OTPOL-142; No. of Pages 4

Case report/Kazuistyka

Chyle leak: A rare complication post-hemithyroidectomy. Case report and review ofliterature

Almoaidbellah Rammal 1, Faisal Zawawi 1,2,*, Rickul Varshney 1,Michael P. Hier 1, Richard J. Payne 1, Alex M. Mlynarek 1

1Department of Otolaryngology – Head and Neck Surgery, McGill University, Montreal, QC, Canada2Department of Otolaryngology – Head and Neck Surgery, King Abdulaziz University, Jeddah, Saudi Arabia

o t o l a r y n g o l o g i a p o l s k a x x x ( 2 0 1 4 ) x x x – x x x

a r t i c l e i n f o

Article history:

Received: 02.03.2014

Accepted: 27.03.2014

Available online: xxx

Keywords:� Chyle� Thyroidectomy� Benign� Neck� Dissection

a b s t r a c t

Background: Thyroidectomy is one of the common neck surgeries. Well recognized com-

plications include postoperative bleeding, hypocalcaemia and recurrent laryngeal nerve

injury. Chyle leak post-thyroidectomy is extremely rare. Most of the reported cases have

had a complete central compartment neck dissection. Methods and results: This is

a case report of a patient who suffered from chyle leak after a left hemithyroidectomy

without a complete central compartment neck dissection. The patient was managed

conservatively with low fat diet and observation. A protocol for approaching thyroid

patients with chyle leak is proposed based on a comprehensive literature review.

Conclusion: Chyle leak post-thyroidectomy for a benign disease is a very rare complica-

tion. Nevertheless, head and neck surgeons should consider it in the differential diagno-

sis of neck swelling post-thyroidectomy.

© 2014 Polish Otorhinolaryngology - Head and Neck Surgery Society. Published by

Elsevier Urban & Partner Sp. z o.o. All rights reserved.

Available online at www.sciencedirect.com

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Introduction

Thyroidectomy is a common head and neck procedure. Theextent of the procedure, with regard to neck dissection andlymph node excision, varies depending on the surgicalindication and clinical setting of each patient. The wellrecognized postoperative complications following a thyroid-ectomy include bleeding, hypocalcaemia, recurrent laryngealnerve injury, and on rare occasions, thyroid storm [1, 2].

* Corresponding author at: Department of Otolaryngology – Head anE3-37, Montreal, Canada H3A1A1. Tel.: +1 514 513 3365.

E-mail address: faisalzawawi@gmail.com (F. Zawawi).

Please cite this article in press as: Rammal A, et al. Chyle leak: A rareliterature. Otolaryngol Pol. (2014), http://dx.doi.org/10.1016/j.otpol.2014.03

http://dx.doi.org/10.1016/j.otpol.2014.03.0030030-6657/© 2014 Polish Otorhinolaryngology - Head and Neck Surgeryreserved.

Due to the potential of airway compression, thyroid sur-geons are always cautious regarding postoperative neckswelling. The latter is most commonly due to a postopera-tive hematoma in the first few hours post-operatively, butthere may also be other delayed causes such as seroma andon rare occasions, an abscess [2].

Chyle leak following neck surgery is a relatively uncom-mon complication. The incidence varies from <1 to 8.3%depending on the extent and type of the surgical procedure[1, 3–6], and it is highest after a lateral neck dissection [4].

d Neck Surgery, McGill University, 687 Pine Avenue West, Room

complication post-hemithyroidectomy. Case report and review of.003

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OTPOL-142; No. of Pages 4

Chyle leak can occur after a thyroidectomy when a centralcompartment neck dissection is performed for malignancy(0.5%) [1]. On the other hand, only 3 cases of chyle leakpost-thyroidectomy for benign lesions have been reported.

This is a case report of a 77-year-old lady who developeda low-output chyle leak after a left hemithyroidectomy andpre-tracheal central compartment lymph node dissection forsentinel lymph node biopsy.

Case presentation

A 77-year-old, otherwise healthy female was referred to theMcGill Thyroid Cancer Center by her family physician toassess her left thyroid nodule. Apart from her age, she didnot have any other risk factors for malignancy. On physicalexamination, a large left thyroid nodule, cystic in nature,was noted.

