Chylous fistula is an infrequent complication of head and neck surgery, with an incidence reported in % of patients undergoing major neck surgery. Postoperative chylous fistulas occur as a complication in 12 percent of. Since stuart in 1907 described the first case, we have only found 21 similar cases in the literature. Clinically, chylous fistulas may be difficult to manage because of significant electrolyte, fluid, and protein imbalance. First described in the 17th century as complications of trauma, chyle fistulas most commonly occur secondary to lymphatic. Its lymphatic fluid contains protein, white blood cells wbcs, electrolytes, fatsoluble vitamins, trace elements, and glucose absorbed from the interstitial fluid, to be. Chylous ascites is defined as the accumulation of milky white lymph fluid in the peritoneal cavity. Obstructed labour is one of the leading causes of maternal mortality in developing countries and. Novel management of intractable cervical chylous fistula. An untreated chyle fistula is a potentially dangerous condition. 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. Dear editor, we would like to share an interesting case of congestive.
Most chylous fistulae after radical neck dissection are successfully treated conservatively. Lymphoscintigraphy examination indicated that a chylous fistula was present in the plane of the tracheal carina. 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. Chyle from the greek word chylos, juice is a milky bodily fluid consisting of lymph and emulsified fats, or free fatty acids ffas. Open access a report of congestive myelopathy as a result. 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. What should be avoided, however, is the failure to. The thoracic duct is the primary structure that returns lymph and chyle from the entire left and right lower half of the body. Plastic surgical treatment of a chronic thoracic duct. Chylous fistula of the neck free download as powerpoint presentation. Renal artery to inferior vena cava arteriovenous fistula after retrieval of an 8yearold fractured optease inferior vena cava filter. Neck dissection postoperative complications include hematoma, wound infection, skin flap loss, salivary fistula, facial edema, electrolyte disturbances, carotid artery rupture and chylous fistula.
Minimally invasive management of chylous fistula after. Chylous fistula is a rare complication of esophagectomy that is reported to occur in 24% of cases. Thoracic duct fistula is a rare but potentially serious complication of head and neck surgery. Sinard, md otolaryngologyhead and neck surgery 2000 122.
Efficacy of octreotide in the treatment of chyle fistulas. A pancreatic fistula pf is defined as an abnormal connection between the pancreas and adjacent or distant organs, structures, or spaces. Although chyle fistulae can be diagnosed through examination of the drained fluid, a chylous fig. Evolution of chylous fistula management after neck. Treatment of a postoperative cervical chylous lymphocele. Journal of vascular and interventional radiology vol 31. Pdf chylous fistula following axillary lymphadenectomy. Others evaluate the drainage fluid for characteristics such as triglyceride content, alkaline ph, and presence of fat, when chyle leaks. Chylous fistula following axillary lymphadenectomy.
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. The most usual complications are seroma, chronic lymphoedema, and sensitive alterations on the inner arm. 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. 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. Chylothorax is the accumulation of chyle in the pleural space. The chyloma which forms finally ruptures the mediastinal pleura producing a pleural effusion. 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. Severe cervical chyle fistula after radical neck dissection. 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. Chylous fistula occurs in 1%2% of patients after neck dissection, especially when level iv nodes are dissected.
Ahmed, 23 july 2007, pages s4s9 abstract fulltext pdf 160 kb. Postoperative cervical chyle fistula after neck dissection is a complication with potentially serious morbidity. Management of chyle leaks following pancreatic resection. Pdf chyle leak following axillary lymph node clearance is a rare yet important complication. One simple method several authors advocate is to restrict enteral fat intake. Chyle fistula is defined as a leakage of lymphatic fluid from the. A case of successful surgical treatment of a chronic thoracic duct fistula is presented. Chylothorax can be due to several etiologies, among which malignancy and surgical trauma are the commonest table 1. Chylous fistulae as a complication of neck surgery are seen in less than 2% of cases. 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. This manuscript received at thn laryngoscort office and accepted for pub.
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. In addition, chyle contains between 2000 and 20,000 wbcsmm 3, most of which are lymphocytes. A milky appearance of the drainage fluid is often the initial clue. The fistula occurred in a 51yearold female following treatment of a solitary.
