Post‐mastectomy chylous fistula: Anatomical and clinical implications

Abstract

A chylous fistula after a modified radical mastectomy is a rare occurrence; however, major anatomical variations in the termination of the thoracic duct may occur, rendering it susceptible to injury. High output chylous fistulae are difficult to manage and have local, metabolic, and immunologic complications with a mortality rate varying from 12.5-50%. Herein such a case of postmastectomy chylous fistula and its management are discussed. A 56-year-old postmenopausal woman with invasive duct carcinoma of the left breast underwent modified radical mastectomy with complete axillary clearance (Level I, II, III nodes). The operative procedure was uneventful. On the commencement of a normal diet, however, the patient started exuding milky fluid from the axillary drain and analysis of the fluid revealed biochemical features compatible with chyle. After 2 weeks of failed conservative management, the axilla was re-explored. A continuous flow of clear fluid was observed originating from a single major lymphatic trunk inferior to the axillary vein in the region of the former Level II nodes. The leak was controlled by the application of multiple mass ligatures using 2-0 silk suture. A part of the pectoralis major muscle was rotated and sutured over the area of the leak as additional reinforcement. Suturing a muscle flap over the leak has been described previously and functions theoretically by causing fibrosis. The chylous fistula in the present case was managed successfully with mass ligatures and muscle flap reinforcement.

Management of chylous leakage after breast surgery: Report of four cases

“…Only studies from the last 8 years that were published in English were included. [6][7][8][9][10][11][12][13] It was concluded that most chylous leakage occurred on the left side, and only two of the pooled cases occurred on the right side. Level II or III axillary dissection was performed in 20 cases (our 4 cases included).…”

Chyle Leak Following Axillary Lymph Node Clearance – a Benign Complication: Review of the Literature

“…In most cases, b chyle leakage subsided spontaneously by simply leaving the drain in situ [1][2][3]. Treatment of the chyle leakage required surgery in 2 cases [4,5]. In our case, chyle leakage subsided spontaneously by simply leaving the drain.…”

“…Purkayastha et al [5] observed chyle leakage at the time of its surgical repair at level I. A more aggressive dissection may not necessarily put the patient at an increased risk of this complication.…”

“Axillary Space Obliteration”—An Effective Technique in Reducing Seroma Formation after Mastectomy and Axillary Dissection

“…contrary to popular belief electrocautery revealed to be a contributing factor increasing incidence of seroma, and as regards to arm movement some found benefit of delaying arm movement depending on that chest wall motion and shoulder use create shearing forces that hinders flap adherence and this will act as a pump forcing lymph into the empty axillary fossa [10], however others have found no benefit of delaying arm movement [11] [12].…”