Chyle leakageBy

DR EUNICE RABIATU ABDULAI(otorhinolaryngology (snr. resident))

Venue : ENT DEPARTMENT KORLE- BUDATE: 23rd march 2016

OUTLINE• Introduction• Definition• Epidemiology• Anatomy• Aetiology/ pathogenesis• Clinical characteristics{signs and symptoms}• Investigations• Treatment• Conclusion

INTRODUCTION• Damaging 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

• rare• 1% 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 marrow• Single layer of endothelial tissue• Special capillaries in small intestines absorb digested fat

Unidirectional valves

• Filter micro organisms, infected cell and other materials that do not belong to the lymph

Unidirectional valves

• Lumber, intestinal, intercostal , Broncho mediastinal , subclavian, jugular trunks

• They drain in to ONE of two collecting duct

Lymphatic capillaries

Lymphatic vessels(3layers like vain)

Lymphatic nodes

Lymphatic 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 vein

• Lymph from left side of head, left arm and part of the chest enter thoracic duct• Lymph 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 ducts1. Right lymphatic duct2. Thoracic duct

Lymph node

vein

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)continuation

• it 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 LEAK• Prolonged hospitalization. • Electrolyte imbalance, • Fluid depletion(dehydration)/hypovolemia • protein abnormalities(hypoalbuminemia) • Coagulopathy, • immunosuppression, • chylothorax, • Prolonged chyle leak can therefore lead to mortality.

AETIOLOGY(ENT)• Iatrogenic

• Neck dissection• Excision of lymphangioma (e.g.. cystic hygroma)• Thyroidectomy(mediastinal extension/ mediastinal thyroid)• Low tracheostomy• Complicated oesophagoscopy (perforation)• Oesophagostomy ( in mediastenitis 2⁰ to oesophageal

perforation)• oesophaectomy (oesophageal tumours, external approach

e.g. in impacted foreign body)• Total laryngectomy

• Trauma: e.g.. Penetrating neck injury• Infection: e.g.. head and neck T.B • Tumour : e.g.. malignant invasion of lymphatic system• Congenital: 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 CAUSES• Subclavian 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 operations

• Approximately • 75% of postoperative chyloperitoneum cases occur after abdominal aortic aneurysm repair, • 19% after aortofemoral bypass, and • 7% after resection of infected aortic grafts

pathogenesis• Thoracic 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.

pathogenesis• Consists of • fat, protein, electrolytes, and lymphocytes.

• Daily production• dependent 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).

pathogenesis• long-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.

history• Pc

• 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 swelling

• HISTORY OF PRESENTING COMPLAINT;• Nature of discharge (colour), amount of discharge

• ON DIRECT QUESTIONING• Palpitation, fever ,hemoptesis(TB),

• PAST MEDICAL AND SURGICAL HISTORY• Neck dissection, excision of neck tumour,

• DRUG HISTORY• FAMILY HISTORY• SOCIAL HISTORY

HX/ EX Clinical characteristics{signs and symptoms}

• Intraoperative /post operative• Drainage 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) to• high-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 locales• Wound drain (colour and amount )• wound infection,• local skin breakdown• Gaping wound

• CVS: capillary refill time , BP ↑↓↔,Pulse↑↓↔, heart sounds• CHEST: clear, decrease air entry, bronchial breath sounds, transmitted sounds.• ABDOMEN: full, flat, scaphoid organomegaly• CNS: 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

Investigations• FBC… ↓↑WBC,↓platelets ,deranged clotting profile• RFT

• BUNC and electrolytes…..• ↔,↑urea, • ↑,↔nitrogen,• ↑,↔creatinine and • ↔,↑,↓,electrolyte inbalance

• LFT• Hypoalbuminemia

• Chest x-ray

• U/S

Treatment• Medical

• 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 diet• Total parenteral nutrition is given if the fistula persists

Treatment(conservative )• drain less than 600 mL of chyle per day• Head elevation• closed wound drainage/ continued suction drainage• pressure 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 or• total 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 clip• kept bloodless area when dissecting• before closing wound, observed for 20

or 30 seconds while the anesthesiologist increases the intrathoracic pressure;• smallest leak should be pursued until

arrested.

Treatment• Avoid Indiscriminate clamping and ligating• fragility of the lymphatic vessels and the surrounding fatty tissue.

• Hemoclips are ideal for clearly visualized leakage

• Otherwise, suture ligatures with pliable material, such as No. 5-0 silk, which are tied over a piece of hemostatic sponge to avoid tearing

• Fibrin sealant, Non absorbable suture, Surgicel, and sclerosing agents (e.g., tetracycline) have been recommended for this use

• NB: Tetracycline or doxycycline as a sclerosing agent; (known to be neurotoxic)

Treatment(surgical exploration )• When the daily output of chyle exceeds 600

ML

• Especially when the chyle fistula becomes apparent immediately after surgery,

• conservative closed wound management is not likely to succeed.

Treatment(surgical exploration )cont.• early surgical exploration is

preferred, b/4 tissues exposed to the chyle become •markedly inflamed and

fibrinous material that coats these tissues becomes adherent, thus obscuring and jeopardizing important structures, such as the phrenic and vagus nerves.

Treatment(surgical exploration )cont

Complication(Chylothorax)2 theories :• (1) fluid extravasates through the wall of the thoracic duct in the

mediastinum because of increased pressure in the system after the duct is ligated in the neck

• (2) fluid continues to leak after unsuccessful ligation in the neck but passes downward into the mediastinum.

• MX Of complication • chest drainage and • Total Parental Nutrition,• Injection subcutaneous somatostatin for 1 week along with other conservative

measures in treating bilateral chylothorax after neck dissection.

Controversies • Authors have recommended re-operation in selective cases when the chyle fistula

does not resolve upon conservative treatment of persistent low output fistulas, high output fistulas treated medically for one week, or when complications arise.

• There are currently no clear standards to indicate the exact time for re-operation if the patient does not meet one of the above criteria . Previous studies have demonstrated management of high output chyle fistulas as medical management for the first week, then surgical treatment for leaks persisting over one week.

• Surgical management includes using a sternocleidomastoidmuscle flap or an omohyoidmuscle flap to close over the fistula with use of fibrin sealant . An additional surgical method is an intra-thoracic ligation of the thoracic duct for a refractory fistula

Conclusion• loss of milky fluid ( chyle ) rich in protein, lipids, fluids and electrolytes.• can lead to fluid depletion and malnutrition with high output fistula.• Special feeds and pressure on wound can help decrease output. • Surgical exploration can sometimes localise the leak. • Occasionally thoracoscopic ligation of the duct in the chest can be

undertaken. Percutaneous embolization of the thoracic duct can also be done

• This is a serious condition and is best avoided • when incurred; conservatively or surgical mx

Thanks for listening