Review of the management of chylous fistula as a complication of neck dissection

We were very interested in an excellent review by Santaolalla et al. (2009), on chylous fistula after neck dissection. We agree with the intra-operative management as outlined, although we do use tetracycline powder as an adjunct and we concur with their conservative management of two patients immediately post surgery for persistent leaks.

However, the majority of leaks are not identified for 3–4 days post-operatively (Erisen et al. 2002) and they fail to present the timing of fistula development in the remaining two patients in their cohort. It has been recommended that as leakages discovered and reported during surgery carry a high risk of chylous drainage post surgery, that the immediate post-operative use of low-fat medium chain triglycerides diet and other conservative measures should be utilised from the outset after surgery even in those patients deemed to have had a successful per-operative repair (De Gier et al. 1996). In our experience in the departments of Otolaryngology, Head and Neck Surgery at the Mid-Western Regional Hospital, Limerick, and the Aintree University Hospital, Liverpool, we have introduced this prophylactic approach in addition to an intra-operative repair in all patients noted to have chyle extravasations during surgery and thus far have not had a post-operative leak in those patients.

In their conclusion, Santaolalla et al. state that all chyle leaks are on the left but this is somewhat ambiguous and it should have read that all of the fistulae reported in their study were on the left as the right lymphatic duct can be also be damaged during surgery.