Indian Journal of Cancer
Home  ICS  Feedback Subscribe Top cited articles Login 
Users Online :1857
Small font sizeDefault font sizeIncrease font size
Navigate here
  Search
 
  
Resource links
   Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
   Article in PDF (153 KB)
   Citation Manager
   Access Statistics
   Reader Comments
   Email Alert *
   Add to My List *
* Registration required (free)  

 
  In this article
   References

 Article Access Statistics
    Viewed2128    
    Printed66    
    Emailed0    
    PDF Downloaded342    
    Comments [Add]    

Recommend this journal

 

  Table of Contents  
LETTER TO EDITOR
Year : 2013  |  Volume : 50  |  Issue : 1  |  Page : 8
 

Always expect the unexpected - chyle leak: Revisiting the entity


Department of Otorhinolaryngology, Head and Neck Surgery, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication20-May-2013

Correspondence Address:
R Kumar
Department of Otorhinolaryngology, Head and Neck Surgery, All India Institute of Medical Sciences, New Delhi
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.112313

Rights and Permissions



How to cite this article:
Preetam C, Sikka K, Kumar R, Kumar R. Always expect the unexpected - chyle leak: Revisiting the entity. Indian J Cancer 2013;50:8

How to cite this URL:
Preetam C, Sikka K, Kumar R, Kumar R. Always expect the unexpected - chyle leak: Revisiting the entity. Indian J Cancer [serial online] 2013 [cited 2020 Jun 5];50:8. Available from: http://www.indianjcancer.com/text.asp?2013/50/1/8/112313


Sir,

Since the earliest report of by Cheever in 1875, till date, chyle leak has been a menacing problem encountered by most of the head and neck oncology surgeons at some point of their career. We would like to share an interesting case of unanticipated chyle leak occurring after selective neck dissection. A 70 year old male presented to us with tongue carcinoma in the left lateral border staged T2N0M0. He underwent a left sided hemiglossectomy and left supraomohyoid dissection. The surgery was uneventful and patient was recuperating well. However, on third postoperative day, 15 ml of creamy whitish fluid collected in the drain, clinically suggestive of chyle. As we had only performed a supraomohyoid dissection, chyle leak was not expected. The fluid was sent for biochemical analysis. It suggested the fluid to be positive for triglycerides (>500 md/dl), chylomicrons and also had presence of leucocytes on microscopy, which fulfilled the criteria for chyle of having triglycerides >100 mg/dl and leucocyte count of 2000-20,000/mm3. [1] In view of it being a low-output leak, we treated the patient conservatively with relative bed rest and dietary modification enticing a fat free, medium chain triglyceride diet, with daily monitoring of wound status, electrolytes, proteins and serum analysis. We avoided using total parenteral nutrition and local pressure dressing in view of high complications associated with TPN and chance of local microvascular compromise of the flap with pressure dressing. [2],[3] Initially, the leak progressively increased to 35 ml by P. O. D 7 and then gradually decreased by POD 11 after which the drain was removed and patient was discharged

Though chyle leak has been described in literature with incidence of 1 to 5.7%, it is mostly associated with neck dissection involving the level 4 region with the variable anatomy of thoracic duct position, varying from 0.5 to 4 cm above the clavicle being the major cause. [4] The significant chyle leak after a level 1-3 lymph node dissection has been rarely described. The reason for such leak in our case could have been continuous lymphatic seepage from amputated jugular trunk that manifested later as patient resumed near normal feeding. The possibility of abnormally high thoracic duct seems less likely as the leak was not very high output. The dangers of significant chyle include derangement of biochemical profile, leucopenia, wound sepsis, malnutrition, and it can even prove lethal. The currently reported case just emphasizes the possibility of chyle leak even in cases of selective neck dissection not involving level IV neck nodes. There is a need to detect a chyle leak intra operatively and managing it at the first instance to prevent morbidity and a prolonged hospital stay. Maneuvers such as pre operative fat rich diet and intra operative trendelenburg position with positive pressure ventilation can be performed in cases of neck dissection to make latent chyle leak obvious in suspected cases. Even though these minor leaks respond very well to conservative measures, the morbidity and hospital stay can be significantly prolonged, as in our case.

 
  References Top

1.Rodgers GK, Johnson JT, Petruzzelli GJ, Warty VS, Wagner RL. Lipid and volume analysis of neck drainage in patients undergoing neck dissection. Am J Otolaryngology 1992;13:306-9.  Back to cited text no. 1
    
2.McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med 2003;348:1123-33.  Back to cited text no. 2
    
3.Lucente FE, Diktaban T, Lawson W, Biller HF. Chyle fistula management. Otolaryngol Head Neck Surg 1981;89:575-8.  Back to cited text no. 3
    
4.deGier HH, BalmAJ, Bruning PF, Gregor RT, HilgersFJ. Systematic approach to the treatment of chylous leakage after neck dissection. Head Neck 1996;18:347-51.  Back to cited text no. 4
    




 

Top
Print this article  Email this article
 

    

  Site Map | What's new | Copyright and Disclaimer
  Online since 1st April '07
  2007 - Indian Journal of Cancer | Published by Wolters Kluwer - Medknow