Ultrasound examination revealed the presence ofa heterogeneously echoic thyroid with a left cystic lesion(5.3 cm � 5.5 cm � 4.7 cm) with mild increase in vascularitywithout calcifications. Fine needle aspiration biopsy showeda benign lesion, most consistent with nodular goiter withhurthle cell metaplasia. After careful discussion with herendocrinologist and thyroid surgeon, she decided to undergoa left-hemithyroidectomy with sentinel lymph node biopsy.

Intraoperatively, a left hemithyroidectomy was perfor-med through a 5 cm skin incision. A sentinel lymph nodebiopsy was done as well, with the lymph nodes beingpresent in the pre-tracheal central neck compartment. Thelatter technique requires an injection of 0.3 cm3 of methy-lene blue into 4 quadrants of the thyroid nodule, andfollowing of the blue lymphatic channels to the centralcompartment, where the sentinel nodes are excised. Thelateral central neck compartment was not dissected. The leftrecurrent laryngeal nerve and both superior and inferiorparathyroid glands were identified and preserved. Afterremoving the left thyroid lobe and adequate hemostasis, theanesthetist performed an artificial valsalva at 30 mm Hg for5 s, during which the surgeon inspected the surgical bedfor bleeding or chyle leak. In this case, no chyle was noted.Wound closure was carried out without the use of a suctiondrain. The patient was discharged on the first postoperativeday (POD) without any signs of neck swelling.

On POD 7 follow-up visit, a mild and soft swelling aroundthe surgical wound was noted. Initially, suspicious fora seroma, the surgeon performed a needle aspiration, notingserosanguinous fluid. The patient was then asked to observethe neck and to report any recurrence. The swelling recurredafter two days, and another fluid aspiration was performed.However, this time a milky fluid was noted indicatinga suspected lymphatic leak. The biochemical analysis of thefluid showed a significantly raised triglyceride level of45 mmol/l (�4000 mg/dl) confirming its chylous nature.Given the slow progression of the swelling, it was decidedto start with conservative management and close observa-tion. The patient was advised to go on a low fat diet and tomonitor the neck girth. After a week of low fat diet, thepatient started noting reduction in the neck swelling withcomplete resolution at 6 weeks. She has resumed full diet

Please cite this article in press as: Rammal A, et al. Chyle leak: A rareliterature. Otolaryngol Pol. (2014), http://dx.doi.org/10.1016/j.otpol.2014.03

with no recurrence. Her final pathology showed a benignthyroid nodule. No further treatment was necessary.

Discussion

Chyle leak develops following central neck dissection asa result of injury to either the ascending part of the thoracicduct medial to the carotid sheath or, in some individuals,the duct terminating in the subclavian vein medial to theinternal jugular vein [4]. The incidence is quite variable anddepends on several factors such as the indication of thethyroidectomy (benign versus malignant), the extent of thesurgery (total or hemithyroidectomy), and with the extent ofthe neck dissection (central or lateral). Roh et al. found thatthe incidence of chyle leak is 8.3% following lateral neckdissection and 1.4% following central neck dissection [4]. Leeet al. estimated the incidence 0.6% following total thyroidec-tomy with central neck dissection for malignant lesions [7].Also, the incidence increases following total thyroidectomyfor papillary thyroid carcinoma. Patients with papillarythyroid carcinoma are more prone to this complicationbecause of the higher rate of nodal metastasis [4]. However,chyle leak could also result from thyroidectomy for papillarycarcinoma even without nodal dissection [8].

Chyle leak following hemithyroidectomy for benign diseaseis a rare event. So far, only three cases have been describedin the literature. The first case of chyloma was reportedby Madnani et al. that developed 3 months post right-thyroidectomy for multinodular goiter [9]. The second case ofchyle leak, reported by Touska et al., was secondary to a rightcompletion thyroidectomy for multinodular goiter [10]. Thethird case was a chyle leak following subtotal thyroidectomyfor a benign lesion without central neck dissection [2]. Con-trary to these reports, our case was a left-hemithyroidectomywith a limited pre-tracheal lymph node dissection. No lymphnode dissection was performed laterally or close to the carotid.Nevertheless, it is unclear whether the pre-tracheal lymphnode dissection contributed to the chyle leak, or whether thelarge size of the thyroid nodule and gland could be the cause.Furthermore, most of the previously reported cases are notclear on the size of the gland or the nodule, making it difficultto compare this patient's findings with them.

