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PubMed1990

The management of chyle fistula.

Over a recent 4-year period, 823 neck dissections that included the lower jugular lymph nodes were performed. Of the 823, 14 (1.9%) patients developed chyle fistulas. Two other patients developed fistulas, one after undergoing a gastric transposition, and the other after a scalene node biopsy. All 16 patients were initially managed conservatively with closed-wound drainage and low-fat nutritional support; this was successful in only 4 patients, 3 of whom had peak 24-hour chyle drainage of less than 600 cc. The remaining 10 patients required open-wound management, which included operative ligation in 4 instances. Continued conservative treatment with an open neck wound resulted in significant additional hospitalization. Our experience indicates that closed-wound management of a chyle fistula is likely to fail when peak 24-hour fistula output exceeds 600 cc. Considering the cost and morbidity of conservative treatment, early reoperation may be appropriate in those patients with high fistula output.

Chyle↗
PubMed1998

Salvage and reinfusion of chyle in closed chest injury.

The aim of this study was to describe a system of salvaging and reinfusing chyle which accumulated in the right pleural cavity of a patient after a thoracic duct lesion caused by a closed chest injury associated with amyelic fracture of the dorsal spine D10-D11. The chyle was collected in a reservoir (BT 844 Dideco), transferred by an electronic pump (BT 797 recovery Dideco) to a storage bag, microfiltered and then reinfused to the patient A solution was needed to prevent the patient with severe chylothorax, from having immunological and metabolic imbalance. The long period of conservative treatment with our system was imposed by the onset of acute post-traumatic myocardic infarction which delayed surgery. From experience gained, we can say that using total parenteral nutrition, chyle can not only be salvaged but also reinfused, respecting the strict rules of hygiene.

Chyle↗
PubMed2004

[The anatomic study of chyle leakage due to operation on abdominal region].

OBJECTIVE: To provide morphological basis for chyle leakage due to operation on upper abdomen or retroperitoneum region. METHODS: The original part of thoracic duct, cisterna chyle, intestinal trunk, left and right lumbar trunks were examined in 32 adult cadavers. RESULTS: (1) The occurrence rate of cisterna chili was 22% (7 cases), among which 4 cases were oval, 3 cases were triangle. The cisterna chyle was (24 +/- 6) mm in length; the width of middle part was (4.1 +/- 0.9) mm. It was located to the right of midline at the level between the twelfth thoracic vertebral body and the second lumbar vertebral body anteriorly. (2) The original part of thoracic duct was (2.8 +/- 0.7) mm in diameter. The confluence form of thoracic duct included: left lumbar trunk and intestinal trunk united to form the common trunk first, right lumbar trunk then joined the common trunk (9 cases, 36%); right lumbar trunk and intestinal trunk united to form the common trunk first, left lumbar trunk then joined the common trunk (8 cases, 32%); left and right lumbar trunk united to form the common trunk first, intestinal trunk then joined the common trunk (4 cases, 16%); left, right lumbar trunk and intestinal trunk joined together (3 cases, 12%). (3) The intestinal trunk was (36 +/- 15) mm in length. It ascended on the left of descending aorta, superior to the left renal artery, crossed the second lumbar vertebra anteriorly, and joined left or right lumbar trunk to form common trunk, which extended to the cisterna chili or thoracic duct to the right of lumbar vertebra. (4) The lengths of left and right lumbar trunks were (107 +/- 24) mm and (111 +/- 18) mm, the external diameters of origins were (1.7 +/- 0.4) mm and (1.9 +/- 0.4) mm, and the external diameters of terminations were (2.2 +/- 0.6) mm and (2.2 +/- 0.5) mm, respectively. CONCLUSION: The larger lymph tubes should be protected emphatically in the relevant region when dissecting the root of celiac and superior mesenteric artery and the termination of inferior mesenteric vein during abdominal operation.

Abdomen↗
PubMed2006

[Chyle fistula. Medical management with octreotide].

