Hostname: page-component-74656f9884-kv2lp Total loading time: 0 Render date: 2026-11-05T18:25:32.431Z Has data issue: false hasContentIssue false
  • English
  • Français

Nutritional Management in Patients with Chyle Leak following Head and Neck Surgery: A Systematic Review

Published online by Cambridge University Press:  18 December 2025

Nimeshi Jayakody Open the ORCID record for Nimeshi Jayakody [Opens in a new window] ,
Phillip Brown ,
Callum Findlay  and
Nimesh N Patel
Nimeshi Jayakody*
Affiliation:
ENT department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
Phillip Brown
Affiliation:
ENT department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
Callum Findlay
Affiliation:
ENT department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
Nimesh N Patel
Affiliation:
ENT department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
*
Corresponding Author: Nimeshi Jayakody; Email: nimeshi01@hotmail.co.uk
Rights & Permissions [Opens in a new window]

Abstract

Objective

We aim to investigate nutritional management of chyle leaks by a systematic review of the published literature.

Methods

We searched the following databases (Medline, Embase, Cochrane) for literature incorporating nutritional aspects in chyle leak management. We excluded non-English papers, paediatric studies, conference papers, and studies without nutritional intervention.

Results

Among 260 patients (out of 26,270), 81.5.% (n=212/260) achieved chyle leak resolution with nutritional management, while 18.5% (n=48/260) required surgery. Median resolution duration with nutritional management was 8.7 days (range: 4.3 to 22.2), compared to surgical treatment’s median of 32 days (range: 18 to 40).

Conclusion

We recommend use of nutritional management in all patients with chyle leaks. There is no evidence supporting one diet over the other however clinically we suggest starting with medium–chain triglyceride/non–/low–fat diets and moving onto total parenteral nutrition, unless medically indicated otherwise.

Keywords

ChyleNeck DissectionFatty Acids, Medium-ChainTotal Parenteral NutritionEnteral NutritionDiet, fat restricted

Information

Type
Review Article
Information
The Journal of Laryngology & Otology , Volume 140 , Issue 5 , May 2026 , pp. 475 - 484
Copyright
© The Author(s), 2025. Published by Cambridge University Press on behalf of J.L.O. (1984) LIMITED.

Introduction

A chyle leak or fistula is defined as the leakage of lymph due to damage to the thoracic duct (or occasionally right lymphatic duct).Reference Allen and Briggs1 As a complication of head and neck surgery it was first reported by Cheevers et al.Reference Allen and Briggs1 The incidence of chyle leaks from all neck operations is in the range of 1–2.5%,Reference Crumley and Smith2 however, it can be as high as 8.3% from left-sided neck dissections.Reference Roh, Yoon and Park3

Cervical chyle leaks can occur due to the vulnerability of both the thoracic duct and the right lymphatic ducts in the supraclavicular fossae, where they run close to the internal jugular veins on either side.Reference Delaney, Shi, Shokrani and Sinha4 Patients who have had left-sided neck dissections,Reference Park, Her, Choe, Kim and Kim5 radical dissection as opposed to selective dissection, and those who have had radiotherapy before surgery are at a higher risk of leaks.Reference Swanson, Hudson, Bhandari, Sinha, Maceri and Kokot6, Reference Nussenbaum, Liu and Sinard7 Chyle leaks can lead to malnutrition, electrolyte abnormalities, immunosuppression, poor wound healing, and flap necrosis.Reference Crumley and Smith2, Reference Delaney, Shi, Shokrani and Sinha4

Diagnosis of a chyle leak can be clinical and biochemical.Reference Allen and Briggs1–Reference Delaney, Shi, Shokrani and Sinha4 Clinically, it can be made intraoperatively (in which case, if it is identified, the duct is ligated) or post operatively due to increase in drain output (particularly after meals) and the milky/creamy consistency of output and erythema/oedema of fluid collection in the supraclavicular region.Reference Crumley and Smith2, Reference Delaney, Shi, Shokrani and Sinha4 Lymph is rich in triglycerides and chylomicrons.Reference Delaney, Shi, Shokrani and Sinha4 If neck drainage fluid has high triglyceride levels (>100 mg/dl), a high ratio of triglyceride compared with the blood, or chylomicrons are identified, the diagnosis of a chyle leak can be biochemically confirmed.Reference Delaney, Shi, Shokrani and Sinha4

The management of chyle leaks depends on whether they are diagnosed intraoperatively or postoperatively.Reference Crumley and Smith2, Reference Delaney, Shi, Shokrani and Sinha4 Intraoperatively, the thoracic duct can be ligated with clips/sutures, application of topical agents (tetracycline, fibrin glue, vicryl mesh), or muscle flaps such as sternocleidomastoid, anterior scalene, and pectoralis major can be used to provide coverage of the surgical bed.Reference Delaney, Shi, Shokrani and Sinha4, Reference Park, Her, Choe, Kim and Kim5

Due to the impact of nutrition on the production of lymph, dietary adjustments have been implemented in managing chyle leaks.Reference Delaney, Shi, Shokrani and Sinha4, Reference Swanson, Hudson, Bhandari, Sinha, Maceri and Kokot6, Reference Nussenbaum, Liu and Sinard7 Nutritional management can replace lost nutrients/electrolytes and introduce nutrients which are able bypass the lymphatic system, for example, medium chain fatty acids, which are mostly absorbed into the blood stream directly, or total bowel rest using TPN may help reduce lymph production.Reference Smoke and DeLegge8–Reference Spiro, Spiro and Strong18

The aim of this paper is to explore the evidence for nutritional intervention in the management of patients with chyle leak following neck surgery.

Materials and Methods

Search strategy

The study design was a limited systematic review. An online literature search was performed using Medical Subject Headings (MeSH). The databases used for the search included Medline, Embase, PubMed and Cochrane search engines/databases for publications from January 1980 to Jan 2023. The terms included chyl*, chyle, lymph leak for chyle leaks, head and neck surgery, and diet, nutrition, non-fat, parental, MCFA, medium-chain fatty acid, TPN, or enteral were used as the type of nutritional management.

