Chyle Fistula Treatment & Management

Updated: Aug 03, 2017
  • Author: Deron J Tessier, MD; Chief Editor: John Geibel, MD, DSc, MSc, AGAF  more...
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Treatment

Approach Considerations

Treatment of chyle fistulas is determined by the following:

  • Etiology of the fistula - Chyle fistulas secondary to malignancy are difficult to treat, whereas a definitive treatment is more successful after trauma or surgery [7, 10, 11, 12, 13]
  • Amount of output - Fistulas with higher output that cause more physiologic derangements may require earlier aggressive therapies
  • Site of the fistula - Fistulas arising in the neck are easier to access and identify than those occurring in the abdomen or thorax

Approaches to the management of chyloperitoneum and chylothorax are outlined in the images below.

Chyle fistula. Management of chyloperitoneum. Chyle fistula. Management of chyloperitoneum.
Chyle fistula. Management of chylothorax. Chyle fistula. Management of chylothorax.
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Nonoperative Therapy

Nutritional intervention

Nutritional intervention remains the mainstay of nonoperative treatment. [7, 10, 11, 12, 13]  It 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 [14]
  • Total parenteral nutrition (TPN) affords full caloric and nitrogenous support while allowing bowel rest; bowel rest achieves a decrease in chyle flow, allowing healing to occur

Other treatments

Several case reports and case series have reported the successful use of octreotide to treat chylous leaks in infants. [15, 16, 17, 18]  One series reported 100% closure of chylous leaks from malignancy when 50 μg of subcutaneous octreotide was given three times per day. A retrospective study [19]  and a prospective study [20]  found octreotide to be effective in managing chylous leaks after neck dissection.

A retrospective case series by Chan et al suggested that chylous fistulae may be managed conservatively with octreotide and TPN but noted that long-term data would be needed to determine if and when surgical intervention is required for control. [21]

Although development of a chylous fistula is unusual after axillary dissection, one study of radical breast cancer procedures shows that they are manageable through conservative methods of treatment. [22]

Transjugular intrahepatic portosystemic shunts (TIPS) have been reported to successfully treat chylous ascites due to cirrhosis. [23]

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, for the following reasons:

  • Results from this treatment modality are poor
  • The chance of infecting chylous fluid is increased
  • Anasarca and cachexia may occur due to rapid loss of body protein, fat, and fluid
  • Loss of lymphocytes may result in immune dysfunction

When accumulation of chyle causes a patient significant problems, such as shortness of breath and lung collapse, drainage through a thoracostomy tube or paracentesis may be necessary despite the obvious adverse effects that this form of therapy may produce. [24]

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Surgical Therapy

What the duration of medical therapy should be and when the decision should be made to proceed operatively are dependent on the individual physician. Because of the relative rarity of chyle fistulas, no definitive data are available to unequivocally direct the duration of therapy.

Surgery is undertaken when conservative therapies fail (~40% of cases). [25, 26]  Surgical approaches vary significantly, depending on the site and etiology of the leak. A throacoscopic surgical approach to the thorax may be tried, provided that adequate expertise is available. [24]

If at all possible, ensure nutritional assessment and repletion before a surgical intervention; malnutrition increases morbidity significantly. [7]  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.

Contraindications to surgical correction of chyle fistulas are based on the patient's comorbidities and his or her ability to tolerate surgery.

Surgical ligation

Surgical ligation generally can be successfully accomplished, provided that 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 (eg, 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 and the use of chemical irritants such as tetracycline.

Peritoneovenous shunts

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.

Denver valves 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.

The LeVeen valve 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).

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Postoperative Care

Antibiotic coverage is continued empirically for 4 days after surgery. Any coagulopathy should be treated aggressively without delay. [3, 27]  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. [3]

Treatment of chyle fistula is very successful. However, unless the underlying etiology is reversed, the problem can be chronic and unrelenting.

If left 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, [28]  as well as complications from shunt placement, including disseminated intravascular coagulopathy, shunt failure, and fluid overload.

Occasionally, when chyle leak is not apparent during surgery, ligation of the bed of the thoracic duct does not stop the leak. In three patients with chylothorax, pleurodesis was achieved using continuous pleural irrigation with minocycline, versus intermittent pleurodesis. [29]

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