Chyle fistula is an infrequent complication after neck surgery. The first line treatment is medical management, with adequate drainage and appropriate nutritional modifications. The use of octreotide in the treatment of chyle fistula is a novel approach that has been documented in only a few cases. We report a new case of thoracic duct injury effectively treated by octreotide, leading to an early decrease in drainage and early fistula closure with minimal adverse effects. This therapy may reduce length of hospital stay and morbidity. Further studies are required to confirm this observation.

Aged↗
PubMed2000

Management of chyle fistulization in association with neck dissection.

Chylous fistula after neck dissection is a relatively rare but potentially lethal complication. Sequelae range from severe fluid, electrolyte, and protein loss to fistula formation, skin-flap necrosis, and carotid blowout. A thorough knowledge of the anatomy is essential to avoid injury to the thoracic duct or right lymph duct. After surgery, drainage of large amounts of fluid, particularly if milky, may alert the surgeon to the danger of chylous leakage. Certain diagnosis, however, is not so easy. Once the diagnosis is made, the management has to address the immediate and late effects of the loss of chyle into an operative site. This article seeks to examine these factors through review of the literature and personal experience with the problem. Total parenteral nutrition allows for control of the fluid and protein loss while avoiding flow of chyle, and in most cases it results in resolution. In those cases that do not resolve, fibrin glue with some type of mesh and muscle flaps usually succeed in closure.

Adult↗
PubMed2000

Systematic management of chyle fistula: the Southwestern experience and review of the literature.

Postoperative cervical chyle fistula after neck dissection is a complication with potentially serious morbidity. Once it is recognized, treatment decisions to optimize patient care can be difficult. Different management strategies have been advocated on the basis of institutional and personal experience. In this study we comprehensively review the published protocols and retrospectively review our experience in the management of 15 patients with chyle fistula. All patients in this study were given a trial of nonoperative management with nutritional modification, pressure dressings, and closed drainage. Medical management ultimately failed in 3 patients (20%). Two patients had prolonged courses of medical management with associated complications. An analysis of our data supports early operative intervention if the peak 24-hour drainage is greater than 1000 mL without a prompt response to medical management. Persistent low-output drainage after 10 days is associated with a prolonged management course and treatment-related complications. Optimal treatment of these patients is unclear.

Adult↗
PubMed2002

Oral absorption of insulin encapsulated in artificial chyles of bile salts, palmitic acid and alpha-tocopherol dispersions.

The hypoglycemic effect of orally given insulin was studied on rabbits, using different bile salts as absorption promoters, in two different carriers to form an artificial chyloform system ready to be absorbed by intestinal mucosa. The rank order of enhancement by bile salts in the presence of 1% ethanol was deoxycholate>cholate>glycocholate>glycodeoxycholate>taurodeoxycholate>no bile salts. The dose response studies with increased insulin loaded in the chyle showed a greater corresponding hypoglycemic effect with the system of cholate-palmitic-alpha-tocopherol dispersions than the cholate-palmitic acid dispersions. A more effective hypoglycemic effect was achieved using lower doses of the deoxycholate-palmitate-tocopherol-chyle dispersions.

Administration, Oral↗
PubMedDate not supplied

Management of chyle fistulae following surgery in the neck.

Chyle fistulae are seen in less than twenty percent of cases following head and neck surgery. At the Cancer Institute, Madras, India, chyle leaks were seen in 19 patients between 1990 and 1999. The leak subsided spontaneously in sixteen patients on conservative management. The neck was re-explored in three patient. The thoracic duct was ligated in one and the wound packed in two. Conservative management in the form of aspirations and strapping is more likely to succeed when the volume of drainage is low or decresing over time and the surgical incision and skin flaps remain healthy. Rightsided leaks and late appearing fistulae are also likely to close on conservative management. Dietary modifications may help in this process. Re-exploration of the neck would be required when conservative management fails. Early exploration would be advised when the drainage is large or does not decrease over a few days or if there is a tendency to wound breakdown. A thorough knowledge of the anatomy of lymphatic pathways from the thorax and abdomen, identification of the thoracic duct during surgery and detection and ligature of all lymphatic leaks intraoperatively using a trendelenburg position and valsalva maneuver will help reduce the occurrence of this problem.

