High Output Chylous Fistula Post First Rib Resection

Area of Science:

• Thoracic Surgery
• Surgical Complications
• Vascular Surgery

Background:

• Neurogenic thoracic outlet syndrome (nTOS) can necessitate surgical intervention, such as first-rib resection.
• Postoperative complications, including chyle leaks, can arise, presenting significant management challenges.
• High-output chylorrhea is a rare but serious complication following thoracic procedures.

Observation:

• A patient developed a persistent, high-output chyle leak after left first-rib resection for nTOS.
• The chylous fistula was refractory to multiple conservative and surgical treatments, including reoperations, dietary modifications, octreotide, and vacuum-assisted closure (VAC) therapy.
• The patient experienced associated complications such as hypovolemia, hyponatremia, and hypoalbuminemia.

Findings:

• A novel surgical technique involving lateral reattachment of the sternocleidomastoid muscle was employed to protect vital structures and redirect lymphatic flow.
• This approach, combined with fibrin sealants and continued VAC therapy, effectively controlled the chylous fistula.
• Complete resolution of the chylous fistula was achieved, allowing for patient discharge.

Implications:

• This case highlights a potentially effective salvage strategy for refractory chylous fistulas after thoracic surgery.
• The described technique offers a new option for managing complex lymphatic leaks in the neck and thoracic region.
• Further investigation into this surgical modification may benefit patients with similar challenging postoperative lymphatic complications.