Repair of chylous fistula in the neck by local muscular flaps

Cervical chylous fistula is an uncommon but serious complication of operative procedures in the neck. This complication is better avoided than treated, thus, the head and neck surgeon should be familiar with the detailed anatomy of the thoracic duct. The purpose of this study was to treat chylous fistulae following neck surgery after failure of conservative measures by free fat grafts and local muscular flaps. Between November 2001 and December 2004, eleven patients complaining of chylous fistula following different types of neck surgery were referred to the departments of otolaryngology and general surgery of Cairo University Hospital of Kasr Al Aini. All patients received conservative treatment before surgical repair in the form of parentral nutrition, pressure dressings and repeated aspirations. Repair was done by identifying the site of leak and over sewing it using non-absorbable suture, or packing it with sponge gel in cases where over sewing was difficult. The site of leak was then covered with Surgicel and a free fat graft. The free fat graft was bolstered in place with a local pedicled muscle flap. One of three muscles were used: the sternohyoid, the sternomastoid or the levator scapulae. All cases had left sided chylous fistula. Immediate closure of the fistula occurred in 4 cases while in the remaining 7 cases the fistula closed in a period varying between 2 and 5 days. Identification and suturing of the fistulous opening was possible in 4 cases and impossible in 7 cases. In all the four cases where the fistulous opening was sutured immediate stoppage of chylous leak occurred postoperatively. The superiorly based sternohyoid muscle flap was used in 3 cases, the inferiorly based sternomastoid muscle flap was used in 2 cases and the superiorly based levator scapulae flap was used in 6 cases. We concluded that the use of pedicled local muscle flaps of the neck in addition to a free fat graft offers great chances of success for closure of chylous fistulae in the neck