Etiology, Diagnosis and Treatment of Lymphocutaneous Fistulas, Chylascites and Chylothorax as Infrequent but Serious Complications Following Surgical Procedures*[1]

Introduction

Lymphorrhea (syn. chylorrhea) is rarely observed and can be considered as a serious complication of various diseases, syndromes and conditions. It is defined as a pathological lymphatic flow “via falsa” due to a leakage of lymphatic vessels. Clinically, the consequences of fluid collection within various cavities and organs predominate including the loss of protein- and fat-enriched fluid as well as immunocompetent cells. 

Invasive procedures and surgical interventions are the most frequent cause of traumatic damage to lymphatic vessels. In lymphocutaneous fistulas, predominantly local problems such as infections and delay of wound healing can be found. In contrast, patients with postoperative chylous ascites or chylothorax are mainly threatened by severe nutritional and metabolic disturbances and occasionally systemic infections. These may strongly complicate the postoperative course, increase mortality and, thus, increase the treatment costs. 

As postoperative lymphorrhea rarely occurs, there is only little clinical experience available and this mainly in large hospitals. Therefore, a systematic review of current diagnostic and therapeutic options for lymphocutaneous fistulas, chylous ascites and chylothorax appears to be useful to help to improve the management of postoperative lymphorrhea. 

1 *Modified version of the manuscript recently published under Benedix et al. Post-surgical lymphocutaneous fistula, chylous ascites and chylothorax – infrequent but serious complications: etiology, diagnosis and therapeutic option.
Zentralbl Chir 2007; 132: 529–538 (DOI 10.1055/s-2007–981364 // ISSN 723–7065). Article in German.

