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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
THANK YOU FOR YOUR
ATTENDANCE AND KIND ATTENTION
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