Management of chyle fistulae following surgery in the neck.

Chyle fistulae are seen in less than twenty percent of cases following head and neck surgery. At the Cancer Institute, Madras, India, chyle leaks were seen in 19 patients between 1990 and 1999. The leak subsided spontaneously in sixteen patients on conservative management. The neck was re-explored in three patient. The thoracic duct was ligated in one and the wound packed in two. Conservative management in the form of aspirations and strapping is more likely to succeed when the volume of drainage is low or decresing over time and the surgical incision and skin flaps remain healthy. Rightsided leaks and late appearing fistulae are also likely to close on conservative management. Dietary modifications may help in this process. Re-exploration of the neck would be required when conservative management fails. Early exploration would be advised when the drainage is large or does not decrease over a few days or if there is a tendency to wound breakdown. A thorough knowledge of the anatomy of lymphatic pathways from the thorax and abdomen, identification of the thoracic duct during surgery and detection and ligature of all lymphatic leaks intraoperatively using a trendelenburg position and valsalva maneuver will help reduce the occurrence of this problem.