Management

A low output leak can usually be managed with aspiration, a pressure dressing, and dietary manipulation. The patient should have nasogastric feeding discontinued and a medium chain triglyceride diet or a compound such as Vivonex (98% fat-free solution) commenced. Collaboration with a dietitian and careful monitoring of electrolytes are also necessary.

Failure of the above regimen or in the presence of a high output leak (>500 ml/day) for 3 days or longer despite conservative management, warrants surgical intervention. A neck reexploration on the 4th or 5th postoperative day is the best approach in this setting.13 Feeding the patient 100 to 200 ml of cream 1 to 3 h preoperatively will improve the changes of identifying the leak at the time of reexploration. Placing the patient in the Trendelenburg position with the use of continuous positive pressure also helps in localization. Also, the application of a sclerosing agent such as tetracycline after ligating the duct may also be beneficial at this stage.13 Close suction drainage is used, and the patient is managed postoperatively with a medium chain triglyceride diet and careful electrolytic monitoring. A thoracoscopic ligation of the thoracic duct is an effective method of controlling a leak if neck reexploration fails or in the rare clinical situation of a chylothorax.14

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