophysiology Complications Etiology Investigation

Management Medical Surgical

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 fluidContains

Protein > 30g/L Lipid > 4 – 40g/L mostly TG Lymphocyte Electrolytes

TITLE AUTHOR YEAR PUBLICATION STUDY DESIGN

Management of chyle fistulization in association with neck dissection

RT Gregor 2000 Otolaryngol Head and Neck

Literature review(South Africa)

Systemic management of chyle fistula

Nussenbaum 2000 Otolaryngol Head and Neck

Retrospective(America)

Three cases of bilateral chylothorax developing after neck dissection

Kiyoaki et.al. 2007 International jornal of ORL & HNS

Case report

Aetiology and management of chylothorax in adults

Sukumaran et.al 2007 European Journal of Cardio-thoracic Surgery

Literature review

Prospective Identification of chyle leakage in patients undergoing lateral neck dissection for metastatic thyriod cancer

Dong -Lyel Roh et.al

2007 Annals of Surgical Oncology

Prospective study

TITLE AUTHOR YEAR PUBLICATION STUDY DESIGN

When Chyle Leaks: Nutrition management option

Carol Rees Parrish & Stacey McCray

2004 Practical Gastroenterology

Systematic Review

Somatosatin in medical management of chyle fistula after neck dissection for papillary thyroid carcinoma

Ali Coskun et al 2009 American journal of ORL

Case report

Management of chyle leak with tetracyline sclerotherapy

Dilip Srinivas et.al

2007 BJOMS Case report

Conservative management of high output cervical chyle leak- an encouraging result with octreotide

PS Raman et.al 2007 IJOMS Case report

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.

Chylous fistulas 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.

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.

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.    .

The flow 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 interventionFat 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 outputDaily 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,2004University 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 reduces gastric, pancreatic

and intestinal secretion. It inhibit the motor activity of

the intestine slows the process of intestinal

absorption reduces splanhnic blood flow decreases hepatic venous

pressure

DECREASES THE THORACIC DUCT LYMPH FLOW RATE

Tetracyline sclerotherapy ( Doxycyline ) Induces inflammatory reaction Place into wound bed by

▪ Percutaneous injection▪ Instillation through the drain tubeIntra-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

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