eMedicine Specialties > General Surgery > Abdomen

Chyle Fistula: Treatment

Author: Deron J Tessier, MD, Staff Surgeon, Kaiser Permanente Medical Center, Fontana, CA
Coauthor(s): Russell A Williams, MBBS, Program Director, Professor, Department of Surgery, University of California Medical Center at Irvine
Contributor Information and Disclosures

Updated: Jan 10, 2008

Treatment

Medical Therapy

Treatment of chyle fistulas is determined by the following:

• Etiology of the fistulas: Chyle fistulas secondary to malignancy are difficult to treat, while a definitive treatment is more successful after trauma or surgery.
• Amount of output: Fistulas with higher output that cause more physiologic derangements may require earlier aggressive therapies.
• Site of the fistulas: Fistulas arising in the neck are easier to access and identify than those occurring in the abdomen or thorax.

Nutritional intervention remains the mainstay of nonoperative treatment. Nutritional therapy includes the following:

• Use of enteral diets with fat restriction or the use of medium chain triglycerides: Medium-chain triglycerides are absorbed directly from the gut into the portal venous circulation.
• Use of total parenteral nutrition (TPN): TPN affords full caloric and nitrogenous support while allowing bowel rest. Bowel rest achieves a decrease in chyle flow, allowing healing to occur.

Several case reports and case series have reported the successful treatment of chylous leaks using octreotide in infants. One series reported 100% closure of chylous leaks from malignancy using 50 mcg of subcutaneous octreotide 3 times per day.

Transjugular intrahepatic portosystemic shunts (TIPS) have been reported to successfully treat chylous ascites due to cirrhosis.

A period of observation from one to several weeks should be allowed before determining whether these therapies are successful.

Repeated paracentesis/thoracentesis should be avoided because (1) results from this treatment modality are poor; (2) the chance of infecting chylous fluid is increased; (3) anasarca and cachexia may occur due to rapid loss of body protein, fat, and fluid; and (4) loss of lymphocytes may result in immune dysfunction.

In patients in whom accumulation of chyle leads to significant problems, such as shortness of breath and lung collapse, the use of drainage through a thoracostomy tube or paracentesis may be necessary despite the obvious adverse effects that this form of therapy may produce.

Surgical Therapy

Surgery is undertaken when conservative therapies fail (approximately 40%). Surgical therapies include the following:

• Surgical ligation of the leaking lymphatic vessels: Surgical ligation can be achieved successfully provided the site of the leak is identified and the primary pathology causing the leak has not caused disruption or blockage of other lymphatic vessels. Finding the leak may be aided by the use of scintigraphy. In some cases, the exact location of the disrupted lymphatic vessel is not identified and surgeons may use flaps (such as muscle flaps) to cover the area where the leak is occurring. Laparoscopic ligation of chyle leaks has been described.
• Other forms of therapy to plug the leak have included fibrin glue or the use of chemical irritants such as tetracycline.
• The use of peritoneovenous shunts (Denver or LeVeen) is a modality of treatment available when other treatments fail. Peritoneovenous shunts are especially useful for the management of chyle fistulas resulting from causes other than prior operations. The main objective of peritoneovenous shunts is to drain the chyle accumulated in the abdomen back to the venous circulation.

Preoperative Details

If at all possible, ensure nutritional assessment and repletion before a surgical intervention because malnutrition increases morbidity significantly.

Administer gram-positive antibiotic coverage with a beta-lactamase inhibitor in the 24 hours prior to insertion of the shunt.

Because of the possible complication of disseminated intravascular coagulopathy, which is especially prevalent in patients with malignancy, include coagulation parameters in the preoperative evaluation.

Intraoperative Details

Surgical approaches vary significantly depending on the site and etiology of the leak. Surgical approach to the thorax using a thoracoscopic approach may be tried, as long as adequate expertise is available. Denver and LeVeen shunts differ in the type of valve each uses.

• Denver valve: These use a slit system that reduces flow by impedance. Insertion of these shunts can be achieved as a minimally invasive procedure, and they can be inserted under local anesthetic, sparing the severely ill patient the trauma of a major operation.
• LeVeen valve: This is a closed-pressure system that opens at pressures of 3 cm of water or less. This prevents leakage of blood into the tubing, thereby decreasing the chances of the system clotting (with subsequent failure).

Postoperative Details

Antibiotic coverage is continued empirically for 4 days after surgery. Any coagulopathy should be treated aggressively without delay.

Follow-up

Patients should be monitored routinely until the resolution of the fistula. Postoperative visits should commence approximately 1 week after the patient is discharged from the hospital.

Complications

Untreated, chyle fistulas can be fatal, with patients dying from severe fluid and electrolyte abnormalities, malnutrition, and overwhelming infections, including peritonitis and empyema. Iatrogenic complications also can occur. Complications from shunt placement, including disseminated intravascular coagulopathy, shunt failure, and fluid overload, also can occur.

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