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| LETTER TO EDITOR |
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| Year : 2013 | Volume
: 50
| Issue : 1 | Page : 8 |
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Always expect the unexpected - chyle leak: Revisiting the entity
C Preetam, K Sikka, R Kumar, R Kumar
Department of Otorhinolaryngology, Head and Neck Surgery, All India Institute of Medical Sciences, New Delhi, India
| Date of Web Publication | 20-May-2013 |
Correspondence Address:
R Kumar
Department of Otorhinolaryngology, Head and Neck Surgery, All India Institute of Medical Sciences, New Delhi
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0019-509X.112313
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 |
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 | |  |
| 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. 
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| 2. | McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med 2003;348:1123-33.
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| 3. | Lucente FE, Diktaban T, Lawson W, Biller HF. Chyle fistula management. Otolaryngol Head Neck Surg 1981;89:575-8.
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| 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.
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