Unfortunately, thoracic duct injury is not always recogni-zed intraoperatively [4, 11]. Most patients (86%) usuallypresent with neck swelling between POD 1 and 3 [12].However, a delayed chyle leak can occur up to 3 monthsfollowing thyroidectomy [9]. Our diagnosis was based on thepresence of suggestive clinical signs mentioned by Roh et al.such as milky fluid upon aspiration along with a highlevel of drainage having higher concentration of triglyceride(i.e., >100 mg/dl or more) than serum [11]. Many researchershave proposed that a sudden increase in drainage volume isa strong indicative sign for chyle fistula [3, 4, 11]; however,our patient did not have any drainage. The diagnosis isusually delayed until the chyle accumulates and found bythe aspiration; that is why it is usually misdiagnosed, at thebeginning, as seroma or abscess [10].

Different management approaches, both medical and sur-gical, have been described in the literature. The conservative

complication post-hemithyroidectomy. Case report and review of.003

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approach is found to be very successful with a success rateranging from 58 to 100% [4, 12, 13]. This approach consists ofsuction drains, compressive dressings, rest, and low fat dietthat is directly absorbed into the portal circulation resulting inreduced lymphatic flow of chylous fluid. Total parenteralnutrition (TPN) is recommended as a second-line approach[12, 14]. Somatostatin derivative (octreotide) can be added toTPN with success rate of 90% [15, 16]. Octreotide reduces thegastrointestinal chyle production by decreasing splanchnicblood flow along with gastric, biliary, pancreatic and intestinal

Fig. 1 – Flow diagram for chyle leak management [12, 14, 19] (TPN

Please cite this article in press as: Rammal A, et al. Chyle leak: A rareliterature. Otolaryngol Pol. (2014), http://dx.doi.org/10.1016/j.otpol.2014.03

secretions. However, the exact mechanism of octreotide actionis still unknown [12]. Surgical approach, by ligation of thethoracic duct, fibrin glue, or muscle flap, is usually reservedfor patients who do not respond to conservative management(persistent drainage output >600 ml/day for 5–7 days) and forhigh output leakage (>1.5–2 L/day) [12]. Ligation should beundertaken either by ligature or by suture in cases where theleak is identified Intraoperatively. Thoracoscopic approacheshave also been successfully used as minimally invasivemodalities of postoperative chyle leak surgical management

; total parenteral nutrient, MCT; medium chain triglycerides)

complication post-hemithyroidectomy. Case report and review of.003

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[17, 18]. The presented case was a low output chyle leak thatresponded well to conservative management. Based on theinformation available in the literature, this paper proposesa protocol for approaching thyroid patients with iatrogenicchyle leak (Fig. 1).

To our knowledge, this is the fourth case in the literaturewith chyle leak, presenting post-thyroid surgery for a benigndisease, and the first as a left hemithyroidectomy.

Conclusion

Chyle leak following neck surgery is not a common finding.Although, the chyle leak reported in this case is an extremelyrare complication of thyroidectomy, it should still be conside-red in the differential diagnosis of neck swelling postoperati-vely.

Summary

1. Chyle leak post-thyroidectomy is a rare complication.2. When evident, chyle leak will present as a neck swelling

in the post-operative period.3. The management approach should depend on the clinical

presentation and degree of chyle leak output present.4. The suggested protocol helps guide head and neck surgeon

to systematically manage chyle leak post-thyroidectomy.

Authors' contributions/Wkład autorów

AR – data collection and interpretation, statistical analysis,literature search; FZ – study design, data collection andinterpretation, statistical analysis, acceptance of finalmanuscript version, literature search; RV, MPH, RJP – studydesign, acceptance of final manuscript version; AMM – studydesign, acceptance of final manuscript version, literaturesearch.

Conflict of interest/Konflikt interesu

None declared.

Financial support/Finansowanie

None declared.

Ethics/Etyka

The work described in this article has been carried out inaccordance with The Code of Ethics of the World MedicalAssociation (Declaration of Helsinki) for experiments invol-ving humans; EU Directive 2010/63/EU for animal experi-ments; Uniform Requirements for manuscripts submitted toBiomedical journals.

Please cite this article in press as: Rammal A, et al. Chyle leak: A rareliterature. Otolaryngol Pol. (2014), http://dx.doi.org/10.1016/j.otpol.2014.03

r e f e r e n c e s / p i �s m i e n n i c t w o

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