The management of chyle fistula

Over a recent 4-year period, 823 neck dissections that included the lower jugular lymph nodes were performed. Of the 823, 14 (1.9%) patients developed chyle fistulas. Two other patients developed fistulas, one after undergoing a gastric transposition, and the other after a scalene node biopsy. All 16 patients were initially managed conservatively with closed-wound drainage and low-fat nutritional support; this was successful in only 4 patients, 3 of whom had peak 24-hour chyle drainage of less than 600 cc. The remaining 10 patients required open-wound management, which included operative ligation in 4 instances. Continued conservative treatment with an open neck wound resulted in significant additional hospitalization. Our experience indicates that closed-wound management of a chyle fistula is likely to fail when peak 24-hour fistula output exceeds 600 cc. Considering the cost and morbidity of conservative treatment, early reoperation may be appropriate in those patients with high fistula output.