Carcinoma, Squamous Cell↗
PubMed1990

Generalized lymphangiectasis in a dog with subcutaneous chyle and lymphangioma.

A 2 1/2-year-old spayed Great Dane was evaluated for large, fluctuant, chyle-containing swellings on the ventral portion of the left side of the abdomen. Multiple abnormalities of the lymphatic system were diagnosed, including thoracic duct obstruction, lymphangioma, subcutaneous chyle reflux, intestinal lymphangiectasia, and dilatation of hepatic, mesenteric, and pleural lymphatic vessels. Mesenteric lymphangiography revealed leakage of contrast medium into the subcutaneous tissues adjacent and to the left of the second lumbar vertebral body. Dietary and surgical management to control the chylous reflux were unsuccessful, and the dog died approximately one year after the skin lesions were first observed.

Animals↗
PubMed1998

Pericolonic mass containing chyle as a presumed sequela to chronic pancreatitis in a dog.

A 9-year-old dog was admitted because of recurrent episodes of chronic pancreatitis. Ultrasonography revealed a multiloculated, fluid-filled cystic mass at the caudal portion of the stomach. Guided fine-needle aspirates yielded a fluid consistent with chyle. The dog underwent surgery during which a 6- to 8-cm mass was found adhered to the mesocolon and serosa of the transverse colon. Intraoperative lymphangiography revealed lymphangiectasia, but contrast medium did not accumulate within the mass. The mass and a portion of transverse colon were removed en bloc. Results of histologic examination were consistent with an abscess. Pancreatic enzymatic digestion may allow abscesses to extend beyond pancreatic parenchyma, cause severe local inflammation, and encapsulate and incorporate adjacent abdominal lymphatics. Subsequent lymphatic leakage can result in chyle within the abscess. Inflammatory masses of the pancreas are a rare, but serious, complication of pancreatitis in dogs. Familiarity with these types of lesions can aid in selection of appropriate treatments.

Abscess↗
PubMedDate not supplied

Diagnosis and treatment of postoperative chyle leakage via percutaneous transabdominal catheterization of the cisterna chyli: a preliminary study.

PURPOSE: To assess the feasibility of percutaneous transabdominal puncture and catheterization of the cisterna chyli or lymphatic ducts (PTCLD) in patients with postoperative chyloperitoneum and chylothorax, and to identify and possibly embolize the chylous fistula. MATERIALS AND METHODS: Five patients had postoperative uncontrolled chyle fistulas. Two patients with chylothorax had thoracic duct (TD) ligation after esophagectomy and neck surgery. The other three patients had chylous ascites after surgery of the pancreas, the aorta, and the esophagus, respectively. After lymphographic opacification, the cisterna chyli (CC) or retroperitoneal lymph ducts were punctured transabdominally with a 21-gauge needle and catheterized with a 3-F catheter to reach the TD if possible. Microcoils were used to embolize a TD laceration. RESULTS: Lymph ducts as small as 2-3 mm were catheterized successfully in three patients. The TD was catheterized in two patients; one TD fistula was embolized with cure of chylothorax. In one patient with a surgically tied TD, duct occlusion was confirmed despite continued pleural effusion. Three fistulas, not seen with lymphography, were identified in two of three chylous ascites and one chylothorax. There was no morbidity. As a result of this procedure, four of five patients did not require repeated operation. CONCLUSIONS: PTCLD in the study of chyle fistulas was feasible and safe in the management of five patients and clinically useful in four patients; transabdominal catheter lymphography with aqueous contrast medium is more sensitive than pedal lymphography. Further evaluation is necessary.

Aged↗
PubMed2006

Isolated chyle duct injury in blunt trauma.

We present a case of a patient sustaining an isolated injury to the right main branch of the cysterna chyli due to a high-speed motor vehicle accident. A 42-year-old man presented after a high-speed collision. CT revealed a collection of hypodense fluid in the gallbladder fossa, which was the clue to take him to the OR. We proceeded to laparoscopic exploration, and based on the milky white color of the fluid, identified a chyle leak. In an open fashion, the retroperitoneum was explored and the injury was identified as disruption of the right lumbar branch entering the cisterna chyli, and this was ligated with silk ties. Chyle duct injury secondary to blunt trauma is a rare finding. The use of CT imaging can identify this injury. Laparoscopy can confirm the injury. Open ligation of the injured duct is the best treatment.