Exclusion criteria for the publications were non-English articles, animal/experimental studies, conference articles, paediatric cases, individual case reports, papers with less than 10 patients in a study, doesn’t use nutritional management, uses surgery alone or uses medical/drug management alone. After selection of publications based according to title, then abstract and full text, duplicate papers were removed. For publications that presented the same data or were follow-up studies, the latter was chosen to prevent an overlap. A hand search was conducted in major journals, and reference lists were interrogated.

Data extraction and quality assessment

The literature search was carried out by one researcher (NJ). Each article was critically appraised by two researchers (PB and NP) using the Joanna Briggs Institute Critical Appraisal for case series on a scale of 1 – 10, which is a validated tool for use in assessment of the quality of case series.Reference Moola, Munn, Tufanaru, Aromataris, Sears and Sfetcu9

Data extraction was performed by one researcher (NJ). The data extracted included the number of patients, patient characteristics, type of surgery, type of nutritional treatment, diagnostic method used, drainage output, as well as confidence intervals of quantitative data of these parameters when available. The main outcome measures considered from the studies was resolution of chyle leak with nutritional management and the need for surgical intervention, as well as the percentage of patients who underwent each of these types of treatment. The secondary outcome looked at the duration of inpatient stay in each of the above groups. It was entered into a proforma, which was independently reviewed by two researchers (PB and NP), and any disagreements on inclusion/omission of papers were resolved through consensus.

Data analysis

Due to the non-standard methodology, missing data, and heterogenicity between the studies, a meta-analysis was not appropriate. However, descriptive statistical analysis was determined to be more appropriate. For continuous data (such as number of days to chyle leak resolution and days to discharge), the mean was used as the outcome measure. For binary data (such as need of surgery for chyle leak resolution), the percentage of affected patients was used as the outcome measure. Calculation of statistics was done through the Statistical Package for Social Sciences (IBM SPSS). Graphs were produced using Microsoft Excel 365 package.

Results

The use of MeSH terms in combination for the initial search identified a total of 601 articles (72 from Cochrane, 124 from PubMed and 405 from Medline/Embase combined). After applying de-duplication and screening the abstracts, 60 papers were selected for full-text review, and 32 were considered to have the correct theme of research. Following the application of the inclusion/exclusion criteria,10 papers were included in this systematic review (see Prisma diagram (Figure 1) for more information on the systematic selection of publications).

Figure 1.

PRISMA flow diagram showing search strategy for systematic review.

A flowchart illustrating the systematic review process, starting with 601 publications, leading to 10 papers included after de-duplication, abstract screening and full-text review. See long description.
Figure 1 Long description

The flowchart outlines the systematic review process across four stages: Initial Search, Abstract Screening, Eligibility and Final Review. Initially, 601 publications were identified, with an additional 11 from reference lists. After de-duplication, 518 publications remained. Abstract screening reduced this to 70, with 448 papers excluded. The exclusion criteria included case series with fewer than 10 cases and lack of nutritional management. A full-text review of 32 publications followed, resulting in 10 papers included in the final review.

All the articles included in this systemic review were observational case series. All 10 studies that were included were retrospective case series. The Joanna Briggs Institute Appraisal checklist for case series was used for quality scoring of the publications.Reference Moola, Munn, Tufanaru, Aromataris, Sears and Sfetcu9 The score for all publications ranged from 4/10 to 9/10 signifying the heterogeneity of the studies.

Only two of the ten publications were prospective.Reference Lee, Kim, Chang and Park10, Reference Ahn, Sohn and Jeong11 The number of participants included in the studies ranged from 11 to 131, with publications based on a wide variety of populations.Reference Park, Her, Choe, Kim and Kim5, Reference Izzard, Crowder and Southwell14, Reference de Gier, Balm, Bruning, Gregor and Hilgers15 There was a breadth of demographics represented overall as the studies were from a wide range of countries (South Korea, United States, United Kingdom, Netherlands, Germany and New Zealand).Reference Park, Her, Choe, Kim and Kim5, Reference Nussenbaum, Liu and Sinard7, Reference Lee, Kim, Chang and Park10, Reference Lucente, Diktaban, Lawson and Biller12–Reference Spiro, Spiro and Strong18 The average occurrence of chyle leaks for all publications was averaged at 3.6% (0.5% - 15.9%).Reference Park, Her, Choe, Kim and Kim5, Reference Nussenbaum, Liu and Sinard7, Reference Lee, Kim, Chang and Park10, Reference Lucente, Diktaban, Lawson and Biller12–Reference Spiro, Spiro and Strong18 See Table 1 for baseline characteristics.

Table 1.

Baseline characteristics of publications included in the analysis

The table compares chyle leak characteristics across 10 studies, highlighting variations in patient numbers, surgical methods, and treatment approaches, with JBI scores ranging from 4 to 9. See long description.
Table 1 Long description

This table presents baseline characteristics of publications analyzing chyle leaks, detailing patient numbers, surgical types, and treatment methods across 10 studies from various countries. The number of patients with chyle leaks varies significantly, with Park et al. 2017 reporting the highest at 131 out of 15,233 patients. Surgical procedures include neck dissections and thyroid surgeries, with treatment methods such as MCT, TPN, and dietary modifications. JBI quality scores range from 4 to 9, indicating varying study quality. Diagnostic methods and definitions of high output also differ, with some studies using triglyceride concentration and others relying on clinical signs. The data suggests a lack of standardization in treatment and diagnosis across studies.

