From the Guidelines
Management of chyle leak post-thyroid surgery should initially focus on conservative measures, including dietary modifications and total parenteral nutrition, with consideration of invasive interventions like thoracic duct embolization (TDE) if conservative management fails. The approach to managing chyle leak involves confirming the diagnosis by draining the fluid for studies, which also serves as a palliative measure [1@]. After replacing fluid and protein losses, a decision about conservative versus invasive therapies can be made, with the choice guided by daily outputs and the underlying etiology of the leak [1@].
Conservative Management
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@]. Adjunctive therapy may include somatostatin, etilefrine, or nitric oxide, although the evidence for these treatments remains scarce [1@]. The success of conservative therapy approaches 50% in nonmalignant etiologies but is only minimally beneficial in neoplastic etiologies [1@].
Invasive Management
Invasive treatments, including surgical thoracic duct ligation, pleurodesis, and thoracic duct embolization (TDE), are considered if conservative treatment has not resolved the chylothorax after 2 weeks, in higher-output chylothoraces, and in underlying neoplastic etiologies [1@]. TDE is a percutaneous alternative to thoracic duct ligation, with studies showing effective percutaneous treatment in >70% of cases [1@]. Itkin et al reported 90% clinical resolution postembolization and 72% clinical resolution of the chyle leak with thoracic duct disruption [1@].
Key Considerations
- The choice between conservative and invasive management should be guided by the patient's daily output and the underlying cause of the leak.
- TDE has higher clinical success treating traumatic compared with nontraumatic chyle leaks and with TDE compared with thoracic duct disruption [1@].
- Acute complications associated with TDE are minor and generally self-limited, estimated at 2% to 6%, while long-term complications may be seen in up to 14% of patients [1@].
From the Research
Management of Chyle Leak Post-Thyroidectomy
- Chyle leak is a rare complication post-thyroidectomy, with an incidence of 0.9% 1
- Most reported cases have had a complete central compartment neck dissection, but it can also occur without it 2
- Conservative management with a low-fat diet and observation can be effective in managing chyle leak 2, 1
- Dietary modification, such as NPO, can reduce chyle drainage and lead to a shorter hospital stay 1
- Surgical management should be considered if the drainage amount does not decrease by >50% of the original amount after 2 days of NPO 1
Treatment Options
- Percutaneous lymphatic embolization and thoracic duct disruption are minimally invasive treatments that can be effective in treating chyle leak 3
- Total parenteral nutrition and octreotide can also be used to manage chyle leak, especially in pediatric patients 4
- Peripheral parenteral nutrition can be considered in cases where enteral intake needs to be minimized 5