Chyle leakage

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Chyle leakage

Chyle leakageBy DR EUNICE RABIATU ABDULAI(otorhinolaryngology (snr. resident))Venue : ENT DEPARTMENT KORLE- BUDATE: 23rd march 2016

OUTLINEIntroductionDefinitionEpidemiologyAnatomyAetiology/ pathogenesisClinical characteristics{signs and symptoms}InvestigationsTreatmentConclusion

INTRODUCTIONDamaging or cutting a thoracic duct while operating low on the neck is frequent, even in experienced hands.

In fact, transecting the duct when carrying out radical surgery low in the neck or the mediastinum may often be necessary.

Important : Avoid , the failure to recognize this complication at the time of surgery, which could lead to serious consequences.

DEFINITION

CHYLE :is a milky fluid consisting of lymph / interstitial fluid and emulsified fats

LEAK :a crack, hole, etc., that allows the accidental escape or entrance of fluid, light, etc.(Collins English dictionary)

CHYLE LEAK: loss of milky fluid ( chyle ) rich in protein, lipids, fluids and electrolytes.

can lead to fluid depletion and malnutrition with high output fistula.

Use

Epidemiology

rare1% to 2% of neck dissections Approximately 75% occur on the left side 25% occur on the right

ANATOMY

Microscopic permeable tubes found in interstitial tissue except C.N.S, Cartilage, cornea, bone and bone marrowSingle layer of endothelial tissueSpecial capillaries in small intestines absorb digested fat

Unidirectional valvesFilter micro organisms, infected cell and other materials that do not belong to the lymphUnidirectional valvesLumber, intestinal, intercostal , Broncho mediastinal , subclavian, jugular trunksThey drain in to ONE of two collecting duct Lymphatic capillariesLymphatic vessels(3layers like vain)Lymphatic nodesLymphatic vessels(tunica intima ,media and adventitia))Lymphatic trunk

Most of the lymph from the lower part of the body flows up in to the thoracic duct and drain into the venous system at level of the left interior jugular vein & subclavian veinLymph from left side of head, left arm and part of the chest enter thoracic ductLymph from right side of the head ,neck ,arm and part of the chest enters the venous system at the junction of rt subclavian and internal jugular vein

Collecting ductsRight lymphatic ductThoracic duct

Lymph nodevein

ANATOMY

ANATOMY

ANATOMY (THORACIC DUCT)Originates from cisterna chyli at T12

Ascends on vertebral column b/n azygos vein & descending aorta,

Passes to the left at the junction of the posterior and superior mediastina, and continues its ascent to the NECK, where

ANATOMY(thoracic duct)continuationit arches laterally to enter the venous system near or at the angle of union of the LEFT INTERNAL JUGULAR and SUBCLAVIAN VEINS (left venous angle).

plexiform (resembling a network) in the posterior mediastinum.

receives jugular, subclavian, and Broncho mediastinal trunks.

ANATOMY(RIGHT LYMPH DUCT )RIGHT LYMPH DUCT is short and formed by union

right jugular,

subclavian, and

Broncho mediastinal trunks

PROBLEMS WITH CHYLUS LEAKProlonged hospitalization. Electrolyte imbalance, Fluid depletion(dehydration)/hypovolemia protein abnormalities(hypoalbuminemia) Coagulopathy, immunosuppression, chylothorax, Prolonged chyle leak can therefore lead to mortality.

AETIOLOGY(ENT)IatrogenicNeck dissectionExcision of lymphangioma (e.g.. cystic hygroma)Thyroidectomy(mediastinal extension/ mediastinal thyroid)Low tracheostomyComplicated oesophagoscopy (perforation)Oesophagostomy ( in mediastenitis 2 to oesophageal perforation)oesophaectomy (oesophageal tumours, external approach e.g. in impacted foreign body)Total laryngectomyTrauma: e.g.. Penetrating neck injuryInfection: e.g.. head and neck T.B Tumour : e.g.. malignant invasion of lymphatic systemCongenital: e.g.. traumatic or infectious ulceration of lymphangioma,

AETIOLOGY (Other specialties)CHEST (Chyle pleural effusion)ABDOMEN (Peritoneal chylus leak)

CHYLE FISTULAS are rare events. (Tessier et al. Chyle Fistula; August 1015)GENERAL CAUSESSubclavian vein thrombosis Primary Lymphatic disease Malignant invasion of the lymphatics Trauma Inflammatory reactions (e.g.. tuberculosis, pancreatitis, cirrhosis, adhesions, pulmonary fibrosis) Postoperative trauma following abdominal, neck, or thoracic operationsApproximately 75% of postoperative chyloperitoneum cases occur after abdominal aortic aneurysm repair, 19% after aortofemoral bypass, and 7% after resection of infected aortic grafts

pathogenesisThoracic duct is the conduit for lymph and dietary fat to the venous bloodstream. Chyle Flow 2-4 L per day against gravity Supported by thoracic and abdominal pressures, transmission of peristaltic bowel contractions, contraction of the lymphatic vessels walls, and Venturi effect at the junction of the thoracic duct and the subclavian vein.

pathogenesisConsists of fat, protein, electrolytes, and lymphocytes.

