CHYLOUS FISTULA EBOOK!
Etiology of the fistula - Chyle fistulas secondary to malignancy are difficult to treat, whereas a definitive treatment is more successful after. This review of patients who received octreotide for neck chylous fistula after neck dissection found that all patients had resolution of the fistula without nee. Chyle leak formation is an uncommon but serious sequela of head and neck surgery when the thoracic duct is inadvertently injured, particularly.
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Intravenous fluids should be administered to achieve euvolemia and electrolytes replenished as needed. Dietary management plays a crucial role in the nonsurgical management of a CL.
All patients with suspected CL should be transitioned to a nonfat diet, low-fat diet, or medium-chain fatty acid MCFA diet [ 51 ]. In general, a MCFA diet with protein, metabolic mineral mixture, and multivitamin supplementation is preferable to a nonfat diet [ 52 ].
Because short- and medium-chain fatty acids are largely water soluble and absorbed via the portal venous circulation rather than the gastrointestinal lymphatics, this special diet bypasses the gastrointestinal lymphatic system, resulting in decreased chyle flow at the CL site, allowing the thoracic duct injury to heal faster.
Despite this, a MCFA diet does not stop chyle production entirely. Orlistat, a pancreatic lipase inhibitor, interferes with lipid metabolism in the duodenum and prevents lipid absorption and may be given as an adjunct to decrease chyle production [ 53 ].
Alternatively, patients can be made NPO if the drain output is low and suspected duration of CL is short. NPO is rarely implemented today, as alternative superior dietary options are available that do not contribute to ongoing hypovolemia and malnutrition.
Patients chylous fistula persistent or high output CL will likely require total parental nutrition TPNwhich chylous fistula the lymphatic system completely [ 854 ]. While more effective than a MCFA diet at reducing chyle production, the use of TPN must be carefully weighed against its need for central venous access, potential complication of increase infection risk, and metabolic disturbances and high cost [ 55 ].
Wound Care The use of pressure dressings remains controversial. Some recommend its use to expedite closure of a CL [ 6850 ], while others are concerned with its potential compromise of skin flap perfusion [ 4956 ]. Suction drainage, placed at the time of surgery, is invaluable in the evacuation of extravasated chyle and monitoring of drain output to assess both severity of the CL and treatment effectiveness.
While helpful in evacuating high output CL, however, some advocate for the timely removal of suction drainage once its output has diminished sufficiently, to avoid the possibility that the drain suction may prohibit the complete resolution of a CL [ 5 ].
Negative wound pressure therapy, or vacuum-assisted closure, with placement of an air-tight seal over the wound and application of negative pressure to the entire wound bed to remove fluid and shrink wound size has had promising results in preliminary reports, but additional studies are needed to test its true effectiveness [ 51 ].
Furthermore, negative wound pressure therapy requires exposure of the wound bed. Somatostatin and Octreotide Somatostatin is a neuroendocrine hormone discovered inwith numerous effects on the digestive and lymphatic systems [ 57 ], and has broad applications for use in therapy for acromegaly, intractable diarrhea, hyperinsulinism, severe gastrointestinal bleeding, pancreatitis, metastatic carcinoids, and tumors secreting vasoactive intestinal peptides [ 58 ].
Animal studies in dogs during the early s revealed that intravenous somatostatin significantly reduced thoracic duct lymph flow [ 59 ]. Somatostatin decreases chyle production via reduction of gastric, pancreatic, and intestinal secretions [ 365160 chylous fistula.
It constricts smooth muscles in splanchnic and lymphatic vessels to decrease lymph production [ 51 ] and lymph flow [ 42 ], respectively. Octreotide has gained considerable popularity in the management of CL, first in thoracic surgery and more recently with head and neck surgery.
Octreotide is a cost-effective therapy for iatrogenic CL that significantly decreases morbidity, length of stay, and need for surgical intervention [ 34 ].
The management of chyle fistula.
From to seventeen studies investigating the effectiveness of octreotide in the management of cervical CL were published Table 2. With the exception of two large case series, most publications were case reports. In these studies, chylous fistula of 49 patients were treated with subcutaneous octreotide for their CL.
Surgeries cited included thyroidectomy with or without neck dissection, modified radical and radical neck dissection, and parathyroidectomy.
International Journal of Otolaryngology
Chyle leaks occurred with both left and right neck dissections. Nearly all of the studies cited use chylous fistula suction drainage and dietary modifications. Less than one-third of the authors applied pressure dressings.
Literature review of somatostatin and octreotide for treatment of chyle leak. To date, there are no consensus guidelines on the optimal octreotide treatment dose and duration in CL management.
In our literature review, the decision of what dosage to use was often anecdotal chylous fistula occasionally increased by some of the authors when perceived ineffective.