Perilymph Fistula Treatment & Management

• Lymphatic fistula: Medical management of lymphatic fistulae after infrainguinal reconstruction consists of bed rest and leg elevation, local wound care, and administration of intravenous antibiotics.
• Chylous ascites: Administration of a low-fat, high-protein, medium-chain triglyceride diet may be implemented in mild-to-moderate cases of chylous ascites. Severe cases may require complete bowel rest, TPN, and paracentesis. Somatostatin has also been used successfully in the treatment of chylous ascites.^{[4, 5]}
• Chylothorax: Therapeutic thoracentesis and/or tube thoracostomy and administration of a low-fat, high-protein, medium-chain triglyceride diet are used in the management of chylothorax. Complete bowel rest and TPN may be used to further reduce lymphatic output. As with chylous ascites, somatostatin has also been effective in reducing chyle accumulation.^[6] In refractory cases not amenable to surgical intervention, pleurodesis, pleurovenous/pleuroperitoneal shunting, and percutaneous embolization of the lymphatic vessels have been effective.

Suture ligation of the injured lymphatic (infrainguinal, lumbar, mesenteric, or paraaortic) is the treatment of choice for these lymphatic injuries when conservative therapy fails. For injured infrainguinal lymphatic vessels not visualized, fibrin glue may be used as a substitute for suture ligation. Injuries to the cisterna chyli or thoracic duct should have lateral closure with a 6-0 to 8-0 Prolene suture. If unsuccessful, proximal suture ligation of the cisterna chyli and thoracic duct may be implemented.

Implement standard preoperative care for the surgical treatment of patients with lymphatic fistulae, chylous ascites, and chylothorax. Careful attention to the nutritional and metabolic status of the patient is important before operative intervention. Specify nothing by mouth (NPO) for patients starting 6-8 hours before surgery. Order an intravenous dose of antibiotics to be administered half an hour before surgery. Have a highly qualified team of anesthesiologists experienced in the physiology of infrainguinal, abdominal, and thoracoabdominal aortic surgery present throughout the operation. The concerns and fears of both the patient and the family must be addressed by the surgeon because this is a reoperative procedure for a surgical complication.

Meticulous sterile technique must be used because this is reoperative surgery, often in the presence of prosthetic vascular grafts, which are at risk for infection.

• Lymphatic fistula: Infrainguinal, intra-abdominal, and intrathoracic lymphatic injury may be better defined by the interdigital injection of 5 mL of isosulfan blue (Lymphazurin dye) into the first and third web spaces of the foot. Upon infrainguinal reexploration, blue fluid droplets are emitted from the site of lymphatic injury. Infrainguinal sites of lymphatic injury should then be suture ligated if clearly visualized (use fibrin glue if not clearly visualized), then closed meticulously in multiple layers. A Jackson-Pratt drain may be left near the site of lymphatic injury for 24 hours.
• Chylous ascites: Lumbar, mesenteric, and paraaortic lymphatic vessels may also be suture ligated or oversewn after identification with the isosulfan blue technique. However, injuries involving the cisterna chyli should have lateral closure with a 6-0 to 8-0 Prolene suture. A Jackson-Pratt drain may be left intra-abdominally near the site of injury.
• Chylothorax: Thoracic duct injuries may be repaired primarily by lateral closure using 6-0 to 8-0 Prolene. If unsuccessful, complete ligation of the thoracic duct may be performed. Leave a chest tube in place for any further drainage.

Postoperatively, close surveillance must be initiated, preferably in an intensive care unit, to optimize patient outcome after reoperative surgery. Qualified staff familiar with reoperative infrainguinal, abdominal, and thoracoabdominal aortic surgery must be available. Special attention to drain output, chest tube output, and wound care is essential. An attentive staff to allay patient and family concerns is also helpful.

• Lymphatic fistula: Remove the Jackson-Pratt drain after 24 hours unless evidence of further lymphatic leakage is found. Have patients begin immediate incentive spirometry and early rehabilitation for ambulation 24-48 hours after surgery. Continue antibiotics for 24 hours postoperatively unless other indications for their continuance exist.
• Chylous ascites: Incentive spirometry and early ambulation are the mainstays of postoperative care after exploratory laparotomy. Drains may be removed once drainage decreases to 30 mL/d and no further evidence of lymphatic leakage is seen. Antibiotics may be discontinued after drain removal. Deep vein thrombosis prophylaxis, consisting of systemic compression devices and low molecular weight heparin, is warranted unless contraindications exist. A regular diet may be resumed once bowel function returns to normal.
• Chylothorax: Aggressive incentive spirometry must be instituted following thoracotomy for thoracic duct injury. The chest tube may be removed once drainage diminishes to 75 mL/d and no further evidence of lymphatic injury exists. Antibiotics may be discontinued with chest tube removal, and a regular diet may be resumed once chylous drainage has ceased.

Implement standard surgical follow-up care after repair of lymphatic fistulae and lymphatic injuries that result in chylous ascites and chylothorax. Lymphoscintigraphy may be performed before discharge to confirm successful operative closure of these lymphatic injuries.

After discharge from the hospital, follow patients bi-weekly for the first 1-2 months and then monthly for the following 6 months. Three-month intervals may be used for surveillance once the surgeon and the patient are satisfied with the outcome.

Lymphatic fistulae and lymphatic injuries resulting in chylous ascites and chylothorax are complications of infrainguinal, abdominal, and thoracoabdominal aortic reconstruction. Nonoperative or conservative management of these complications reduces morbidity and mortality rates.

Operative intervention implemented to treat lymphatic injuries requires reoperation, which is both physically and mentally challenging for the patient and the surgeon. Reoperative surgery results in further systemic and procedural complications. Systemic complications include pneumonia, myocardial infarction, pulmonary embolus, cerebrovascular accident, sepsis, multiorgan failure, and death. Procedural complications include bleeding, wound and graft infections, and graft failure. Prevention of lymphatic injuries is essential after vascular reconstruction in order to avoid further reoperation.

Both operative and nonoperative management of lymphatic injuries may worsen surgical outcome and prognosis after vascular reconstruction. The operative repair of lymphatic fistulae after infrainguinal reconstruction carries a better outcome and prognosis than the operative repair of lymphatic injuries that result in chylous ascites and chylothorax. Repair of the latter two complications requires reoperative exploratory laparotomy and/or thoracotomy.

In general, chylous ascites and chylothorax secondary to traumatic injury during vascular reconstruction carry a better prognosis than that occurring secondary to underlying neoplasia. A mortality rate of approximately 18% has been reported for chylous ascites developing after aortic surgery. Mortality rates ranging from 44-83% have been reported for chylous ascites developing secondary to an underlying neoplasm. A survey of several case reports revealed 1 patient of 6 who died after conservative treatment of chylothorax.

Few controversies exist in the management of lymphatic complications after vascular reconstruction. Use good clinical judgment to determine the patients who might benefit from more conservative medical management. Reserve operative intervention only for patients who can tolerate the physiologic stress of reoperation. Lymphatic complications after infrainguinal vascular reconstruction occur more frequently in diabetic patients and in those requiring reoperation.

The advent of endovascular reconstruction has limited tissue handling and dissection and has reduced the incidence of lymphatic complications. Further advancements in endovascular techniques will enable more complex procedures to be performed with a consequent reduction in operative morbidity and mortality rates.