No fat diet for chyle leak management,weight loss tips and medicine,how to lose weight fast for a 12 year old is - How to DIY

02.10.2015
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1MD, Texas Tech University Health Sciences Center, Department of Surgery, 1400 S Coulter St, Amarillo, TX 79106, USA. 2MD, Consultant Radiologist, Department of Radiology, Northwest Texas Hospital, 1501 S Coulter St, Amarillo, TX 79106, USA. 3MD, Texas Tech University Health Sciences Center, Department of Internal Medicine, 1400 S Coulter St, Amarillo, TX 79106, USA. 4MD, Associate Professor of Surgery, Texas Tech University Health Sciences Center, Department of Surgery, 1400 S Coulter St, Amarillo, TX 79106, USA.
5MD, Assistant Professor of Surgery, Texas Tech University Health Sciences center, Department of Surgery, 1400 S Coulter St, Amarillo, TX 79106, USA.
A 29-year old Caucasian female with no significant past surgical or medical history was admitted with a several day history of right upper quadrant pain, nausea, and intolerance to food. Chyle leak is a rare postoperative complication that requires early recognition and knowledge of its pathophysiology due to high morbidity from malnutrition and excellent response to conservative management in the era of parenteral nutrition. Chyle leak is a known postoperative complication of thoracic and abdominal surgical procedures. A case of a 29-year-old Caucasian female with no significant past medical or surgical history who was admitted with several day history of right upper quadrant pain, nausea and intolerance to food. Chyle is a fluid in the lymphatic system that consists of lymph from interstitial fluid and emulsified fat from intestinal lacteals. Chyle leak is most often associated with malignancies, penetrating trauma, node biopsies, neck dissection, esophagectomy, and resections of the lung, pancreas or cervical rib that causes injury to lymphatic vessels or enzymatic damage or mechanical compression of the lymphatics by an inflamed pancreas. Treatment of chyle leak varies, primarily based on the volume of chylous drainage and is generally supportive.
Chyle leak is an uncommon complication of commonly performed surgical procedures which requires prompt identification and treatment due to high morbidity and associated health care cost.
Chyle is transported through the lymphatic system and eventually drains into the thoracic duct, a large lymphatic vessel found on the left side of the torso. Within the villi of the small intestine fatty acids are blended with proteins and cholesterol to form chylomicrons. Chyle is a bodily fluid with a milky appearance that is a combination of lymphatic fluid, or simply lymph, and lipoproteins called chylomicrons.
Lymphatic fluid is similar in composition to blood plasma and is one of the main components of chyle. The other major components that give the fluid its milky consistency are globules of fat and protein called chylomicrons.
Lacteals are specialized lymphatic capillaries that absorb the chylomicrons from the intestinal villi and then transport the resulting chyle. My neighbor got injured in a car wreck last week, and he developed a chyle leak in his neck. Massive Chylorrhea following Total Thyroidectomy and Neck Dissection CASE REPORT Massive Chylorrhea following Total Thyroidectomy and Neck Dissection Shivakumar Thiagarajan, Ashok Mohan Shenoy, Prashanth Veerabadriah, Purushotham Chavan, Rajshekar HalkudABSTRACTChylorrhea, following thyroid surgery, is a known complication mentioned in the literature, but massive chylorrhea is uncommonly encountered.
Few cases of chyle leak involving biliary tree have been reported following laparoscopic cholecystectomy. Workup revealed a dilated common bile duct with filling defect consistent with choledocholithiasis. It refers to accumulation of triglyceride rich "milky" fluid in the peritoneal cavity due to a breech in the lymphatic channels. To our knowledge, only one case of a retroperitoneal chylous cyst following choledochotomy and cholecystectomy has been reported in Japanese literature while only a handful of cases reporting chyle leakage following cholecystectomy have been depicted in English literature [2] [3] [4] [5].
The cause of chyle leak in our patient is unknown, as she did not have any of the above mentioned procedures.
Presenting features are usually non-specific and include abdominal pain with distension, anorexia, nausea, vomiting, dyspnea, weight gain, and early satiety. Those who do not respond to low fat diet with medium chain triglyceride (MCT) supplementation are candidates for bowel rest and total parenteral nutrition [9]. Chylous ascites after post-chemotherapy retroperitoneal lymph node dissection: review of the M. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. It originates in the small intestine during the digestion of foods with high fat content, and enters the lymphatic system through lymphatic capillaries called lacteals. The fluid begins in the circulatory system, then exits the blood vessels and becomes known as interstitial fluid, or the fluid found between cells.
Chylomicrons are largely composed of triglycerides, which are fatty acids found in vegetable oils and animal fats.
As the lacteals move upwards through the body, they branch out into a network of larger lymphatic vessels. Here, we report two such cases of thyroid malignancy (papillary carcinoma) where the patient developed massive chylorrhea following total thyroidectomy and neck dissection, one of whom underwent tracheal resection and anastomosis in addition. Patient underwent open cholecystectomy and choledochotomy for common bile duct exploration and removal of the stone. The incidence is especially high where dissection involves retroperitoneal structures thereby posing cistern chyli at risk of injury [1].
