Decision making for treatment of chylous firstula following neck surgery: A challenge to the Surgeon.

Abstract

Chylous Fistula following neck surgery is an uncommon but challenging complication encountered by head and neck surgeons. This leads to skin flap necrosis, infection, vascular blow outs and chylothorax. Co-morbidities like malnutrition, diabetes mellitus, radiated neck predispose to chylous fistula. The common site of leak is thoracic duct or lower jugular lymphatics. Identification of chyle leak intra-operatively can be difficult. Chyle leaks more than 500ml/day are termed high output leaks and require re-exploration of the wound and ligation of injured lymphatic duct. Low output leaks settle down with conservative treatment like high protein and low fat naso-gastric feeds, dependent drain, aspiration of collected chyle, antibiotics and octreotide, a somatostatin derivative. Chyle leaks less than 500ml/day and more than 200ml/day are a dilemma in deciding the treatment modality. Chylous fistula not responding to conservative treatment can cause life threatening complications and contaminate or macerate the neck making re-exploration at a later stage difficult. The decision to abandon conservative treatment and the ideal time for it is controversial. We are presenting our experience with the outcome of post-operative chylous fistula in a series of 11 under-nourished patients following neck dissection for malignancies, cystic hygroma and traumatic, contaminated neck injuries. All these patients developed left sided chylous fistula measuring 300ml to 400ml/day, 2 to 4 days after surgery. They were successfully managed by re-exploration of neck and ligation of injured lymphatic duct after 3 to 5 days trial of conservative management. There were no major complications or delay in adjuvant treatment