References

• 1 Kwaan J H, Bernstein J M, Connolly J E. Management of lymph fistula in the groin after arterial reconstruction.  Arch Surg. 1979;  114 1416-1418
• 2 Pimpl W, Thalheimer J, Rieger R et al. Immunologic capacity and blood circulation of splenic autotransplants – experimental results in swine.  Langenbecks Arch Chir. 1986;  369 399-403
• 3 Kent K C, Bartek S, Kuntz K M et al. Prospective study of wound complications in continuous infrainguinal incisions after lower limb arterial reconstruction: incidence, risk factors, and cost.  Surgery. 1996;  119 378-383
• 4 Giovannacci L, Eugster T, Stierli P et al. Does fibrin glue reduce complications after femoral artery surgery? A randomised trial.  Eur J Vasc Endovasc Surg. 2002;  24 196-201
• 5 Tyndall S H, Shepard A D, Wilczewski J M et al. Groin lymphatic complications after arterial reconstruction.  J Vasc Surg. 1994;  19 858-864
• 6 Schwartz M A, Schanzer H, Skladany M et al. A comparison of conservative therapy and early selective ligation in the treatment of lymphatic complications following vascular procedures.  Am J Surg. 1995;  170 206-208
• 7 Steele S R, Martin M J, Mullenix P S et al. Intraoperative use of isosulfan blue in the treatment of persistent lymphatic leaks.  Am J Surg. 2003;  186 9-12
• 8 Croft R J. Lymphatic fistula: a complication of arterial surgery.  Br Med J. 1978;  2 205
• 9 Neu B, Gauss G, Haase W et al. Radiotherapy of lymphatic fistula and lymphocele.  Strahlenther Onkol. 2000;  176 9-15
• 10 Dietl B, Pfister K, Aufschläger C et al. Die Strahlentherapie inguinaler Lymphfisteln nach gefäßchirurgischen Eingriffen.  Strahlenther Onkol. 2005;  181 396-400
• 11 Mayer R, Sminia P, McBride W H et al. Lymphatic fistulas: Obliteration by low-dose radiotherapy.  Strahlenther Onkol. 2005;  181 660-664
• 12 Hillerdal G. Chylothorax and pseudochylothorax.  Eur Respir J. 1997;  10 1157-1162
• 13 Cnotliwy M, Gutowski P, Petriczko W et al. Doxycycline treatment of groin lymphatic fistulae following arterial reconstruction procedures.  Eur J Vasc Endovasc Surg. 2001;  21 469-470
• 14 Hackert T, Werner J, Loos M et al. Successful doxycycline treatment of lymphatic fistulas: report of five cases and review of the literature.  Langenbecks Arch Surg. 2006;  391 435-438
• 15 Greer S E, Adelman M, Kasabian A et al. The use of subatmospheric pressure dressing therapy to close lymphocutaneous fistulas of the groin.  Br J Plast Surg. 2000;  53 484-487
• 16 Argenta L C, Morykwas M J. Vacuum-assisted closure: a new method for wound control and treatment: clinical experience.  Ann Plast Surg. 1997;  38 563-576
• 17 Morykwas M J, Argenta L C, Shelton-Brown E I et al. Vacuum-assisted closure: a new method for wound control and treatment: animal studies and basic foundation.  Ann Plast Surg. 1997;  38 553-562
• 18 Carcoforo O, Solani G, Maestroni U et al. Octreotide in the treatment of lymphorrhea after axillary node dissection: a prospective randomized controlled trial.  J Am Coll Surg. 2003;  196 365-369
• 19 Coveney E C, O’Dwyer P J, Geraghty J G et al. Effect of closing dead space on seroma formation after mastectomy – a prospective randomized clinical trial.  Eur J Surg Oncol. 1993;  19 143-146
• 20 Schultz I, Barholm M, Grondal S. Delayed shoulder exercises in reducing seroma frequency after modified radical mastectomy: a prospective randomized study.  Ann Surg Oncol. 1997;  4 293-297
• 21 Moore M, Burak W, Nelson E et al. Fibrin sealant reduces the duration and amount of fluid drainage after axillary dissection: a randomized prospective clinical trial.  J Am Coll Surg. 2001;  192 591-599
• 22 Mustonen P K, Härmä M A, Eskelinen M J. The effect of fibrin sealant combined with fibrinolysis inhibitor on reducing the amount of lymphatic leakage after axillary evacuation in breast cancer. A prospective randomized clinical trial.  Scand J Surg. 2004;  93 209-212
• 23 Erisen L, Coskun H, Basut O. Objective and early diagnosis of chylous fistula in the postoperative period.  Otolaryngol Head Neck Surg. 2002;  126 172-175
• 24 Suver D W, Perkins J A, Manning S C. Somatostatin treatment of massive lymphorrhea following excision of a lymphatic malformation.  Int J Pediatr Otorhinolaryngol. 2004;  68 845-850
• 25 Cardenas A, Chopra S. Chylous ascites.  Am J Gastroenterol. 2002;  97 1896-1900
• 26 Browse N L, Wilson N M, Russo F et al. Aetiology and treatment of chylous ascites.  Br J Surg. 1992;  79 1145-1150
• 27 Jensen E H, Weiss C A. Management of chylous ascites after laparoscopic cholecystectomy using minimally invasive techniques: a case report and literature review.  Am Surg. 2006;  72 60-63
• 28 Halloul Z, Meyer F, Burger T et al. Chylous ascites, a rare complication of aortic surgery.  Vasa. 1995;  24 377-381
• 29 Leibovitch I, Mor Y, Golomb J et al. The diagnosis and management of postoperative chylous acites.  J Urol. 2002;  167 449-457
• 30 Kaas R, Rustman L D, Zoetmulder F A. Chylous ascites after oncological abdominal surgery: incidence and treatment.  Eur J Surg Oncol. 2001;  27 187-189
• 31 Chan K Y, Teoh C M, Sukumar N. Chylous ascites after anterior resection for rectal carcinoma: a rare but significant incident.  Asian J Surg. 2006;  29 46-48
• 32 Aalami O O, Allen D B, Organ C H. Chylous ascites: a collective review.  Surgery. 2000;  128 761-778
• 33 Pui M H, Yueh T C. Lymphoscintigraphy in chyluria, chyloperitoneum and chylothorax.  J Nucl Med. 1998;  39 1292-1296
• 34 Laterre P F, Dugernier T, Reynaert M S. Chylous ascites: diagnosis, causes and treatment.  Acta Gastroenterol Belg. 2000;  63 260-263
• 35 Combe J, Buniet J M, Douge C et al. Chylothorax and chylous ascites following surgery of an inflammatory aortic aneurysm. Case report with review of the literature.  J Mal Vasc. 1992;  17 151-156