Key: JBI (Joanna Briggs Institute), MCT Medium Chain Triglycerides, TPN Total Parenteral Nutrition, ND Neck Dissection

A total of 260 patients were included for this systematic review.Reference Park, Her, Choe, Kim and Kim5, Reference Nussenbaum, Liu and Sinard7, Reference Lee, Kim, Chang and Park10, Reference Lucente, Diktaban, Lawson and Biller12–Reference Spiro, Spiro and Strong18 The entire population of all the studies included was noted to be 26,270.Reference Park, Her, Choe, Kim and Kim5, Reference Nussenbaum, Liu and Sinard7, Reference Lee, Kim, Chang and Park10, Reference Lucente, Diktaban, Lawson and Biller12–Reference Spiro, Spiro and Strong18 The majority of patients had a range of neck operations including thyroidectomies and a range of neck dissections.Reference Park, Her, Choe, Kim and Kim5, Reference Nussenbaum, Liu and Sinard7, Reference Lee, Kim, Chang and Park10, Reference Lucente, Diktaban, Lawson and Biller12–Reference Spiro, Spiro and Strong18 The nomenclature of the definition of the neck dissections ranged between publications (e.g. right/left/central/modified/selective/partial/radical/redo surgery).Reference Park, Her, Choe, Kim and Kim5, Reference Nussenbaum, Liu and Sinard7, Reference Lee, Kim, Chang and Park10, Reference Lucente, Diktaban, Lawson and Biller12–Reference Spiro, Spiro and Strong18 The summarised overview of those described in detail is as follows: Left sided (n=120, 50.4%), Bilateral (n=70, 29.4%), Right sided (n=28, 11.8%), Central (n=14, 5.9%) neck dissections, and Thyroidectomies (n=3, 1.3%) out of a total 238 patients with chyle leaks.Reference Park, Her, Choe, Kim and Kim5, Reference Nussenbaum, Liu and Sinard7, Reference Lee, Kim, Chang and Park10, Reference Lucente, Diktaban, Lawson and Biller12–Reference Spiro, Spiro and Strong18

The nutritional interventions used in the studies included Total Parenteral Nutrition (TPN), MCT (Medium Chain Triglyceride), Low fat, and Non-fat diets.Reference Park, Her, Choe, Kim and Kim5, Reference Nussenbaum, Liu and Sinard7, Reference Lee, Kim, Chang and Park10, Reference Lucente, Diktaban, Lawson and Biller12–Reference Spiro, Spiro and Strong18 Some of the studies used a variety of nutritional management methods; five used TPN, five used MCT, two used low-fat diets, and three used no-fat diets.Reference Park, Her, Choe, Kim and Kim5, Reference Nussenbaum, Liu and Sinard7, Reference Lee, Kim, Chang and Park10, Reference Lucente, Diktaban, Lawson and Biller12–Reference Spiro, Spiro and Strong18 Out of a cohort of 233 patients, the following categorisation of diets was noted: TPN (n=123, 52.8%), MCT (n=42, 18%), No-fat diet (n=39, 16.7%), Low fat diet (n=18, 7.7 %), and mixed MCT and TPN (n=11, 4.8%).Reference Park, Her, Choe, Kim and Kim5, Reference Nussenbaum, Liu and Sinard7, Reference Lee, Kim, Chang and Park10, Reference Lucente, Diktaban, Lawson and Biller12–Reference Spiro, Spiro and Strong18 See Table 2.

Table 2.

Primary outcomes (Length of time for resolution of chyle leak in patients who had nutritional management and those who had surgical treatment, percentage of patient who had nutritional and surgical management) and Secondary outcomes of the study (Length of inpatient stay in patients who had nutritional management and those who had surgery)

The study compares chyle leak resolution times and inpatient stays across various treatments, with nutritional management showing higher resolution rates than surgical intervention in most cases. See long description.
Table 2 Long description

The table examines the resolution time of chyle leaks and inpatient stay durations in patients undergoing nutritional versus surgical treatments. Key findings include a higher incidence of chyle leaks in studies with smaller patient populations, such as Roh et al. 2008, with a 15.9% incidence rate. Nutritional interventions, including MCT and TPN, generally resulted in quicker resolution times, with Lee et al. 2012 showing a mean resolution time of 4.3 days. Surgical intervention was less common, with the highest percentage of surgical cases being 34.5% in Lorenz et al. 2010. Mortality rates were low across all studies, with only Seow et al. 2010 reporting one death. The data suggests that nutritional management is effective in resolving chyle leaks, though the incidence rate varies significantly across studies.

Seven studies reported the time taken for resolution of the chyle leak in patients who only had nutritional management it was 8.7 days (4.3 to 22.1) (Median (Range)).Reference Nussenbaum, Liu and Sinard7, Reference Lee, Kim, Chang and Park10, Reference Seow, Murray and McKee13–Reference Lorenz, Abuazab, Sekulla, Nguyen-Thanh, Brauckhoff and Dralle17 The time taken for the resolution of chyle leak in those patients who had surgical management was 32 days (18 to 40).Reference Park, Her, Choe, Kim and Kim5, Reference Nussenbaum, Liu and Sinard7, Reference Lee, Kim, Chang and Park10, Reference de Gier, Balm, Bruning, Gregor and Hilgers15–Reference Spiro, Spiro and Strong18

The number of chyle leaks that stopped with nutritional modification alone was 212 out of 260 (81.5%).Reference Park, Her, Choe, Kim and Kim5, Reference Nussenbaum, Liu and Sinard7, Reference Lee, Kim, Chang and Park10, Reference Lucente, Diktaban, Lawson and Biller12–Reference Spiro, Spiro and Strong18 The remaining needed surgery to arrest the leak.Reference Park, Her, Choe, Kim and Kim5, Reference Nussenbaum, Liu and Sinard7, Reference Lee, Kim, Chang and Park10, Reference de Gier, Balm, Bruning, Gregor and Hilgers15–Reference Spiro, Spiro and Strong18 See figure 2 for a graphical representation of these data for all the publications included in this review.

Figure 2.

