Occasional articleNutritional support in adults with chyle leaks
Introduction
Chyle leaks are a relatively rare complication following surgical procedures from the abdomen to the lower neck areas, which involves the risk of damage to para-aortic lymphatic system and the chylous system. Most leaks occur after surgery in the chest but procedures in the abdomen and the neck may also result in chyle leaks. Large volumes of lymph can be lost, leading to significant morbidity due to loss of fluid, protein, micronutrients, and white blood cells.
Multiple management options exist. These include nonoperative management, intervention via radiologic procedures, and intervention via surgery. Initial management consists of decreasing the flow of lymph fluid through the lymphatic system via limiting oral intake, restricting fats in enteral feeding, providing parenteral nutrition (PN), diuresis to decrease total volume status, and medications to decrease alimentary tract secretions. Throughout the management of chyle leaks, nutritional support is needed, based on the physiology of chyle production and the damaging effects of continued loss from the body. This review provides a pragmatic and clinical approach. Our recommendations are made based on the authors' cumulative years of clinical experience, the study of the available literature that consists mainly of small observational trials, retrospective analyses, and case reports.
Section snippets
Anatomy of the lymphatic system
Lymph fluid circulates in ill-defined lymphatic vessels throughout the body. Most lymphatics interconnect lymph nodes. However, an important plexus of lymphatics exists as lacteals draining the small intestine and mesentery. These pool lymph fluid in the cisterna chyli, usually found on the right side of the abdominal aorta at the level of, and posterior to, the insertion of the right diaphragmatic crus onto the vertebrae. The cisterna chyli feeds into the ascending thoracic duct, which
Iatrogenic causes of chyle leaks
Injury to the lymphatic system resulting from surgery represents the leading cause of intraabdominal, intrathoracic, and cervical chyle leaks. Given the meandering anatomic pathway of lymphatic drainage from the abdomen, through the chest to the left neck, one can anticipate causes of surgical trauma to the lymphatic system. These are the most commonly injury, occurring during abdominal aortic aneurysm repair, complicated abdominal aortic surgery, retroperitoneal lymph node dissection [3],
Composition of chyle and clinical implications of loss
Volume: Chyle is lymphatic fluid from the interstitium and intestinal lacteals. Approximately 2500 mL of chyle per day flows through the thoracic duct and into the venous system. The rate of flow ranges from 0.38 mL/min (550 mL/24 h) during fasting to 3.9 mL/min in the postprandial state [1]. Most of this fluid is from the intestinal lymphatics and liver with minimal amount from the extremities. Lymph from the lungs contributes to the volume more superiorly toward the neck.
Lipids: The presence
Diagnosis of chyle leaks
Suspect a chyle leak when milky or high volume drainage of fluid is noted from drains placed in the chest, abdomen, or neck. It should be suspected when a new, unexplained pleural effusion is detected on imaging studies or when unexpected abdominal ascites occurs, (especially after undergoing procedures done in proximity to the major lymphatics) and following the start of an oral diet.
A high index of suspicion of chyle leak is required since chyle's opalescent appearance may not occur in over
Imaging studies to identify site of leak
The degree to which imaging studies influence therapy is controversial [19]. Clinical or laboratory diagnosis of a chyle leak in conjunction with site of recent surgery, trauma, or malignancy usually indicates where the leak has occurred. Lymphangiography and lymphoscintigraphy are generally limited to patients with uncertain diagnosis after other workup, for recurrent leaks, and when major anatomic anomalies are suspected [20]. Computed tomography is not useful in identifying the site of chyle
Complications of chyle leak
In patients with atraumatic chyle leaks, the initial management is focused on the underlying condition such as malignancy, sarcoidosis, or infections. Adequate drainage of the fluid from the abdomen or chest cavity decrease complications due to accumulation of fluid due to losses of circulating volume, protein, lymphocytes, electrolytes, and micronutrients.
Preoperative prevention
Although preoperative oral nutritional supplements, even in patients who appear to be well nourished, decrease gastrointestinal anastomotic leaks [21], there is no data whether this applies to chyle leaks. The exact component of ONS responsible for the benefits noted is not clear, however it is clear that protein intake must be adequate. It is also likely that ONS corrects unrecognized micronutrient deficiencies, especially in obese patients [22], [23]. It is beneficial to have a hospital-wide
Management strategies of chyle leaks: Non-surgical and nutritional support
Many publications on management of chyle leaks mention standard recommendations: nil per os, fat-free diet, medium chain triacylglycerol rich diet, enteral feeding, or PN, but do not explain clearly how one can “mix and match” various nutrition strategies [29]. Recent reviews on this topic are lacking. Therefore, we offer a practical approach to a patient with a chyle leak. Trade names of the several commercially available enteral products, with varying amounts and types of fat, as well as
Management strategies: Pharmacologic
The use of somatostatin and octreotide in the management of chyle leaks has been reported both in the pediatric and adult literature. Although there are several case reports, their use is considered controversial [46]. Side effects include gastrointestinal symptoms such as nausea and diarrhea, which interfere with adequate enteral nutrition intake, digestion and absorption, as well as cardiovascular effects such as cutaneous flushing and sinus bradycardia, and elevated liver function laboratory
Management strategies: Surgery
There is no set cut-off indicating surgical management of the chyle leak. Some have suggested operative treatment for chyle leak producing >500 cc/d for 7 d [3], [47]; others suggest >1.5 L for > 5 to 7 d [48]. The decision regarding timing of reoperative surgery to close or control chyle leaks is multifactorial. Factors to consider include the technical difficulties faced during the initial procedure including exposure and fibrosis making identification of lymphatics difficult, diagnosis
Conclusions
The management of chyle leaks after trauma or surgery, or spontaneously, involves a thorough knowledge of the physiology of chyle and its composition. Clinicians must understand that the loss of fluids, electrolytes, proteins, lymphocytes, and micronutrients in high volume chyle leaks results in deleterious effects. Providing standard enteral feeding or oral diets is limited by the fact that long chain fatty acids are absorbed through intestinal lacteals and form a major component of chyle,
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2021, Clinical NutritionCitation Excerpt :The key initial step in management is to optimize the patient's nutritional status [128]. Many publications on the management of chyle leaks mention standard recommendations: surgical options, nil per os, fat-free diet, MCT-rich diet, EN, or PN, but do not explain clearly how one can “mix and match” various nutrition strategies [127]. The duration of nutritional interventions also remains unclear.