Introduction
Chyle leaks (CL) following neck dissection are an infrequent but can
represent a serious complication. An incidence of 1-2.5% is reported in
patients undergoing neck dissections and is associated with thoracic
duct (TD) injury, particularly in the left side of the neck at the
terminal portion of the duct1. The incidence rises
with metastatic lymphadenopathy in level 4 of the neck (most commonly
seen in thyroid and hypopharyngeal malignancy), bilateral neck
dissection or salvage surgery2.
CL noted intra-operatively during neck dissection should be repaired
promptly. Recognition that diathermy and bipolar haemostasis is not
effective on dilated lymphatics due to lack of the haemoglobin protein
is mandated. Intra-operative techniques include the use of
non-absorbable suture, metallic ligaclips and fibrin sealant
utilisation. Fat-free diet is recommended to commence prophylactically
post-operatively to limit the pressure within the ligated TD in the hope
that this minimises CL post-operatively3.
Post-operative CL noted by the presence of milky coloured fluid in the
drain should be promptly managed in a multi-disciplinary approach
involving dieticians, head and neck surgeons and thoracic surgeons.
Whilst awaiting biochemical confirmation with analysis of the drained
fluid by assessing the presence of elevated lymphocyte count,
triglycerides over 110mg/dl and chylomicron of more than
4%4, medical management is usually
commenced7.
Currently there is no standardised treatment for the management of
CL5. In 2011, we published a departmental instituted
guidelines on the management of CL based on best evidence available
(Figure 1) 3. Its aim was early identification,
risk-stratification and management of postoperative CL in order to
minimise morbidity. If surgical intervention is warranted, we advocated
Video Assisted Thoracic Surgery (VATS) procedure due to approaching the
TD in a non-operated field and thus in theory should be less morbid than
neck re-exploration.
At our institution, all CL are initially managed medically with a trial
of low-fat diet either via the oral intake route, naso-gastic feeding or
total parenteral nutrition, orlistat and octreotide. Low volume leaks
(<500ml/24h) are managed medically for 7-10 days. Moderate
volume leaks (500-1000ml/24h) are managed medically for 5-7 days. High
volume CL (>1000 ml/24h) are planned for early surgical
intervention whilst concurrently medical management is commenced.
Surgical intervention in the form of Video-Assisted Thoracoscopy Surgery
(VATS) thoracic duct (TD) ligation is pursued if the CL remain
unresolved despite medical management in low and moderate CL and where
the risk of medical complications such as infection and wound breakdown
is high.
The aim of this quality improvement study is to present the outcomes and
effectiveness of our management approach of CLs following the
implementation of the departmental standard operational protocol.