The authors have no funding, financial relationships, or conflicts of interest to disclose.
Chylous fistula is a distressing complication resulting from thoracic duct injury during neck dissections. We have successfully managed chylous fistula using negative-pressure wound therapy (NPWT) in a case where all conservative treatments failed. A 60-year-old man with tongue cancer underwent subtotal glossectomy and bilateral neck dissections. On postoperative day 4, a chylous fistula with large drainage developed in the right neck. Conservative treatments were not effective, therefore, NPWT was started from postoperative day 9. The drainage volume then began to decrease, and the chylous fistula was closed 6 days after starting NPWT. In our case, the effects of wound shrinkage and fluid removal by NPWT were considered to contribute to early closure. Although preliminary, NPWT can be an important treatment choice for the management of a chylous fistula after neck dissections.
Chylous fistula is one of the troublesome complications after neck dissections. Conservative treatments are preferably selected as the initial treatment, such as dietary modifications (low-fat diet, noneating, or total parenteral nutrition), compressive bandage, intravenous medication (somatostatin analog), and open drainage.1–5 In the case of failure of conservative treatments, surgical treatments such as ligation of the thoracic duct and muscle flap transfer are performed.1–3 However, surgical treatments involve invasive techniques, require prolonged hospitalization of patients, and do not always give promising results.
Negative-pressure wound therapy (NPWT), introduced by Argenta and Morykwas in 1997, is a relatively new treatment for intractable complicated wounds.6 This treatment is now widely adapted for various types of wounds such as postoperative mediastinitis,7 enterocutaneous fistula,8 and severe open fracture,9, 10 and its efficacy is well known to general surgeons. However, there have been few reports about the utility of NPWT for head and neck complicated wounds,11, 12 and especially, there are no reports about postoperative chylous fistula after neck dissection.
We have successfully managed intractable chylous fistula conservatively using NPWT. In this report, we present the potential of NPWT in the treatment of chylous fistula.
A 60-year-old man with recurrent tongue cancer underwent subtotal glossectomy, bilateral neck dissections, and rectus abdominis musculocutaneous flap transfer. Microsurgical anastomoses were performed in the right neck, and suction drainage tubes were placed bilaterally in the neck.
Nasogastric tube feeding was started on postoperative day (POD) 4, which resulted in an increased amount of right neck drainage (Fig. 1). The fluid in the suction tube turned whitish and milky, suggesting chylous fistula. In addition to noneating, we stopped nasogastric tube feeding and started total parenteral nutrition from POD 6. Somatostatin analog was administered intravenously from POD 6 through POD 8; however, the drainage volume increased up to more than 300 mL per day, and swelling developed in the right lower neck. Because microsurgical anastomoses were performed in the right neck, we avoided a compression bandage and open drainage. Conservative treatments were no longer considered effective and applicable, and NPWT was started from POD 9. The right lower neck wound was reopened through the previous incision (Fig. 2a). A 14-Fr nasogastric tube with multiple side holes was placed in the lower neck, and its tip was covered with a small piece of gauze (Fig. 2b,c,d). The common carotid artery and internal jugular vein were additionally covered with the gauze to avoid bleeding. After sealing the wound with film dressing, a continuous negative pressure of −50 mm Hg was applied. The NPWT device was changed, and the wound was irrigated every 2 days. After the first day of NPWT, drainage volume decreased to 105 mL, less than half of that of the previous day (236 mL). On the next day, the drainage volume further decreased to 60 mL. Six days after the beginning of NPWT, chylous drainage completely stopped. During the course of treatment, there were no complications related to NPWT.
NPWT involves covering and sealing the wound with a drape and applying subatmospheric pressure. This results in various effects such as wound shrinkage, increase in blood flow, increase in granule formation, and removal of fluids, which lead to early wound closure.6, 13 NPWT is also reported to be effective for postoperative fistula-accompanied wounds such as enterocutaneous fistula,8 bronchopleural fistula,14 and groin lymphatic fistula,15, 16 although there is no report on NPWT for chylous fistula after neck dissection.
Chylous fistula can sometimes be a severe and lethal complication because of persistent fluid drainage of more than 1,000 mL per day.2, 3, 17 For our first application of NPWT for chylous fistula, we selected relatively low pressure (−50 mm Hg) because there were concerns about an unexpected increase in drainage due to negative pressure. However, contrary to our concern, the amount of drainage decreased after the first day of NPWT, and the fistula was closed within 6 days. Wound shrinkage and removal of excessive fluid around fistula potentially contributed to early closure.
As massive bleeding was reported when NPWT was applied around the main vessels,13 the most important caution is to avoid rupture of common carotid artery and internal jugular vein when NPWT is applied to the head and neck region. Chylous fistula usually occurs close to the internal jugular vein in the lower neck. Thus, we covered the tip of the tube and surrounding soft tissues around the main vessels and microsurgical anastomoses by gauze and successfully avoided their rupture.
NPWT is considered effective for mild chylous fistula as in this case. However, its effectiveness for high-volume chylous fistula, which would drain more than 1,000 mL of fluid per day, is uncertain. Nevertheless, because this method is minimally invasive and is less burdensome to patients, it can be applied for intractable chylous fistula when conservative treatments fail. Careful selection of patients and further accumulation of data are recommended.
Although preliminary, NPWT has shown potential to be the treatment of choice for the management of chylous fistula after neck dissection.