Chylous Leakage Post Mastectomy and Axillary Dissection
Mwongeli Matheka1, Ronald Wasike1
Aga Khan University Hospital, Nairobi.
Correspondence to: Mwongeli Matheka; Email:
Chylous leakage is a rare complication following mastectomy and axillary dissection. We report a case of a 46-year-old female who underwent modified radical mastectomy and developed chylous leakage. She was treated successfully with conservative management.
Key words; Chylous leakage, chyle, mastectomy, axillary dissection
Ann Afr Surg. ****; **(*):***
Conflicts of Interest: None
© 2020 Author. This work is licensed under the Creative Commons Attribution 4.0 International License.
Chylous leakage, though rare, usually follows neck dissection or thoracic surgery and is hardly seen following breast and axillary surgery(1). It occurs due to injury of aberrant branches of the thoracic duct(2). Diagnosis is often clinical from the appearance of milky white fluid in the drain. Laboratory tests may be done in case of uncertainity to confirm the diagnosis(3). Conservative management with continuous drainage, low fat diet and octreotide is usually sufficient. However some cases may require surgical management(4). A literature search on PubMed with the terms “chyle” AND “breast” OR “axilla” found no reports or literature from Africa. We herein present a case of chyle leakage post mastectomy and axillary dissection which we managed conservatively.
Consent was given by the patient for the case report and the use of the images. Institutional ethical approval was also obtained.
A 46 year old female presented with pleomorphic micro calcifications in her left breast seen on a routine screening mammogram. Stereotactic biopsy done showed ductal carcinoma in situ (DCIS). Due to the diffuse pattern of the microcalcifications spanning an area of more than 5 cm, she was planned for mastectomy. Although she was a candidate for sentinel lymph node biopsy, our gamma probe was out of order. Therefore, she underwent left modified radical mastectomy. Level II axillary dissection was done and a drain was placed in the wound. Her post operative period was uneventful until day 2 post surgery when she was noted to have a milky white discharge from the drain. Triglyceride levels done on the fluid were 219 mmol/L (reference range 0.3-1.7mmol/L) which confirmed chylous drainage. The drain output was initially 313 ml in 24 hours. She was started on low fat diet and octreotide 50 mcg SC every 8 hours. The drain output reduced gradually. Drainage on post-op day 6 was 120 ml and she was discharged home with the drain. She was followed up in the breast clinic a week later and drainage had reduced to 54 ml per day. The drain was removed on post-op day 18 when it was draining less than 50ml per day. Histology confirmed DCIS grade 3 with 11 out of 11 nodes negative.
Chylous leakage is a rare complication post axillary dissection. Nakajima et al reported 4 cases out of 851 patients undergoing breast cancer surgery, an incidence of 0.4%(1). Similar studies have reported incidence of 0.36-0.68% (5, 6). A systematic review on 51 reported cases of chylous leakage post axillary dissection by Farkas et al found that 92% of the cases were on the left side. 82% of the patients had undergone level II or III axillary lymph node dissection with 5 patients undergoing sentinel lymph node biopsy. Similar to our patient, 59% of the leaks were identified on day 2 post surgery. 96% were managed conservatively initially with 22% requiring surgical intervention after failure of conservative management. Our patient’s drain was removed on day 18 post surgery which corresponds to the mean time to resolution from initial surgery reported of 17.3 days(7).
The thoracic duct and its branches are rarely encountered in the axilla and therefore injury is uncommon. However, anatomic variations in the branches of the thoracic duct occur and predispose to injury during axillary surgery.
The thoracic duct is the main lymphatic vessel that transports lymph from 75% of the body back into the venous system. The thoracic duct originates at the cisterna chyli at L2-T12 from the confluence of the left lumbar and intestinal lymphatic trunks. It ascends into the thorax through the aortic aperture in the diaphragm and runs on the right side of the vertebrae, ventral to the aorta, up to the level of T6 where it crosses over to the left side. Here it runs posterior to the esophagus up to the junction of the internal jugular and subclavian vein where it terminates(8). Several anatomic variations in the termination of the thoracic duct have been found. Type A (38%) at the venous angle, Type B (28%) at the internal jugular vein, Type C (27%) at the external jugular vein and Type D (7%) in a complex configuration. The thoracic duct is often separated into 2-3 branched before draining into the vein(9). A study of 334 lymphoscintigraphy results showed 2 cases (0.6%) draining into the left axilla(2). Therefore, injury to an aberrant branch of the thoracic duct during axillary dissection could lead to a chylous leak.
Chylous leakage is often diagnosed clinically from the classical appearance of milky white fluid in the drain. This is often noted on the first or second post operative day following resumption of normal diet containing fats(10). Diagnosis can be confirmed by lipid, protein, cell count and pH levels in the the fluid. Triglyceride level > 110 mg/ml are diagnostic of chyle(3). Lymphoscintigraphy is also a useful adjunct in localizing the chylous leak when surgical intervention is required (11).
Management of chylous leakage is often conservative. The patient is put on low fat diet (<10g of fat/day), pressure dressing and negative pressure drainage. Octreotide may be given to reduce chyle output. This is a somatostatin analogue which reduces absorption of triglycerides, reduces splanchnic blood flow and reduces intestinal motility, therefore reducing lymph flow(12). Local injection with tetracycline hydrochloride has also been used in chyle leakage following neck dissection. However, high output leakage more than 700 ml per day or persistent leakage beyond two weeks may require surgical intervention. Ligation of the injured branches of the thoracic duct or embolization may be done(4).
We acknowledge that for widespread DCIS, mastectomy plus sentinal lymph node biopsy should have been done instead of axillary dissection due to a low positive nodal rate of 1%(13). However, due to technical difficulties, axillary lymph node dissection was performed for this patient.
Although a rare complication, it is important to be aware of possible chylous leakage post axillary dissection. Diagnosis can be made clinically and the management is often conservative.
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