Octreotide versus oral dietary modification for the treatment of chylous fistula following neck dissection: A systematic review and meta-analysis.

AIMS: Chylous fistula following neck surgery is a rare, but significant complication. Currently, there is no standardised treatment, which may comprise pressure dressings, oral dietary modification (ODM), surgery or a combination of such measures. Octreotide is a somatostatin analogue that has gained popularity in the management of cervical chyle leaks. The effectiveness of octreotide compared with ODM is unclear. We provide a comprehensive, systematic review of the literature pertaining to the management of chylous fistulae, comparing both treatment strategies. METHODS: The bibliographic databases MEDLINE, Cochrane, PubMed, EMBASE and Google Scholar were searched from inception to October 2019. Search terms included (chyle [title/abstract]) OR (chylous [title/abstract]) AND (fistula [title/abstract]) OR (fistulae [title/abstract]) OR (leak [title/abstract]) AND (neck [title/abstract]) OR (dissection [title/abstract]). The study was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Risk of bias was assessed using guidelines from the Joanna Briggs Institute. Outcome measures included the proportion of chylous fistulae that spontaneously resolved without the need for surgery and time taken until resolution, for both DM and octreotide, respectively. RESULTS: The primary search identified 20 articles for review, comprising 313 patients. Two studies were suitable for pooled analysis. There was no statistically significant difference in the time taken for chylous fistula to resolve between groups (octreotide 10.0 days; ODM 12.0 days; P = .38). The overall rate of resolution was 89.6% and 81.5%, respectively (P = .25). Surgery was highly effective in cases failing to resolve following intervention with either method (96% [53/55] patients). CONCLUSION: The use of octreotide for chylous fistula following neck dissection surgery is associated with a high rate of spontaneous resolution. However, significant heterogeneity, bias and concurrent use of ODM/TPN for patients in studies investigating octreotide precludes universal recommendation at this time. Further research in the form of randomised controlled trials is required to establish an independent treatment effect.

Chyle fistula as complication of thyroid surgery in malignant pathology. / Fístula quilosa como complicación de la cirugía tiroidea en patología maligna.

INTRODUCTION: Cervical chyle fistula (CF) is exceptional, and there is no agreement on its treatment. The study objective was to assess the efficacy of conservative and surgical treatment in this condition. METHOD: Study population: Patients undergoing thyroid surgery who experience CF after the procedure. Study groups: 1) Group with conservative treatment: CF with flow rates less than 300cm3/day, late or collected in the neck; and 2) Group with surgical treatment: early CF with flow rates greater than 300 cm3/day. STUDY VARIABLES: Cure rates and rate of conversion to surgery were analyzed. RESULTS: Nine patients experienced CF. Conservative treatment was started in all of them, in 67% (n=6) with curative intent. Fifty percent of treated cases were resolved (n=3). The remaining patients were hospitalized after more than 150 days of treatment to add absolute diet and parenteral nutrition. The condition resolved in one patient, and the other two were referred for surgery. In the remaining patients (33%, n=3), surgery was indicated as the initial definitive treatment. A cervical approach, with ligature and transfixion stitch of the thoracic duct, was used. In one of the patients, who also had chylothorax, thoracoscopy was also performed. In the two patients where conservative treatment failed, cervicotomy was indicated, identifying in both the lymphatic reflux point. Fistula resolved in all operated patients. CONCLUSIONS: Conservative treatment was effective in 66% of low flow CFs. Surgery effectively and rapidly resolves fistulas with a high flow or not responding to conservative treatment.

Long-term evaluation of canine perianal fistula disease treated with exclusive fish and potato diet and surgical excision.

The records of 33 dogs that had perianal fistula disease treated with en bloc surgical excision and bilateral anal saculectomy, and that were perioperatively administered an exclusive white fish and potato diet, were reviewed to determine outcome. By 1 year after surgery, 87.9% of the dogs had complete or near-complete resolution of visible fistula disease, while only 20.7% continued to have mild intermittent clinical signs. Fecal incontinence was not reported in any dog. Overall, complications were considerably less in both severity and frequency when compared with previous reports.

Fístula del conducto torácico. Tratamiento médico con octreótida / Chyle fistula. Medical management with octreotide

La fístula del conducto torácico en una complicación poco frecuente tras la cirugía cervical. El primer escalón terapéutico es el tratamiento médico, con un adecuado drenaje y mediante medidas dietéticas. El uso de la octreótida en el tratamiento de la fístula quilosa es novedoso, y los casos comunicados son anecdóticos. Aportamos un nuevo caso en que el tratamiento con octreótida fue efectivo en el tratamiento de la lesión del conducto torácico y el cierre temprano de la fístula, con mínimos efectos secundarios. Este tratamiento permite reducir la estancia hospitalaria y la morbilidad del paciente. Creemos necesarios estudios posteriores que confirmen estos hallazgos (AU)

Chyle fistula is an infrequent complication after neck surgery. The first line treatment is medical management, with adequate drainage and appropriate nutritional modifications. The use of octreotide in the treatment of chyle fistula is a novel approach that has been documented in only a few cases. We report a new case of thoracic duct injury effectively treated by octreotide, leading to an early decrease in drainage and early fistula closure with minimal adverse effects. This therapy may reduce length of hospital stay and morbidity. Further studies are required to confirm this observation (AU)

[Resolution of a neck chylous fistula with oral diet treatment]. / Resolución de una fístula linfática cervical con tratamiento dietético oral.

Chylous fistula after neck dissection is a well-described complication. This pHatology can lead to serious respiratory and nutritional complications. Therapeutical options for chylous fistula remains controversial. On last reviews, there are an agreement on the conservative management. Within of this management, low long-chain triglycerides fat diet is an essential part.

Nutritional support in gastrointestinal disease.

Nutritional support is capable of spontaneously healing many gastrointestinal fistulas, particularly if the fistula arises from bowel that is not involved with inflammatory bowel disease or a malignant growth. The choice of either enteral or parenteral nutrition can be used in the treatment of any fistula, the use of enteral nutrition should be more selective. It is recommended that enteral therapy for an upper gastrointestinal fistula be carried out by distal infusion of the diet by either tube or operative jejunostomy. Infusion of the diet distal to the site of the fistula should not increase drainage of the fistula. If drainage does increase in response to enteral feeding, then enteral therapy should be discontinued, and parenteral therapy should be started. Similarly, a fistula of the ileum or colon may also be treated with enteral therapy into the proximal bowel as long as sufficient length of normal bowel exists to absorb the diet proximal to the fistula.