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.