Chylous fistula following an injury of the thoracic duct during neck surgery is an uncommon complication, its occurrence being higher with radical neck dissections. The treatment is controversial: usually conservative as first choice, surgical in case of persistence despite adequate medical treatment or in case of high output. The conservative management has a good success rate, but it is usually long and expensive, so several attempts to shorten it have been made. We present a case of postoperative chylous fistula in which octreotide administration was added to conventional conservative treatment, with resolution in four days. We also review the other reported cases in which the association of somatostatin to standard conservative treatment has been applied and we discuss the results. A 41 years old lady was referred to our Department for diagnostic resection of a left supraclavicular node swelling. FNAC was consistent with primary lymphatic disease. The patient underwent biopsy under general anaesthesia. Neoplastic tissue was involving as a single block both the supraclavicular and jugular lymphatic chains, and was partially resected. No intraoperative chyle leak was noted. The next morning the patient started oral feeding and 12 hours later 250 cc of white, milky fluid were collected. We started total parenteral nutrition (TPN), converted the drain from suction to gravity, adopted a semi-seated posture and applied pressure dressings. In order to reduce maximally the intestinal secretions we also started e.v. somatostatin (2 mg /day). At the end of first p.o. day the drain collected further 300 cc of chylous fluid. We then shifted to subcutaneous octreotide (0,1 mg x 3 /die). The output dropped to 60 cc (2nd p.o.), 30 cc (3rd p.o.). By 4th day the drain was nearly empty and in 6th day p.o. the patient was allowed to restart semiliquid oral feeding and, after a fatty meal test, the drain was removed and parenteral support and hormonal treatment were stopped. By day 8th the lady left the hospital. When the chylous fistula is recognised only postoperatively (usually after resuming oral feeding), first line treatment is usually conservative. It may lasts several weeks, is associated to high costs and is tedious to the patient. Nevertheless it has a good success rate, thus limiting the number of surgical re-exploration. SMS and its long acting analogues could act synergically with TPN in reducing gastrointestinal secretions, and allowing both the collapse of transected edge(s) of the duct and a correct repairing action of the naturally occurring inflammatory processes. According to our and other reported experiences, early association of octreotide to TPN seems to resolve chylous leaks in a few days, thus sensibly reducing in-hospital stay and related costs.

Conservative treatment of chylous fistulas following neck surgery

PUCCINI, MARCO;MICCOLI, PAOLO
2002-01-01

Abstract

Chylous fistula following an injury of the thoracic duct during neck surgery is an uncommon complication, its occurrence being higher with radical neck dissections. The treatment is controversial: usually conservative as first choice, surgical in case of persistence despite adequate medical treatment or in case of high output. The conservative management has a good success rate, but it is usually long and expensive, so several attempts to shorten it have been made. We present a case of postoperative chylous fistula in which octreotide administration was added to conventional conservative treatment, with resolution in four days. We also review the other reported cases in which the association of somatostatin to standard conservative treatment has been applied and we discuss the results. A 41 years old lady was referred to our Department for diagnostic resection of a left supraclavicular node swelling. FNAC was consistent with primary lymphatic disease. The patient underwent biopsy under general anaesthesia. Neoplastic tissue was involving as a single block both the supraclavicular and jugular lymphatic chains, and was partially resected. No intraoperative chyle leak was noted. The next morning the patient started oral feeding and 12 hours later 250 cc of white, milky fluid were collected. We started total parenteral nutrition (TPN), converted the drain from suction to gravity, adopted a semi-seated posture and applied pressure dressings. In order to reduce maximally the intestinal secretions we also started e.v. somatostatin (2 mg /day). At the end of first p.o. day the drain collected further 300 cc of chylous fluid. We then shifted to subcutaneous octreotide (0,1 mg x 3 /die). The output dropped to 60 cc (2nd p.o.), 30 cc (3rd p.o.). By 4th day the drain was nearly empty and in 6th day p.o. the patient was allowed to restart semiliquid oral feeding and, after a fatty meal test, the drain was removed and parenteral support and hormonal treatment were stopped. By day 8th the lady left the hospital. When the chylous fistula is recognised only postoperatively (usually after resuming oral feeding), first line treatment is usually conservative. It may lasts several weeks, is associated to high costs and is tedious to the patient. Nevertheless it has a good success rate, thus limiting the number of surgical re-exploration. SMS and its long acting analogues could act synergically with TPN in reducing gastrointestinal secretions, and allowing both the collapse of transected edge(s) of the duct and a correct repairing action of the naturally occurring inflammatory processes. According to our and other reported experiences, early association of octreotide to TPN seems to resolve chylous leaks in a few days, thus sensibly reducing in-hospital stay and related costs.
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Utilizza questo identificativo per citare o creare un link a questo documento: https://hdl.handle.net/11568/73043
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