Chylous Fistula

Chylous fistulae occur in approximately 2% of neck dissections and mostly on the left side (75% of cases).12 Chyle is composed of the products of fat digestion (chylomicrons), and therefore persistent loss can lead to significant electrolyte disturbance, impaired wound healing, and nutritional imbalance. Intraoperatively, a leak may be recognized by the presence of a clear/milky fluid collection in the lower neck or by a greasy feel to the surgical gloves.

A suspected leak should be confirmed by placing the patient in the Trendelenburg position and asking the anaes-thesiologist to apply continuous positive airway pressure (i.e., Valsalva). This increases the flow of chyle by raising the venous and lymphatic pressures. Ligation of the thinned walled thoracic duct in isolation is not recommended, and it is better to include the surrounding tissue with the duct using a nonabsorbable suture. The scalene muscle can be included with this suture ligature. Many leaks are not treated adequately when noticed intraoperatively; attention at this stage will reduce the incidence of fistula formation. Surgical glues and sclerosing agents such as tetracycline have been used with some reported success.12

The presence of fluid with a milky appearance or continuous fluid from the neck drains once feeding begins is likely to be due to a chylous fistula. An intense inflammatory response due to chyle may cause flap compromise or loss of the overlying skin. When in doubt, the presence of triglycerides in this fluid confirm the diagnosis. The goal of management is to optimize the patient's nutritional status and reduce the volume of chyle production.

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