Figure showing the percentage of patients who underwent nutritional or surgical management (out of all the patients who developed a chyle leak.

Bar graph comparing surgical and nutritional management of chyle leaks across ten publications from 1980 to 2017. See long description.
Figure 2 Long description

The x-axis is labeled 'Management of people who developed chyle leak (As percentage)' and the y-axis is labeled 'Publication'. Each publication is represented by two bars: one for surgical management and one for nutritional management. The percentages for nutritional management are: Park et al (2017) 80.2, Lee et al (2012) 100.0, Seow et al (2010) 90.0, Lorenz et al (2010) 65.5, Roh et al (2008) 84.6, Izzard et al (2007) 100.0, Nussenbaum et al (2000) 80.0, Degrier et al (1995) 81.8, Spiro et al (1990) 71.4 and Lucente et al (1980) 100.0. The percentages for surgical management are: Park et al (2017) 0.0, Lee et al (2012) 0.0, Seow et al (2010) 0.0, Lorenz et al (2010) 34.5, Roh et al (2008) 15.4, Izzard et al (2007) 0.0, Nussenbaum et al (2000) 20.0, Degrier et al (1995) 18.2, Spiro et al (1990) 28.6 and Lucente et al (1980) 0.0.

There was a total of one mortality, which was noted to be due to sepsis/cellulitis/multiorgan failure.Reference Seow, Murray and McKee13

Discussion

A chyle leak is a potentially serious complication of a head and neck surgery.Reference Allen and Briggs1–Reference Delaney, Shi, Shokrani and Sinha4 Anatomically, both main lymphatic ducts of the body, the thoracic duct, and the right lymphatic duct, connect to the venous circulation at the base of the neck, making it susceptible to injury during neck surgery.Reference Delaney, Shi, Shokrani and Sinha4 The ducts drain in to the left internal jugular vein (IJV) and right subclavian vein (SV), respectively.Reference Delaney, Shi, Shokrani and Sinha4 However, the thoracic duct has been identified to have several anatomical variations where it joins the venous system at left IJV (46%), fusion of left IJV and SV (32%), and left SV (18%), which can be further complicated by bifurcation or trifurcation of the duct.Reference Phang, Bowman, Phillips and Windsor19, Reference Langford, Daudia and Malins20 This also makes it more likely for iatrogenic injury to occur when neck surgery is carried out on the left side.Reference Delaney, Shi, Shokrani and Sinha4 In this systematic review 52.5% of chyle leaks followed left sided neck dissections.Reference Park, Her, Choe, Kim and Kim5, Reference Nussenbaum, Liu and Sinard7, Reference Lee, Kim, Chang and Park10, Reference Lucente, Diktaban, Lawson and Biller12–Reference Spiro, Spiro and Strong18 The true result is likely to be closer to 75% with 29.4% of chyle leaks occurring in bilateral neck dissections which did not specify which side the leak occurred.Reference Park, Her, Choe, Kim and Kim5, Reference Nussenbaum, Liu and Sinard7, Reference Lee, Kim, Chang and Park10, Reference Lucente, Diktaban, Lawson and Biller12–Reference Spiro, Spiro and Strong18

The lymphatic drainage system is important for fluid balance as well as transport of fat substrates, particularly chylomicrons, which are made of long chain fatty acids (products of bile salts) absorbed into the intestinal lymphatic system.Reference Delaney, Shi, Shokrani and Sinha4 In contrast, small/medium chain fatty acids are water-soluble and therefore bypass lymphatics and are absorbed directly into the blood.Reference Smoke and DeLegge8 The transport of chyle in the lymphatic ducts is through smooth muscle activity, aided by difference in pressure in the thoracic cavity. Production of chyle is based on the presence of fatty substances in food, and general intestinal activity.Reference Delaney, Shi, Shokrani and Sinha4, Reference Bach and Babayan21 Therefore, most of the treatment strategies work to reduce production or transport of chyle4, Reference Bach and Babayan21. See Table 3 for a summary of currently used treatments for chyle leaks and reasoning behind each method.

Table 3

Postoperative conservative/medical and surgical management of the chyle leaks

The table outlines various management strategies for chyle leaks, including positional, dietary, medical, wound care, surgical, and radiological methods, each with specific reasoning. See long description.
Table 3 Long description

The table details postoperative management strategies for chyle leaks, categorizing them into positional, dietary, medical, wound care, surgical, and radiological methods. Positional management involves bed rest and elevation to reduce intrathoracic pressure. Dietary approaches include non-fat and medium-chain fatty acid diets to bypass lymphatic absorption. Medical treatments like Orlistat and Octreotide aim to reduce fat absorption and gut activity. Wound care involves suction drainage and negative pressure dressings, while surgical re-exploration is considered for high output leaks. Radiological management includes embolization using lymphography. Each method is accompanied by specific reasoning, highlighting the importance of reducing lymph flow and promoting healing.

The importance of diagnosing and treating chyle leaks are twofold: the loss of homeostasis (fluid balance, electrolytes, and fat) and the effect on wound healing.Reference Delaney, Shi, Shokrani and Sinha4 A chyle leak can lead to loss of fat/protein/fat-soluble vitamins, resulting in malnourishment, while the loss of electrolytes and volume can lead to shift in the homeostasis, resulting in electrolyte imbalance and hypovolaemia.Reference Allen and Briggs1–Reference Delaney, Shi, Shokrani and Sinha4 Wound healing can be affected as the chyle serves as a physical barrier to wound healing and a potential source for infection.Reference Allen and Briggs1–Reference Delaney, Shi, Shokrani and Sinha4 It can also affect the immune reaction by causing the loss of lymphocytes (which travel within the lymphatic system) and by triggering an exaggerated inflammatory response.Reference Crumley and Smith2, Reference de Gier, Balm, Bruning, Gregor and Hilgers15, Reference Ilczyszyn, Ridha and Durrani22, Reference Wada, Duh, Sugino, Iwasaki, Kameyama and Mimura23