Daily productiondependent on the diet and daily dietary intake.

pathogenesis

Chemical composition of chyle

similar to that of tissue lymph

higher concentration of

cholesterol,

phospholipids, and

fat particles, (particularly triglyceride rich chylomicrons and long-chain (>10 carbon atoms) esterified fats).

pathogenesislong-chain triglycerides are broken into fatty acids and glycerol. Fatty acids are packaged into chylomicrons and absorbed into the lymphatic duct.

Medium-chain fatty acids are absorbed directly into the portal system and bypass the lymphatics. The use of Medium-chain Triglycerides through an enteral pathway has been shown to be effective in the management of postoperative chylous fistula and has prevented the need for parenteral hyperalimentation, with its associated morbidity.

historyPc Milky discharge in neck drain post neck surgery, post surgical neck swelling, Penetrating neck injury, discharging neck swelling, post operative Neck discharge, dizziness, supraclavicular neck swellingHISTORY OF PRESENTING COMPLAINT;Nature of discharge (colour), amount of discharge

ON DIRECT QUESTIONINGPalpitation, fever ,hemoptesis(TB),PAST MEDICAL AND SURGICAL HISTORY Neck dissection, excision of neck tumour,DRUG HISTORYFAMILY HISTORYSOCIAL HISTORY

HX/ EX Clinical characteristics{signs and symptoms}

Intraoperative /post operativeDrainage of "milky white" fluid; Patients on NPO/on fat-free diet, may present with leakage of clear fluid.

Volume of drainage low output fistula (< 500 mL/day) tohigh-output fistulas(>3 L per day )

CLINICAL EXAMINATION(SIGNS)General : colour of drain and amount in 24hrs ,Wasted , peripheral oedema, silky hair, pale, sunken eyes , dry skin and lips, skin recoil Status localesWound drain (colour and amount )wound infection, local skin breakdownGaping woundCVS: capillary refill time , BP ,Pulse, heart soundsCHEST: clear, decrease air entry, bronchial breath sounds, transmitted sounds.ABDOMEN: full, flat, scaphoid organomegalyCNS: conscious, unconscious, confused, restless, aggressive

Investigations(SPECIFIC BIOCHEMISTRY TEST)

Analysis for triglyceride content

Chyle contains 2-8 times the amount of triglycerides compared to serum (greater than 110 mg/dl).

chylomicrons does not necessarily imply the presence of a chyle fistula, because uncomplicated neck drainage show up to 4% chylomicrons, even after centrifugation

InvestigationsFBC WBC,platelets ,deranged clotting profileRFTBUNC and electrolytes..,urea, ,nitrogen,,creatinine and ,,,electrolyte inbalance

LFTHypoalbuminemiaChest x-rayU/S

TreatmentMedical

Surgical

combined

Treatment

Depends Time of onset of the leak and Amount of chyle drainage in a 24-hour period and physician's ability to prevent accumulation of chyle under the skin flaps.

Treatment (medical)

Somatostatin ( Sc. Octreotide ( sandostatin) 50 to 100mcg 8hrly for 7days) decrease gastrointestinal and pancreatic secretions, reduce splanchnic blood flow, and lower hepatic venous pressure. Diet consisting of medium chain triglycerides because they are absorbed directly into the portal system bypassing the lymphatics. Low fat dietTotal parenteral nutrition is given if the fistula persists

Treatment(conservative )drain less than 600 mL of chyle per dayHead elevationclosed wound drainage/ continued suction drainagepressure dressings, and low-fat nutritional support. replacement of fluid lost through the fistula, which can reach up to 4 L/day.nutritional modification medium chain triglyceride (MCT) enteral diet ortotal parenteral nutrition (TPN) should be instituted.

NB; Parenteral alimentation through a central line can further reduce chylous output and may be considered for high-output or intractable fistulas.

Treatment (surgical indications)

Revisiting the wound, identifying leakage and ligating it Indication: drain more than 600 mL of chyle per day Intraoperative chyle leak warrants immediate repair. Success of surgery declines in the prolong postoperative period because of fibrosis and

the effect chyle has on the soft tissue of the neck. Failure of medical therapy and Radiological intervention advocates

neck exploration or

ligation of the thoracic duct, particularly in patients with high-output fistulas. Percutaneous embolization of the thoracic duct

Surgical management

Treatment (intraoperatively)

avoid injury ligate or clipkept bloodless area when dissecting before closing wound, observed for 20 or 30 seconds while the anesthesiologist increases the intrathoracic pressure; smallest leak s