Recurrent High Output Chyle Fistula Post Neck Dissection Resolution with Conservative Management
✍ Scribed by Samer Al-khudari; Lisa Vitale; Tamer Ghanem; Scott McLean
- Book ID
- 102927222
- Publisher
- John Wiley and Sons
- Year
- 2010
- Tongue
- English
- Weight
- 674 KB
- Volume
- 120
- Category
- Article
- ISSN
- 0023-852X
No coin nor oath required. For personal study only.
✦ Synopsis
Objective: To present a unique case of neck dissection with intraoperative chyle leak and subsequent recurrent high output chyle fistula treated with conservative management. Study Design: Case report Methods: Literature review of intra-operative chyle leak and post operative chyle fistula management with discussion of a recent representative case within our health system. Results: We present a case of a 35 year old male who underwent a total laryngectomy and bilateral selective neck dissection for a T4N1 Stage IVA Squamous cell carcinoma of the right supraglottis. Intraoperatively, a chyle leak was identified and surgical measures and fibrin sealant were used to control the leak with a negative fistula test at the completion of the dissection. On post operative day 4, a chyle fistula was identified with a peak output of 2.4 liters over 24 hours. The patient was treated with conservative non-operative measures and the output decreased daily. He was discharged on post operative day 22 with a drainage tube in place, which was removed on post operative day 26. He subsequently developed a recurrence of this fistula on post operative day 37, which was treated conservatively and resolved on post operative day 45. Conclusions: High output recurrent chyle fistula may be managed conservatively even if it persists greater than 10 days or output is greater then 2L over 24 hours if the chyle output is responding appropriately and the patient's volume and nutritional status are closely monitored.
History:
•R.R. is a 35 year old male who underwent primary treatment with total laryngectomy and bilateral selective neck dissection for T4N1 Stage IVA Squamous cell carcinoma of the right supraglottis.
Intra-operative Course:
•While dissecting left lower jugular lymph nodes, thoracic duct was injured.
•Topical sealant and pressure was applied to leak.
•Prior to completion of procedure, patient had negative fistula test.
Post-operative Course:
•On post operative day 1, chyle was confirmed via left drain with output of 1.6 liters over 24 hours on continuous wall suction drainage.
•Patient was managed with compressive dressings, continuous wall suction, high medium chain triglyceride diet, and meticulous electrolyte management.
•Peak output was 2.4 L over 24 hours on post operative day 4.
•Enteral feeding discontinued and patient started on total parental nutrition.
•14 day course of octreotide treatment instituted with aggressive compression dressings and wall suction of left neck drain.
•Output on post operative day 8 was less than 0.5 L over 24 hours and on post operative day 16 was less than 5 mL over 24 hours. •Patient's electrolytes were managed carefully, with replenishments as needed.
•Length of stay was 22 days after surgery and patient was discharged with dependent drainage neck drain and low fat diet.
•On postoperative day 26, output was less than 2 mL over 24 hours and drain was removed.
•Compressive pressure dressings discontinued on postoperative day 30.
•On postoperative day 37, patient presented with left neck swelling after eating high fat meal and 50 mL of serous fluid was aspirated signifying recurrence of chyle fistula.
•Compressive dressings reapplied and low fat diet reinstituted.
•On postoperative day 45, fistula recurrence was resolved with well-healed incisions and no evidence of recurrence of chyle leak.