Some of the publications considered for this review have noted malignant high-grade thyroid cancer,Reference Park, Her, Choe, Kim and Kim5, Reference Roh, Kim and Park16 particularly papillaryReference Park, Her, Choe, Kim and Kim5, Reference Lee, Kim, Chang and Park10, Reference Izzard, Crowder and Southwell14 and metastatic neck nodes as a major risk factor for occurrence of a chyle leak.Reference Roh, Kim and Park16 Other risk factors identified from publications include squamous cell carcinoma,Reference de Gier, Balm, Bruning, Gregor and Hilgers15 previous radiotherapy,Reference Nussenbaum, Liu and Sinard7 age over 50Reference Lee, Kim, Chang and Park10, Reference de Gier, Balm, Bruning, Gregor and Hilgers15, Reference Roh, Park and Park24 and female gender.Reference Lee, Kim, Chang and Park10, Reference de Gier, Balm, Bruning, Gregor and Hilgers15

  • • Chyle leaks result from lymphatic duct injury during neck surgery, occurring in 1–2% of cases and up to 8.3% after left-sided dissections; risk factors include radical surgery, prior radiotherapy, and advanced malignancy.

  • • Nutritional management options include TPN, medium-chain triglyceride (MCT) diets, and low-/no-fat diets, but comparative evidence between diets and against surgical management is currently limited in literature.

  • • This systematic review of 10 studies (260 patients) found that nutritional interventions alone resolved 81.5% of chyle leaks, with quicker resolution (∼8.7 days) and shorter hospital stays (∼9 days) than surgical treatment.

  • • TPN was linked to higher complication rates and greater likelihood of requiring surgery, whereas MCT/low-/no-fat diets were better tolerated and more effective as first-line options.

  • • No single nutritional strategy proved superior, but evidence supports starting with enteral diets and reserving TPN for refractory or high-output leaks.

  • • Further prospective studies and standardised treatment protocols are needed to guide optimal management.

Limitations of studies included

The primary limitation of the majority of the studies reviewed is their reliance on level 3 evidence, predominantly derived from case series.Reference Park, Her, Choe, Kim and Kim5, Reference Nussenbaum, Liu and Sinard7, Reference Lee, Kim, Chang and Park10, Reference Lucente, Diktaban, Lawson and Biller12–Reference Spiro, Spiro and Strong18, Reference Howick, Chalmers, Glasziou, Greenhalgh, Heneghan and Liberati25 To enhance reliability, we selected publications encompassing more than 10 patients. However, inherent differences persist due to the study designs, such as potential selection biases during data collection.Reference Park, Her, Choe, Kim and Kim5, Reference Nussenbaum, Liu and Sinard7, Reference Lee, Kim, Chang and Park10, Reference Lucente, Diktaban, Lawson and Biller12–Reference Spiro, Spiro and Strong18 The small sample sizes further complicate the assessment of treatment strategy effectiveness, rendering it challenging to formulate definitive recommendations.

The overall incidence rate of chyle leaks in the population was calculated to be 3.6%, with a range from 0.5% to 15.9%.Reference Park, Her, Choe, Kim and Kim5, Reference Nussenbaum, Liu and Sinard7, Reference Lee, Kim, Chang and Park10, Reference Lucente, Diktaban, Lawson and Biller12–Reference Spiro, Spiro and Strong18 Two outliers were identified within the study group: 15.9% and 8.1%, which skewed the result.Reference Roh, Kim and Park16 The first study by Roh et al, which reported an incidence of 15.9%, was conducted prospectively.Reference Seow, Murray and McKee13, Reference Roh, Kim and Park16 The second study by Seow et al, which reported an incidence of 8.1%, included a broader range of thoracic and upper abdominal surgical procedures.Reference Seow, Murray and McKee13 This introduces potential bias related to sample heterogeneity, likely skewing the results.

There is a lack of detail in some of the studies of patient baseline characteristics, the method of diagnosis, the definition of nomenclature used, as well as the heterogeneity in geographic location, type of surgery, and difference in decisions made at different points of the clinical journey, which makes interpretation of the data set challenging.Reference Lucente, Diktaban, Lawson and Biller12, Reference de Gier, Balm, Bruning, Gregor and Hilgers15, Reference Spiro, Spiro and Strong18

The descriptions of the diets themselves were limited, and it was unclear how nutrient and energy requirements were calculated, as well as which formulas were used.Reference Park, Her, Choe, Kim and Kim5, Reference Nussenbaum, Liu and Sinard7, Reference Lee, Kim, Chang and Park10, Reference Lucente, Diktaban, Lawson and Biller12–Reference Spiro, Spiro and Strong18 It was also not clear whether pre-assessment of patients' nutritional status was carried out and whether the management was based on these assessments.Reference Park, Her, Choe, Kim and Kim5, Reference Nussenbaum, Liu and Sinard7, Reference Lee, Kim, Chang and Park10, Reference Lucente, Diktaban, Lawson and Biller12–Reference Spiro, Spiro and Strong18