Adult↗
PubMed1996

Subcutaneous accumulation of chyle after thoracic duct ligation in a dog.

A 3.5-year-old female German Shepherd Dog developed subcutaneous accumulation of chyle in a hind limb after ligation of the thoracic duct for treatment of chylothorax. Lymphangiography revealed severe lymphangiectasia in the abdomen and left inguinal region. Although the pleural effusion resolved, the subcutaneous accumulation of chyle continued even after medical and surgical treatment, which included transplantation of the greater omentum into the subcutaneous tissues of the affected limb. Alternate lymphaticovenous pathways usually develop in dogs after thoracic duct ligation. These apparently did not develop in this dog, resulting in retrograde flow of chylous fluid into the hind limb. To the authors' knowledge, this is a previously unrecognized complication of thoracic duct ligation for treatment of chylothorax in dogs.

Animals↗
PubMed2001

Chyle withdrawal from an implanted port in occult innominate vein stenosis.

Totally implantable venous devices are widely used for chemotherapy and parenteral nutrition. There have been many device-associated complications reported in the literature. Herein, we report a case of chyle withdrawal from an implanted port that occurred secondary to occult innominate vein stenosis in a patient receiving chemotherapy for rectal cancer with lung metastasis. The port remained patent and functioning well after balloon angioplasty.

Brachiocephalic Veins↗
PubMed1995

Uptake of radiolabeled and colloidal gold-labeled chyle chylomicrons and chylomicron remnants by rat platelets in vitro.

This study examined the uptake of chyle chylomicrons (CMs) and chylomicron remnants (CMRs) by rat platelets in vitro. CMs and CMRs were doubly labeled with [3H]arachidonate ([3H]-20:4) and [14C]cholesterol and were incubated with platelets for up to 4 hours. A significant uptake (binding and/or internalization) of CMs by the platelets occurred, as indicated by the parallel increase of [3H]20:4 and [14C]cholesterol in platelets with incubation time. Addition of unlabeled CMs, VLDLs, LDLs, and HDLs decreased the uptake of labeled CMs. The competition experiments suggested that there is both a saturable binding and a nonspecific uptake of CMs. During incubation with CMs, the proportion of [3H]20:4 in phospholipids decreased and that in 1,2-x-diacylglycerol increased. The data indicated that a phospholipase C-mediated degradation of phosphatidylcholine and phosphatidylethanolamine occurred, whereas [3H]20:4 in triglyceride and 14C in cholesterol ester did not change. Electron microscopic studies after incubation with colloidal gold-labeled CMs (CM-Au's) demonstrated an accumulation of CM-Au particles in the open canalicular system of the platelets. Some CM-Au particles were localized in cytoplasmic vacuoles that were not stained by ruthenium red. Some CM-Au's or free gold particles were in vacuoles that showed acid phosphatase activity, indicating that some true endocytosis of CM occurred. The uptake of [3H]-20:4- and [14C]cholesterol-labeled CMRs was low compared with the uptake of CMs. After incubation with colloidal gold-labeled CMRs (CMR-Au's), only a few platelets contained CMR-Au in their open canalicular systems, and no CMR-Au particles were seen in the cytoplasm or in acid phosphatase-positive vacuoles. Rat platelets can thus interact with CMs by a process that leads to a sequestration in the open canalicular system and endocytosis and a net degradation of CM phospholipids. The conversion of CMs to CMRs counteracts this interaction.

Animals↗
PubMed2005

Spontaneous healing of chyle leakage after lymphangiography.

We report a 34-year-old man with the complication of chylous ascites after retroperitoneal lymphadenectomy that was refractory to various conservative therapies. Because surgical treatment for chylous ascites was considered, lymphangiography was performed to identify the area of leakage of chyle, after which the chylous ascites spontaneously healed.

Adult↗