Sepsis is the most common complication considering the high concentration of lipids and proteins.


Presence of fever signifies sepsis and requires prompt identification and drainage of the fluid for further analysis. It has also been suggested that the use of pancreatic lipase inhibitors and somatostatin analogs may decrease the triglyceride absorption and chyle flow [10]. Conservative management is highly successful in postoperative patients and includes the use of a low fat diet containing medium chain triglyceride (MCT), repeat paracentesis, total parenteral nutrition and somatostatin analogs.
Interstitial fluid transports important materials to the body's cells, such as hormones and oxygen, and also bathes the cells, removing foreign materials from them.
Triglycerides make up a large portion of the average person's fat consumption, and contain large amounts of energy.
The patient, in whom only total thyroidectomy and neck dissection was done, developed encysted chyloma postoperatively which was managed surgically.
Post operative course became complicated by repeated episodes of nausea and abdominal pain and finding of a well-defined fluid collection in the pancreaticoduodenal region necessitating repeated image guided drainage of the collection. The incidence of chyle leak following biliary tree surgery is rare and confined to few case reports [2] [3] [4] [5].
Surgical intervention may be needed for higher volume chyle leaks or nutritional compromise especially if the site of the leak is known in selected group of patients [8].
This fluid is associated with a condition called chyle fistula, in which lymphatic fluid leaks from the lymphatic vessels. The majority of this fluid then reenters the circulatory system, but about 10% of it enters the lymphatic vessels instead, where it becomes known as lymphatic fluid. Within the villi of the small intestine, these fatty acids are combined with proteins and cholesterol, a steroid involved in metabolism, to form chylomicrons. The thoracic duct then drains into the left subclavian vein, where the chylomicrons in chyle enter the circulatory system. The other patient who underwent neck exploration twice for his chylorrhea but later developed septicemia and succumbed to it.
After the removal of the common bile duct stent and T-tube, patient again returned back within a week with recurrent symptoms.
We present a case of chyle leak following choledochotomy and open cholecystectomy and its management. Other measurements include low cholesterol and leukocytosis with lymphocyte predominance [8]. Lymphatic fluid moves upwards through the body via lymphatic vessels, and one of its major functions is to transport fats from the digestive system to other bodily tissues where they can be either metabolized or absorbed. It is important that the fats be packaged in this way because both blood plasma and lymphatic fluid are watery, and fat molecules alone are hydrophobic, meaning that they are repelled by water. The blood transports the chylomicrons to different tissues in the body, where they are either stored or metabolized and used for energy.
A computed tomography (CT) scan of the abdomen showed presence of two new small collections thought likely to be abscesses away from the previous collections. Although rare, it still has the potential to significantly increase postoperative morbidity. Nutritional deficiencies due to loss of protein, calories, and vitamins as well as metabolic complications due to loss of electrolytes can also occur [6]. Drainage of the fluid was found to be milky with high triglyceride levels consistent with chyle leak. They are usually seen on the left supraclavicular region following thoracic surgery, radical neck dissection, blunt or penetrating trauma, or tumor erosion, or they can occur secondary to subclavian vein line placement (acquired chyloma).1-3 Rarely, they may be congenital as well. Here, we report a case of left cervical chyloma and another case of massive chylorrhea, subsequent to total thyroidectomy and neck dissection, which was managed surgically after failure of conservative management. CASE REPORT A 65-year-old male patient visited our OPD with complaint of swelling in the left side of the neck for 6 months duration, with no other complaints or comorbidities. On examination, a swelling on the left side of the neck, at level III and IV, measuring about 6 × 6 cm, which was firm to hard in consistency and mobile, was noted.
Thyroid gland was palpable with a nodule in the left lobe which was also hard in consistency. Indirect laryngoscopy revealed bilateral mobile vocal cords, with rest of the examination being within normal limits.
This time, CT scan revealed two new small collections thought likely to be abscesses measuring 2.2 cm each inferior and to the right of the drained collection from previous hospitalization (Figure 3).
With the above clinical picture, patient was taken up for total thyroidectomy and neck dissection (MRND, vein and nerve sparing) under general anesthesia.
In consultation with GI, it was decided to follow a conservative approach, which included liquid strict non-fat diet. Perioperatively, patient had a chyle leak which was identified and sealed using 5.0 prolene suture material with a portion of muscle harvested from sternocleidomastoid. A dietary consultation was obtained and patient was given a brochure with a list of items that she could take. After symptomatic improvement, the patient was discharged home on the same dietary regimen. On the 8th postoperative day, patient developed a swelling in the left supraclavicular area, which was fluctuant. About 40 ml of fluid was aspirated, which was milky and odorless, later confirmed as chyle, followed by pressure dressing. Patient was managed conservatively with medium-chain fatty acids in diet and avoiding the long-chain fatty acids, along with aspiration and pressure dressing.