Overview of chyle management and current guidelines

The variable presentation and cause, accompanied with study heterogeneity and biases inherent in retrospective studies mean that clear protocols for management are difficult to develop. Talwar et al describes general nutritional management of patients undergoing head and neck surgery and makes general recommendations.Reference Talwar, Donnelly, Skelly and Donaldson26 This includes providing nutritional support for up to 2 weeks before surgery for patients at risk of malnourishment and potential carbohydrate loading for all patients.Reference Talwar, Donnelly, Skelly and Donaldson26 They also suggest starting nasogastric tube (NG) feeding within a day and consider introduction of oral diet early in primary laryngectomy.Reference Talwar, Donnelly, Skelly and Donaldson26 If a chyle leak is suspected, they recommend analysing drain fluid for triglycerides and chylomicrons and starting the patient on MCT/non-fat diet orally or via NG2.Reference Talwar, Donnelly, Skelly and Donaldson26 TPN is given to those with extremely high outputs.Reference Talwar, Donnelly, Skelly and Donaldson26 Chan et al suggests decision charts depending on the drainage output, with a more conservative treatment for low output leaks at first with use of octreotide, and the early use of TPN,Reference Chan, Wong, Ng, van Hasselt and Vlantis27 while Weigs et al have advised the use of MCT/non-fat diets before using TPN initially.Reference Chan, Wong, Ng, van Hasselt and Vlantis27, Reference Weijs, Ruurda, Broekhuizen, Gartner and van Hillegersberg29 Meyer et al suggest surgical management within first 24 hoursReference Meyer, McLeod and Gallagher28 for high-output chyle leaks, while Delaney et al advocate a trial of conservative/medical treatment before this.Reference Delaney, Shi, Shokrani and Sinha4 In the following few subsections, we have critically evaluated the evidence to aid in the diagnosis/investigation and management of a chyle leak.

Diagnosis of Chyle leak

Nussenbaum, Ahn and Lorenz et al refer to the ‘milky white’ appearance of chyle to be diagnostic of a chyle leak with the recommendation of measurement of triglycerides >100ml/dl (as the most common laboratory test) or chylomicrons as confirmatory.Reference Nussenbaum, Liu and Sinard7, Reference Ahn, Sohn and Jeong11, Reference Lorenz, Abuazab, Sekulla, Nguyen-Thanh, Brauckhoff and Dralle17

The definition of a high drain output greatly varied amongst the studies (from 200ml to a 1000ml), although the recommended definition is 500ml/24hrs as the cut-off of a low drain output.Reference Park, Her, Choe, Kim and Kim5, Reference Lee, Kim, Chang and Park10, Reference Lucente, Diktaban, Lawson and Biller12, Reference de Gier, Balm, Bruning, Gregor and Hilgers15

Post-operative nutrition management recommendations

There is considerable variability in recommendations regarding nutritional management across various case reviews and publications. In a number of the included studies, patients followed a combination of diets in succession, compromising the evaluation of individual diets.Reference Park, Her, Choe, Kim and Kim5, Reference Nussenbaum, Liu and Sinard7, Reference de Gier, Balm, Bruning, Gregor and Hilgers15–Reference Lorenz, Abuazab, Sekulla, Nguyen-Thanh, Brauckhoff and Dralle17 However, when comparing studies that exclusively used medium-chain triglyceride (MCT) diets, low-fat diets, or no-fat diets (lucente et al,Reference Lucente, Diktaban, Lawson and Biller12 Spiro et al,Reference Spiro, Spiro and Strong18 Izzard et alReference Izzard, Crowder and Southwell14) versus those that used total parenteral nutrition (TPN) (Seow et alReference Seow, Murray and McKee13), a higher number of patients on dietary interventions experienced fistula resolution compared to those on TPN, who more frequently required surgery. This discrepancy could be attributed to the fact that patients on TPN might have had higher initial chyle leak rates (though this is difficult to determine based on the available data) or were more susceptible to morbidities associated with TPN, which is known to cause more electrolyte disturbances than dietary interventions.Reference Park, Her, Choe, Kim and Kim5, Reference Nussenbaum, Liu and Sinard7, Reference Lee, Kim, Chang and Park10, Reference de Gier, Balm, Bruning, Gregor and Hilgers15–Reference Lorenz, Abuazab, Sekulla, Nguyen-Thanh, Brauckhoff and Dralle17

Delayney, Meyer and Steven et alReference Delaney, Shi, Shokrani and Sinha4, Reference Meyer, McLeod and Gallagher28, Reference Steven and Carey30, recommend conservative measures such as pressure dressing, suction drainage, bed rest with measures taken not to increase thoracic pressure (e.g., giving laxatives) and getting the patient started on low-fat/no-fat/MCT (as there is some evidence supporting this) diet together with octreotide (100µm subcutaneously),Reference Delaney, Shi, Shokrani and Sinha4 particularly for low output chyle leaks. Given the other morbidities associated with TPN, it would be sensible to consider this after the initial management has failed.Reference Meyer, McLeod and Gallagher28, Reference Steven and Carey30 However, if the output is extremely high (>1000ml/24hrs), early decision for surgical exploration to prevent prolonged hospital stay and increased morbidity (such as increase in rate of infection and flap necrosis) is indicated.Reference Meyer, McLeod and Gallagher28, Reference Steven and Carey30 Post-resolution, gradual reintroduction of normal diet over a period of 2-4 weeks may result in a reduced risk of recollection of chyle.Reference Meyer, McLeod and Gallagher28

Higher-level evidence is required to establish robust recommendations for the non-surgical management of chyle leaks following neck surgery. Preoperative measures, such as fat loading or the use of cyanodye to aid in the intraoperative diagnosis of chyle leaks,Reference Kawasaki, Sugimoto, Fujii, Miyamoto, Okada and Yamaguchi31–Reference Shah, Ahmed, Smith, Mallina, Akhbari and Khan33 and the medical management with longer-acting somatostatin analogues like lanreotide, as well as the use of sclerosing agents, have been suggested.Reference Roh, Yoon and Park3, Reference Bach and Babayan21 However, further research is necessary to validate their efficacy in managing chyle leaks. Comprehensive investigations, detailed characterizations of patient populations, and standardized treatment protocols in prospective studies are essential to improve our understanding and management of this complex condition.

Conclusion

Nutritional management is recommended for all patients with chyle leaks however there is no evidence showing that one type of diet is better than the other however in clinical practice one should start with MCT/low/no fat diet before TPN (unless other medical factors dictate non-enteral routes) due to side effect profile. We recommend that clinicians conduct thorough individual assessments of each patient, taking into consideration specific risk factors, drain output measurements, and this evaluation should inform decisions regarding the most suitable nutritional management approach and the potential need for re-surgery.

