Chyle Fistula Management

Abstract

Chyle fistula is a potentially devastating phenomenon that results from violation of the thoracic duct or right lymphatic duct in the neck, most commonly during radical neck dissection. It may impair nutrition, compromise and delay wound healing, and prolong hospitalization. In view of the morbidity produced by chyle leak discovered postoperatively and the lack of success of its management by aggressive surgical techniques, we have employed a different protocol for the past six years. It is based on careful intraoperative inspection of the neck for possible chyle fistula, minimal but specific surgical handling of the damaged duct, and a postoperative nutritional program designed to reduce chyle formation and facilitate spontaneous closure. The nutritional element involves the use of medium chain triglycerides (MCT) that are easily ingested, rapidly absorbed, and readily metabolized directly into the portal venous system, bypassing the thoracic duct lymphatic system. During a four-year period, 1976 to 1980, 574 radical neck dissections were performed with only six chyle fistulas being detected postoperatively. All have been successfully treated by the protocol with no patients requiring reexploration. There have been no deaths owing to chyle fistula and no complications or side effects from the use of medium chain triglycerides.