From the Guidelines
A chyle leak suggests a highly morbid condition that can lead to metabolic abnormalities, respiratory compromise, immunosuppression, malnutrition, and even death if left untreated. This condition occurs when lymphatic fluid containing digested fats (chyle) leaks into body cavities instead of flowing normally through lymphatic vessels. Chyle leaks commonly result from surgical procedures in the neck, chest, or abdomen, particularly those involving lymph node dissection, as well as from trauma, malignancy, or congenital abnormalities 1. The presence of a chyle leak is typically identified by milky white drainage with high triglyceride content (>110 mg/dL) from surgical drains or body cavities.
Key Considerations
- Chyle leaks can lead to significant nutritional deficiencies, immune dysfunction, and fluid/electrolyte imbalances if left untreated, as chyle contains essential proteins, lymphocytes, fats, and fat-soluble vitamins.
- Management typically begins with conservative approaches like dietary modifications (low-fat or medium-chain triglyceride diet), drainage, and sometimes somatostatin analogs, progressing to surgical intervention for persistent cases 1.
- Thoracic duct embolization (TDE) is a percutaneous alternative to thoracic duct ligation, with reported clinical success rates of 70-90% in treating traumatic and nontraumatic chyle leaks [1, @5@, @7@].
Treatment Approaches
- Conservative measures include management of the underlying disease, thoracentesis, and dietary modifications such as total parenteral nutrition or a nonfat diet to reduce production of chyle and consequently flow through the thoracic duct 1.
- Invasive treatments include surgical thoracic duct ligation, pleurodesis, and TDE, with exact criteria for implementation not well defined but often considered if conservative treatment has not resolved the chylothorax after 2 weeks, in higher-output chylothoraces, and in underlying neoplastic etiologies 1.
From the Research
Definition and Causes of Chyle Leaks
- A chyle leak occurs when there is interruption to the lymphatic ducts that transport chyle around the body 2
- Chyle leaks can be caused by surgical procedures, trauma, or spontaneously in association with malignancies 3
- Lymphatic injury leading to leakage of chyle can also arise from trauma or surgery in the chest, abdomen, or neck 4
Complications of Chyle Leaks
- Chyle leaks can cause significant morbidity and mortality 5
- The loss of protein-rich, calorie-rich fluid can cause serious complications including dehydration, malnutrition, and immunosuppression 2
- Chyle leaks can impair nutrition and immunity, compromise and delay wound healing, prolong hospitalization, and delay adjuvant therapy 6
Management and Treatment of Chyle Leaks
- Treatment of chyle leaks depends on the underlying cause, which may be surgical, secondary to malignant invasion, or the result of a medical condition 2
- Nutritional support is vital and leads to spontaneous leak closure in many cases 2
- Management options include total bowel rest with parenteral nutrition, enteral feeding with specialized formula, or oral diet with supplementation 2, 3
- A multidisciplinary approach to optimize treatments, including the primary surgical teams, pharmacists, and dietitians, is proposed 5