Patient later received 100 mCi of radioactive iodine ablation after withdrawal of T4 for 6 weeks. During this intervening period, patient was treated conservatively for chyle collection in the left supraclavicular region (6 × 7 cm fluctuant swelling) (Fig. The neck was opened through the previous surgical scar, after which the cyst was entered, about 150 ml of chyle was cleared.
An internal chyle duct draining into the cyst was identified on the posterior aspect of the cyst wall lateral to the left recurrent laryngeal nerve and common carotid artery (Fig. The cyst wall was scraped and the opening sutured with muscle and fat pad with nonabsorbable suture and wound closed.
Patient recovered well in the postoperative period and is on follow-up with TSH suppression. But the chyle leak persisted hence, he was taken up for reexploration on the 14th day once again. It continues superiorly, posterior to the esophagus in the posterior mediastinum between the aorta and the azygos vein. It then ends between left subclavian vein and left internal jugular vein.4 It is here that the duct system is at risk of trauma or injury during neck surgery. The thoracic duct drains lymph from most of the body, the exceptions being the right hemithorax, the right upper limb and the right head and neck.
A further 5% of cases see the duct divide into a left and right branches each draining in their respective hemithoraces.5 The thoracic duct drains chyle from most of the body (and the entire intestinal tract) and is essential in maintaining fluid balance.
The lymphatic system serves to collect and transport large molecules, such as extravasated plasma proteins, absorbed lipids and excess tissue fluids that have leaked from the interstitial spaces back into the bloodstream, it also enables the return of proteins and T-lymphocytes to venous circulation. Chyle is a turbid, milky fluid, composed of emulsified fat, triglycerides, proteins, glucose, electrolytes, antithrombin globulin, pro-thrombin and fibrinogen, as well as cellular components such as lymphocytes and erythrocytes.
Daily lymph flow varies between 2 and 4 liters depending on the intake of long-chain triglycerides. When the thoracic duct is injured, two complications can arise: Chylous leaks and cervical chylomas. Chylous leaks are associated with metabolic derangements secondary to severe fluid, electrolyte and protein loss, a loss of lymphocytes that results in lymphocytopenia, fistula formation, skin-flap necrosis and carotid artery blowout. The incidence of chyle leaks following neck dissection has been estimated to range from 1 to 5.8%.
If this is overt and is in the vicinity of a suction drain, it will manifest as chylorrhea in the suction drains, may cause compressive symptoms as well as massive loss of nutrients and negative nitrogen balance.
JAYPEEMassive Chylorrhea following Total Thyroidectomy and Neck Dissection Establishing the diagnosis of a cervical chyloma requires a determination that the cyst fluid is of chylous origin and that the cyst is in the region of the thoracic duct. All reported cases, including ours, have been associated with either trauma or surgery.6,7 Fluid analysis can be obtained by fine needle aspiration of the mass. Lymphangiography or lymphoscintigraphy can also be useful in making the diagnosis and in making an intraoperative identification of the mass. Conservative management of a chyloma includes aspiration or drainage of the mass and the application of compressive dressings. Dietary management should include instituting a medium-chain triglyceride diet or delaying the feeding of the patient.8,9 Total parenteral nutrition is generally considered not to be beneficial in the management of thoracic duct damage, although some authors have found it to be useful.
However, formal identification of a leak and its successful seal in a reexploration is often unsuccessful because of the diffuse nature of the thin-walled multiple lymph capillaries.
Most chyle leaks need to be conservatively addressed by frequent pressure dressings to promote healing by secondary intention over a period of time. Whenever there is significant nodal disease in tracheoesophageal groove (level VI) and level IV, after dissection in these area it should be a mandatory practice to instruct the anesthetist to perform forced positive pressure hand ventilation so as the raise intrathoracic pressure and 'milk' the lymph to become more evident in areas where the capillaries have been disrupted. Such areas need to be underrun with 3-0' prolene sutures with some mashed muscle mass, harvested from the nearby neck. This should be done until there is no evidence of any leak of chyle during the above anesthetic maneuver.
Care should be taken not to traumatize the recurrent laryngeal nerve in the tracheoesophageal groove or the vagus and phrenic nerve in the proximity of jugulosubclavian vein. In this case, our patient developed a left cervical chyloma subsequent to total thyroidectomy and neck dissection for papillary thyroid cancer.
Inspite of conservative management with repeated aspiration, diet modification and pressure dressing the chyloma did not respond to the treatment, hence, surgical exploration and closure of the leak was done successfully. In the second case, though the massive chyle leak was attempted to be identified and surgically corrected, he subsequently developed septicemia and eventually succumbed to it.
CONCLUSION Massive chylorrhea, following thyroidectomy and neck dissection, is a known complication documented in literature.
We have shared our experience with two such cases of which one developed a chyloma of the left supraclavicular region which was managed successfully, very few cases of chyloma have been reported in literature, especially following surgery for thyroid cancer. The other case with massive chylorrhea was attempted for surgical correction twice but the patient developed septicemia and succumbed subsequently. Treatment of a postoperative cervical chylous lymphocele by percutaneous sclerosing with povidone-iodine.



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