Acknowledgements

No further acknowledgements to be made

Funding

No funding received.

AI contributions

AI was used for editing this publication only. It was not used for writing, referencing or any other purpose.

References

Allen, DP, Briggs, CE. Wounds of the thoracic duct occurring in the neck: report of two cases; resume of seventeen cases. Am J Med 1969;47:401–4Google Scholar
Crumley, RL, Smith, JD. Postoperative chylous fistula prevention and management. Laryngoscope 1976;86:805–13CrossRefGoogle Scholar
Roh, JL, Yoon, YH, Park, CI. Chyle leakage in patients undergoing thyroidectomy plus central neck dissection for differentiated papillary thyroid carcinoma. Ann Surg Oncol 2008;15:2576–80CrossRefGoogle ScholarPubMed
Delaney, SW, Shi, H, Shokrani, A, Sinha, UK. Management of chyle leak after head and neck surgery: review of current treatment strategies. Int J Otolaryngol 2017;2017:1–7CrossRefGoogle ScholarPubMed
Park, I, Her, N, Choe, JH, Kim, JS, Kim, JH. Management of chyle leakage after thyroidectomy, cervical lymph node dissection, in patients with thyroid cancer. Head Neck 2018;40:7–15CrossRefGoogle Scholar
Swanson, MS, Hudson, RL, Bhandari, N, Sinha, UK, Maceri, DR, Kokot, N. Use of octreotide for the management of chyle fistula following neck dissection. JAMA Otolaryngol Head Neck Surg 2015;141:723–7CrossRefGoogle Scholar
Nussenbaum, B, Liu, JH, Sinard, RJ. Systematic management of chyle fistula: the Southwestern experience and review of the literature. Otolaryngol Head Neck Surg 2000;122:31–8CrossRefGoogle Scholar
Smoke, A, DeLegge, MH. Chyle leaks: consensus on management? Nutr Clin Pract 2008;23:529–32CrossRefGoogle ScholarPubMed
Moola, S, Munn, Z, Tufanaru, C, Aromataris, E, Sears, K, Sfetcu, R, et al. Chapter 7: Systematic reviews of etiology and risk. Joanna Briggs Inst Rev Manual 2017:2019–05Google Scholar
Lee, YS, Kim, BW, Chang, HS, Park, CS. Factors predisposing to chyle leakage following thyroid cancer surgery without lateral neck dissection. Head Neck 2013;35:1149–52CrossRefGoogle ScholarPubMed
Ahn, D, Sohn, JH, Jeong, JY. Chyle fistula after neck dissection: an 8-year, single-center, prospective study of incidence, clinical features, and treatment. Ann Surg Oncol 2015;22:1000–6CrossRefGoogle ScholarPubMed
Lucente, FE, Diktaban, T, Lawson, W, Biller, HF. Chyle fistula management. Otolaryngol Head Neck Surg 1981;89:575–8CrossRefGoogle ScholarPubMed
Seow, C, Murray, L, McKee, RF. Surgical pathology is a predictor of outcome in post-operative lymph leakage. Int J Surg 2010;8:636–8CrossRefGoogle ScholarPubMed
Izzard, ME, Crowder, VL, Southwell, KE. The use of Monogen in the conservative management of chylous fistula. Otolaryngol Head Neck Surg 2007;136:S50-3CrossRefGoogle ScholarPubMed
de Gier, HHW, Balm, AJM, Bruning, PF, Gregor, RT, Hilgers, FJM. Systematic approach to the treatment of chylous leakage after neck dissection. Head Neck 1996;18:347–513.0.CO;2-Y>CrossRefGoogle Scholar
Roh, JL, Kim, DH, Park, CIL. Prospective identification of chyle leakage in patients undergoing lateral neck dissection for metastatic thyroid cancer. Ann Surg Oncol 2008;15:424–9CrossRefGoogle ScholarPubMed
Lorenz, K, Abuazab, M, Sekulla, C, Nguyen-Thanh, P, Brauckhoff, M, Dralle, H. Management of lymph fistulas in thyroid surgery. Langenbecks Arch Surg 2010;395:911–7CrossRefGoogle ScholarPubMed
Spiro, JD, Spiro, RH, Strong, EW. The management of chyle fistula. Laryngoscope 1990;100:771–4CrossRefGoogle ScholarPubMed
Phang, K, Bowman, M, Phillips, A, Windsor, J. Review of thoracic duct anatomical variations and clinical implications. Clin Anat 2014;27:637–44CrossRefGoogle ScholarPubMed
Langford, RJ, Daudia, AT, Malins, TJ. A morphological study of the thoracic duct at the jugulo-subclavian junction. J Craniomaxillofac Surg 1999;27:100–4CrossRefGoogle ScholarPubMed
Bach, A, Babayan, VK. Medium-chain triglycerides: an update. Am J Clin Nutr 1982;36:950–62CrossRefGoogle ScholarPubMed
Ilczyszyn, A, Ridha, H, Durrani, AJ. Management of chyle leak post neck dissection: a case report and literature review. J Plast Reconstr Aesthet Surg 2011;64:e223-30CrossRefGoogle ScholarPubMed
Wada, N, Duh, QY, Sugino, K, Iwasaki, H, Kameyama, K, Mimura, T, et al. Lymph node metastasis from 259 papillary thyroid microcarcinomas: frequency, pattern of occurrence and recurrence, and optimal strategy for neck dissection. Ann Surg 2003;237:399–407CrossRefGoogle ScholarPubMed
Roh, JL, Park, JY, Park, CI. Total thyroidectomy plus neck dissection in differentiated papillary thyroid carcinoma patients: pattern of nodal metastasis, morbidity, recurrence, and postoperative levels of serum parathyroid hormone. Ann Surg 2007;245:604–10CrossRefGoogle ScholarPubMed
Howick, J, Chalmers, I, Glasziou, P, Greenhalgh, T, Heneghan, C, Liberati, A, et al. The 2011 Oxford CEBM evidence levels of evidence (introductory document) Oxford: Oxford Centre for Evidence Based Medicine; 2011Google Scholar
