Management of Chyle Leak after Head and Neck Surgery: Review of Current Treatment Strategies

Abstract

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. The thoracic duct is the primary structure that returns lymph and chyle from the entire left and right lower half of the body. Chyle extravasation can result in delayed wound healing, dehydration, malnutrition, electrolyte disturbances, and immunosuppression. Prompt identification and treatment of a chyle leak are essential for optimal surgical outcome. In this article we will review the current treatment options for iatrogenic cervical chyle leaks.

High‐output chyle leak after breast‐conserving surgery and sentinel lymph node biopsy

“…Management of chyle leak is typically conservative and involves drainage, activity/diet modifications, and somatostatin, or its analog octreotide . Given the frequency of axillary surgery required in management of breast cancer, clinically significant chyle leak, or fistula is an exceedingly rare occurrence.…”

“…Postoperative chyle leaks occur secondary to intraoperative lymphatic duct disruption. More commonly described in the head and neck literature, lymphatic injury leading to chyle leak has a reported incidence 0.5%‐8.3% following neck surgery, generally due to thoracic duct injury . Chyle leaks have also been described following major abdominal and pelvic node dissections, pancreatectomy, kidney transplantation, prostatectomy, thoracic, spinal, and gynecological surgery …”

Chyle fistula in advanced and metastatic thyroid cancer

“…Surprisingly, as it may sound, it may occur even when a surgeon is performing a left hemi thyroidectomy with or without paratracheal dissection, a procedure considered as having a very low risk for this problem. Even though this is a quite rare scenario, it happens as aberrant lymphatic vessels might be present (4,10,11). Most of the thyroid related CF cases reported are related to malignant disease in patients with multiple positive nodes in the left mediastinum extending to the neck, especially near the anatomical area where the thoracic duct and the lower neck lymphatic vessels join the drainage system.…”

“…We had similar scenarios in the right neck with nodes attached to the scalene muscles with difficult dissection almost as difficult to the ones experienced in the left side without any clear drainage collected in the drain on the days to follow. However, a surgeon should be aware that extensive and aggressive dissection along this area might eventually cause problems, however such complication might go unnoticed (4,6).…”

“…However, regardless of such careful management of surrounding tissues around the thoracic duct, the fistula might not be apparent during surgery, until is diagnosed in the hospitalization ward, requiring a set of measures such as surgical re-intervention, drainage, a fatfree diet, compressive bandages, etc. (1)(2)(3)(4).…”