The lipids in the chyle are colloidally suspended in chylomicrons clinical significance. Case report chylous fistula following axillary lymphadenectomy. Component concentration calories 200 kcall lipids 530 gl protein 2030 gl lymphocytes 4006800mm 28 sodium 104108 mmoll potassium 3. Once it is recognized, treatment decisions to optimize patient care can be difficult. 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. In fact, transecting the duct when carrying out radical surgery low down in the neck or the mediastinum may often be necessary. Chylous fistulas are known to lead to prolonged hospitalization. Management of chyle leak after head and neck surgery. Mogensen ms, rdap, ldn, cnsc team leader dietitian specialist, department of nutrition, brigham and women s hospital, boston, ma. Treatment of chyle fistulas is determined by the following see treatment.
Chylous fistula is a wellrecognised but rare complication of headandneck. 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. Chylous fistula following radical neck dissection is a disturbing and potentially serious complication. 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. Lymphangiography to treat postoperative lymphatic leakage. Operative treatment may be an option, but identification of the leak. Case report a 56yearold patient was admitted to our hospital with a malignant tumor of the left floor of the mouth t3nomx.
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. Different management strategies have been advocated on the basis of institutional and personal experience. Mediastinal chyloma a roentgenographic sign of chylous fistula. 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.
Chyle fistula is a rare but potentially devastating and morbid condition. Repair of chylous fistula in the neck by local muscular flaps. Fistula is an abnormal tubelike passage between two points within the body or with one point on the skin surface. An unexpected complication after microsurgical breast. Such fistulae may be difficult to treat, and several techniques, both operative and nonoperative, have been advocated. Management of chylous fistulas myers en, dinerman ws.
Chylothorax is associated with significant morbidity and mortality if left untreated. Chylous pericardial effusion is an uncommon entity that is most commonly associated with postcardiac surgery, in particular aortic valve and minimally invasive cardiac surgery. Journal articles obstetric fistula research project. The treatment of postoperative chyle fistula still. Chylous fistula is often located in the lower left portion of the neck, so this characteristic location helps raise the suspicion of this complication. Prompt identification and treatment of a chyle leak are essential for optimal surgical outcome. Cervical chylous fistula is an uncommon complication after neck dissection, but it might lead to some serious clinical outcomes.
Prompt identification and treatment of a chyle leak are essential. Initial presentation of patient with leftsided cervi. Chylous ascites after abdominal aortic surgery, clinical. Axillary chylous fistula is a complication with an incidence of less than 0. The cells in our body are surrounded by tissue fluid. 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.
Chylothorax is even less frequent, and can exceptionally present bilaterally. Although most cervical chylous fistulas can heal in a few days with standard treatments, some can be intractable. Lalonde, 23 july 2007, pages s1s3 fulltext pdf 102 kb critical issues public health challenges in measuring obstetric fistula c. It is formed in the small intestine during digestion of fatty foods, and taken up by lymph vessels specifically known as lacteals.
Chylous pericardial effusion after pulmonary lobectomy. 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. Meticulous surgical technique in the areas of the thoracic duct on the left and the lymphatic ducts. 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. It serves as a medium for substances to move in an out of cells and the blood vessels. Chest radiographs in patients with chylous fistula can demonstrate a softdensity opacity at the root of the neck. The treatment of postoperative chyle fistula still remains.
Presentation as a postoperative lymphocele is rare. Chyle leak following axillary lymph node clearance is a rare yet important complication. Chylothorax is an uncommon complication of chylous fistula and may be seen on chest radiographs as a pleural effusion. Chyle extravasation can result in delayed wound healing, dehydration. 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. Pdf evolution of chylous fistula management after neck. Usually, an injury of the duct manifests immediately after the operation with chylous drainage. Treatment for this series could be divided into two groups. Chylous fistula is a rare complication of axillary lymph node dissection, with some 10 cases having been described in the literature. A case of spontaneous chylous pericardial effusion in. Posttreatment ct and mr imaging in head and neck cancer.477 795 618 1416 1385 1160 1140 671 78 895 968 1132 36 1502 359 605 1450 633 1261 585 1452 1215 1176 942 402 953 494 610 1174 366 827 980 1250 105 1068 582 1203