Conservative management of postoperative chylous fistula with octreotide and peripheral total parenteral nutrition.

Postoperative chylous fistula after neck dissection is an uncommon complication associated with significant patient morbidity. Octreotide acetate is a somatostatin analogue established in the treatment of chylothorax; however, its utility in the management of cervical chylous fistulae has not been fully evaluated. The investigators hypothesized that chylous fistula can be managed by a combination of octreotide and peripheral total parenteral nutrition (TPN). A retrospective review of cases compiled at our institution from 2009 to 2015 was conducted. Ten patients, all men, were identified as having a postoperative chylous fistula after a neck dissection. All patients were treated with peripheral TPN and intravenous octreotide. Mean age of the patients was 63.0 years (range 49 to 82). Five (50.0%) had a neck dissection for the management of metastatic nasopharyngeal carcinoma and had previous neck irradiation. In 8 (80%) patients, chylous fistula occurred in the left neck. Seven (70.0%) of the leaks occurred within the first 2 postoperative days. Eight (80%) leaks were controlled using TPN and octreotide, with 2 (20%) patients requiring surgical intervention. No factors were significant in the successful conservative management of chylous fistulae. One patient with a chylous fistula of 1,800 ml/day was managed successfully without surgical intervention. The results of this case series suggest that chylous fistulae may be managed conservatively with octreotide and TPN. However, long-term evaluation is needed to define if and when surgical intervention is required for control.

Visualization of the thoracic duct with injections of dyes or contrast media into the testicular parenchyma in the rabbit.

The thoracic duct drains lymph from the caudal part of the body to the venous system. The visualization of the thoracic duct is important for diagnosis of chylothorax, which may be caused by the damage of the duct. However, it is not easy to visualize the thoracic duct by injecting dyes and/or contrast media into peripheral lymph nodes and mesenteric lymphatics. In the present study, we examined whether the thoracic duct can be visualized by injecting dyes and contrast media directly into the testicular parenchyma. Under deep pentobarbital anesthesia, 14 male Japanese White rabbits were percutaneously injected with dyes (India ink or methylene blue) or contrast media (iohexol 240, 300, or Lipiodol(TM)) into the testicular parenchyma. Then, we grossly observed the stained thoracic duct or took radiographs and CT images of the duct. In all cases with dyes injections, the thoracic duct was successfully visualized. We observed stained lymphatic vessels from the testis to the duct. In case of contrast media injections, the thoracic duct was visualized with X-ray and CT imaging, when 1.5-2.0 ml per one testis of iohexol 240 at 37 degrees C were injected into the right or both testes. The duct was most clearly visible, 3-5 min after the injections. The results show that the thoracic duct is reliably visualized simply by injecting dyes or contrast media into the testicular parenchyma. Our visualization method may also be applicable to the diagnosis of chylothorax in male animals.

[Chylothorax]. / Le chylothorax.

PHYSIOLOGY: Chylothorax corresponds to the intrathoracic presence of chyle. Chyle is a lymph of intestinal origin containing the product of digested fat. This lymph joins the blood circulation through the thoracic duct. The thoracic duct receives a part of the lymphatic drainage from the viscera below the diaphragm, from the diaphragm and from the sterno-costal wall. PHYSIOPATHOLOGY: Intrapleural chyle issue is explained by an acquired or spontaneous lesion of the thoracic duct or of one of its collaterals in the thorax. The iatrogenic or spontaneous lesions of the collaterals suggest that the latter are incontinent and have lost their valve capacity, and hence provoke a reflux of chyle from the thoracic duct. The anatomy of the chylothorax (occasionally pathological) can be specified by a pedal lymphography. FROM A THERAPEUTIC POINT OF VIEW: Treatment, essentially medical, can be completed by surgery. The medical treatment is based on re-nutrition and a diet excluding fat, supplemented by medium chain triglycerides. Surgery consists in pleural symphysis and/or suture of the damaged collaterals, or ligature of the thoracic duct. The indications depend on the severity of the chyle leakage and the type of original lesion. The indications therefore depend on the etiology and clinical evolution of each case. These different treatments, isolated or combined, lead to the regression of the effusion in nearly all cases.