Talwar, B, Donnelly, R, Skelly, R, Donaldson, M. Nutritional management in head and neck cancer: United Kingdom National Multidisciplinary Guidelines. J Laryngol Otol 2016;130:S32-40CrossRefGoogle ScholarPubMed
Chan, JYK, Wong, EWY, Ng, SK, van Hasselt, CA, Vlantis, AC. Conservative management of postoperative chylous fistula with octreotide and peripheral total parenteral nutrition. Ear Nose Throat J 2017;96:264–7CrossRefGoogle ScholarPubMed
Meyer, CD, McLeod, IK, Gallagher, DJ. Conservative management of an intraoperative chyle leak: a case report and literature review. Mil Med 2016;181:e1180-4CrossRefGoogle Scholar
Weijs, TJ, Ruurda, JP, Broekhuizen, ME, Gartner, TCLB, van Hillegersberg, R. Outcome of a step-up treatment strategy for chyle leakage after esophagectomy. Ann Thorac Surg 2017;104:477–84CrossRefGoogle ScholarPubMed
Steven, BR, Carey, S. Nutritional management in patients with chyle leakage: a systematic review. Eur J Clin Nutr 2015;69:776–80CrossRefGoogle ScholarPubMed
Kawasaki, R, Sugimoto, K, Fujii, M, Miyamoto, N, Okada, T, Yamaguchi, M, et al. Therapeutic effectiveness of diagnostic lymphangiography for refractory postoperative chylothorax and chylous ascites: correlation with radiologic findings and preceding medical treatment. AJR Am J Roentgenol 2013;201:659–66CrossRefGoogle ScholarPubMed
Klepser, RG, Berry, JF. The diagnosis and surgical management of chylothorax with the aid of lipophilic dyes. Chest 1954;25:409–26Google ScholarPubMed
Shah, SS, Ahmed, K, Smith, R, Mallina, R, Akhbari, P, Khan, MS. Chylous ascites following radical nephrectomy: a case report. J Med Case Rep 2008;2:3CrossRefGoogle ScholarPubMed
Belloso, A, Saravanan, K, de Carpentier, J. The community management of chylous fistula using a pancreatic lipase inhibitor (orlistat). Laryngoscope 2006;116:1934–5CrossRefGoogle Scholar
Ulíbarri, J, Sanz, Y, Fuentes, C, Mancha, A, Aramendia, M, Sánchez, S. Reduction of lymphorrhagia from ruptured thoracic duct by somatostatin. Lancet 1990;336:258CrossRefGoogle ScholarPubMed
Markham, KM, Glover, JL, Welsh, RJ, Lucas, RJ, Bendick, PJ. Octreotide in the treatment of thoracic duct injuries. Am Surg 2000;66:1165CrossRefGoogle ScholarPubMed
Davis, SN, Granner, I. Insulin, oral hypoglycemic agents, and the pharmacology of the endocrine pancreas. In: Hardman, JG, Limbird, LE, Molinoff, PB, Ruddon, RW, Gilman, AG, editors. Goodman Gilman Pharmacol Basis Ther New York: McGraw-Hill; 1996:1487–518Google Scholar
Dhiwakar, M, Nambi, GI, Ramanikanth, TV. Drain removal and aspiration to treat low output chylous fistula. Eur Arch Otorhinolaryngol 2014;271:561–5CrossRefGoogle ScholarPubMed
Muthusami, JC, Raj, JP, Gladwin, D, Gaikwad, P, Sylvester, S. Persistent chyle leak following radical neck dissection: a solution that can be the solution. Ann R Coll Surg Engl 2005;87:379CrossRefGoogle ScholarPubMed
Gregor, RT. Management of chyle fistulization in association with neck dissection. Otolaryngol Head Neck Surg 2000;122:434–9CrossRefGoogle ScholarPubMed
Anestis, N, Christos, FC, Ioannis, P, Christos, I, Lampros, P, Stephanos, P. Thoracic duct injury due to left subclavicular vein catheterization: a new conservative approach to a chyle fistula using biological glue. Int J Surg Case Rep 2012;3:330–2CrossRefGoogle ScholarPubMed
Fitz-Hugh, GS, Cowgill, R. Chylous fistula: complication of neck dissection. Arch Otolaryngol Head Neck Surg 1970;91:543–7CrossRefGoogle Scholar
Itkin, M, Kucharczuk, JC, Kwak, A, Trerotola, SO, Kaiser, LR. Nonoperative thoracic duct embolization for traumatic thoracic duct leak: experience in 109 patients. J Thorac Cardiovasc Surg 2010;139:584–90CrossRefGoogle ScholarPubMed
Deso, S, Ludwig, B, Kabutey, NK, Kim, D, Guermazi, A. Lymphangiography in the diagnosis and localization of various chyle leaks. Cardiovasc Intervent Radiol 2012;35:117–26CrossRefGoogle ScholarPubMed
Figure 0

Figure 1. PRISMA flow diagram showing search strategy for systematic review.Figure 1 long description.

Figure 1

Table 1. Baseline characteristics of publications included in the analysisTable 1 long description.

Figure 2

Table 2. Primary outcomes (Length of time for resolution of chyle leak in patients who had nutritional management and those who had surgical treatment, percentage of patient who had nutritional and surgical management) and Secondary outcomes of the study (Length of inpatient stay in patients who had nutritional management and those who had surgery)Table 2 long description.

Figure 3

Figure 2. Figure showing the percentage of patients who underwent nutritional or surgical management (out of all the patients who developed a chyle leak.Figure 2 long description.

Figure 4

Table 3 Postoperative conservative/medical and surgical management of the chyle leaksTable 3 long description.