• 36 Huang Q, Jiang Z W, Jiang J et al. Chylous ascites: treated with total parenteral nutrition and somatostatin.  World J Gastroenterol. 2004;  10 2588-2591
• 37 Jensen G L, Mascioli E A, Meyer L P et al. Dietary modification of chyle composition in chylothorax.  Gastroenterology. 1989;  97 761-765
• 38 Guillem P, Billeret V, Lecomte Houcke M et al. Successful management of post-esophagectomy chylothorax/chyloperitoneum by etilefrine.  Dis Esophagus. 1999;  12 155-156
• 39 Almakdisi T, Massoud S, Makdisi G. Lymphomas and chylous ascites: review of the literature.  Oncologist. 2005;  10 632-635
• 40 Jonas J, Kaissling G, Druschky K .F et al. The transsternal thymectomy. Indication of operation and perioperative management.  Zentralbl Chir. 2000;  125 671-677
• 41 Kick J, Schelzig H, Heinecke A et al. Resection of lung metastases – risk or chance?.  Zentralbl Chir. 2005;  130 534-538
• 42 Terzi A, Furlan G, Magannelli G et al. Chylothorax after pleuro-pulmonary surgery: a rare but unavoidable complication.  Thorac Cardiovasc Surg. 1994;  42 81-84
• 43 Shimizu J, Hayashi Y, Oda M et al. Treatment of postoperative chylothorax by pleurodesis with the streptococcal preparation OK-432.  Thorac Cardiovasc Surg. 1994;  42 233-236
• 44 Dougenis D, Walker W S, Cameron E W et al. Management of chylothorax complicating extensive esophageal resection.  Surg Gyn Obst. 1992;  174 501-506
• 45 Johnstone D W. Postoperative chylothorax.  Chest Surg Clin N Am. 2002;  12 597-603
• 46 De Beer H GJ, Mol M JT, Janssen J P. Chylothorax.  Neth J Med. 2000;  56 25-31
• 47 Doerr C H, Miller D L, Ryu J H. Chylothorax.  Semin Resp Crit Care Med. 2001;  22 617-626
• 48 Motoyama S, Okuyama M, Saito R et al. Magnetic resonance imaging for chylothorax after esophagectomy.  Jpn J Thorac Cardiovasc Surg. 2005;  53 434-436
• 49 Gomez-Caro A A, Moradiellos Diez F J, Marron C F et al. Conservative management of postsurgical chylothorax with octreotide.  Asian Cardiovasc Thoracic Ann. 2005;  13 222-224
• 50 Pratap U, Slavik Z, Ofoe V D et al. Octreotide to treat postoperative chylothorax after cardiac operations in children.  Ann Thorac Surg. 2001;  72 1740-1742
• 51 Selle G J, Snyder W H, Schreiber J T. Chylothorax: indications for surgery.  Ann Surg. 1973;  177 245-249
• 52 Alexiou C, Watson M, Beggs D et al. Chylothorax following oesophagogastrectomy for malignant disease.  Eur J Cardiothorac Surg. 1998;  14 460-466
• 53 Cerfolio R J, Allen M S, Deschamps C et al. Postoperative chylothorax.  J Thorac Cardiovasc Surg. 1996;  112 1361-1366
• 54 Dugue L, Sauvanet A, Farges O et al. Output of chyle as an indicator of treatment for chylothorax complicating esophagectomy.  Br J Surg. 1998;  85 1147-1149
• 55 Cope C, Salem R, Kaiser L R. Management of chylothorax by percutaneous catheterization and embolization of the thoracic duct: prospective trial.  J Vasc Interv Radiol. 1999;  10 1248-1254
• 56 Cope C, Kaiser L R. Management of unremitting chylothorax by percutaneous embolization and blockage of retroperitoneal lymphatic vessels in 42 patients.  J Vasc Interv Radiol. 2002;  13 1139-1148
• 57 Binkert A B, Kent Yucel E, Davison B D et al. Percutaneous treatment of high-output chylothorax with embolization or needle disruption technique.  J Vasc Interv Radiol. 2005;  16 1257-1262
• 58 Hoffer E K, Bloch R D, Mulligan M S et al. Treatment of chylothorax: percutaneous catheterization and embolization of the thoracic duct.  Am J Roentgenol. 2001;  176 1040-1042
• 59 Schild H, Hirner A. Percutaneous translymphatic thoracic duct embolization for treatment of chylothorax.  Rofo. 2001;  173 580-582
• 60 Litherland B, Given M, Lyon S. Percutaneous radiological management of high-output chylothorax with CT-guided needle disruption.  J Med Imaging Radiat Oncol. 2008;  52 164-167
• 61 Fujiwara Y, Nakagawa K, Kusunoki M et al. Massive pleural effusion and ascites resulting from esophagectomy with extensive lymphadenectomy for cancer of the abdominal esophagus.  Hepato-Gastroenterology. 1999;  46 290-294
• 62 Nadesan S, Ming T C, Thangaveloo G et al. Treatment of delayed chylothorax complicating oesophagectomy.  Asian J Surg. 2005;  28 142-144
• 63 Ulibarri J I, Sanz Y, Fuentes C et al. Reduction of lymphorrhagia from ruptured thoracic duct by somatostatin.  Lancet. 1990;  336 258
• 64 Kelly R F, Shumway S J. Conservative management of postoperative chylothorax using somatostatin.  Ann Thorac Surg. 2000;  69 1944-1945
• 65 Mafe J J, Caravajal J M, Baschwitz B et al. Bilateral chylothorax after thymectomy via median sternotomy and resolution through conservative treatment.  Eur J Cardiothorac Surg. 2003;  24 466-468
• 66 Kalomenidis I. Octreotide and chylothorax.  Curr Opin Pulm Med. 2006;  12 264-267
• 67 Lim K A, Kim S H, Huh J et al. Somatostatin for postoperative chylothorax after surgery for children with congenital heart disease.  J Korean Med Sci. 2005;  20 947-951
• 68 Rosti L, De Battisti F, Butera G et al. Octreotide in the management of postoperative chylothorax.  Pediatr Cardiol. 2005;  26 440-443
• 69 Tachibana M, Kinugasa S, Yoshimura H et al. Does fibrin glue reduce lymph leakage (pleural effusion) after extended esophagectomy? Prospective randomized clinical trial.  World J Surg. 2003;  27 776-781

1 *Modified version of the manuscript recently published under Benedix et al. Post-surgical lymphocutaneous fistula, chylous ascites and chylothorax – infrequent but serious complications: etiology, diagnosis and therapeutic option.
Zentralbl Chir 2007; 132: 529–538 (DOI 10.1055/s-2007–981364 // ISSN 723–7065). Article in German.