Management of lymph fistulas in thyroid surgery

Postoperative lymphatic leakage following thyroid surgery represents a management problem with considerate potential morbidity, psychological, and economical impact. Conservative and surgical management strategies for high- and low-output lymph fistulas are inconsistent. Reliable criteria to predict outcome of conservative versus surgical treatment in clinically evident lymph fistula are lacking.

A retrospective single-center chart review of consecutively quality-control-documented thyroid surgeries from January 1998 to December 2009 was performed to identify reported postoperative lymph fistulas. Documentation of surgical procedures, drainage, medical, and nutritional management was analyzed to identify risk factors for occurrence and criteria for management of evident lymph fistulas.

There were 29 patients identified with postoperative clinical evidence of lymph fistulas following thyroid surgery; incidence was 0.5%. Indication to surgery comprised benign nodular goiter, recurrent nodular goiter, and thyroid carcinoma or local and lymphonodal carcinoma recurrences. There were 12 (41%) primary and 17 (59%) redo surgeries performed. Surgical procedures performed included thyroidectomy, completion thyroidectomy, and primary and redo central and lateral systematic microdissection of lymphatic compartments. All patients were initially submitted to fasting diet and medical treatment, successfully in 19 (66%), whereas ten (34%) patients underwent surgical intervention for fistula closure after failure of conservative treatment. Complications were one wound infection and fistula recurrence in five (26%) patients in the conservative group and two (20%) in the surgical group. Hospital stay was exceedingly prolonged in both groups with a median of 21 and 11 versus 6 days in patients with regular postoperative course following thyroid surgery.

Data of this series support definition of the two categories of high- and low-output fistulas according to drainage collection with >300 versus <200 ml/day. Fasting in low-output fistula facilitates conservative treatment with closed drainage, whereas in high-output fistulas surgical intervention should be sought. Attendant criteria for treatment stratification are equally important, like patient's compliance, nutritional, and general health status as well as evidence for wound infection. Surgical closure of lymph fistula may be demanding when identification of the secreting fistula is limited and even muscle flap fortification may fail. Ultimately, in unsuccessfully reoperated fistula recurrences, open drainage may become necessary. Lymph fistulas cause significantly prolonged hospital stay, possible critical clinical decay, and unfavorable cosmetic and oncologic outcome while the superior management remains to be defined.