Chyle Leak Post-Surgery Medical Slides

Present the stepwise conservative approach: Low-output leak (<500 mL/day): MCT (medium-chain triglyceride) diet — MCTs are absorbed directly into portal venous system, bypassing the thoracic duct (reducing chyle flow by 50-80%). Monitor drain output daily. If output decreasing over 3-5 days, continue MCT diet. High-output leak (>1000 mL/day) or persistent low-output: NPO + TPN (eliminates enteral fat absorption entirely, reduces chyle flow by 80%). Add octreotide 100-200 mcg SC TID (reduces splanchnic blood flow and lymph production — evidence limited to case series but widely used). Replace losses: chyle contains protein (2-6 g/dL), immunoglobulins, and electrolytes. Conservative management succeeds in 50-80% of cases within 2 weeks.

Present the indications for surgical intervention: high-output leak (>1 L/day for >5-7 days), output not decreasing on full conservative management for 2 weeks, metabolic complications (malnutrition, immunosuppression, electrolyte imbalances) despite supplementation. Technique: mass ligation of all tissue between aorta and azygos vein above the diaphragm (captures thoracic duct and all anatomic variants — duct anatomy is highly variable with 40% having duplicate or plexiform channels). VATS approach: identify leak site (preoperative oral fat challenge with cream makes chyle visible intraoperatively), clip/suture specific site if identified, or perform mass ligation of supradiaphragmatic tissue if site not visualized. Success rate 90-95%. Right-sided approach is standard (thoracic duct lies to the right of aorta in the lower thorax).

Present the interventional radiology approach: Step 1 — pedal lymphangiography (inject lipiodol into lymphatic channels in the dorsum of each foot under fluoroscopy, opacifies the thoracic duct and may identify leak site). In 30-50% of cases, lymphangiography alone is therapeutic (lipiodol embolizes the leak site). Step 2 — if lymphangiography unsuccessful, attempt thoracic duct cannulation (transabdominal access to cisterna chyli under fluoroscopy) and glue embolization (N-butyl cyanoacrylate) of the duct proximal to the leak. Success rate: lymphangiography alone 51-71%, combined with duct embolization 73-90%. Advantages over surgery: minimally invasive, can be performed under local anesthesia, particularly valuable in debilitated post-surgical patients. Limitations: requires experienced interventional radiologist, cisterna chyli may be difficult to access.