Octreotide in the medical management of chyle fistula.

CASE REPORT In March 2002, a 75-year-old man was referred to the Otolaryngology–Head and Neck Surgery Department for evaluation of a slowly growing left neck mass. Physical examination revealed a large, indurated mass in the left posterior triangle that was tender and fixed to the underlying tissues. The remainder of the history and physical assessment did not reveal any other abnormalities. A computed tomography (CT) scan with contrast revealed a heterogeneously enhancing left neck mass associated with an irregularly contoured left thyroid. A fine needle aspiration biopsy (FNAB) was obtained from the left neck mass and showed papillary carcinoma. The patient subsequently underwent a total thyroidectomy and modified radical left neck dissection with sparing of the sternocleidomastoid muscle and spinal accessory nerve. The tumor was adherent to the left internal jugular vein and it was elected to remove the vessel in continuity with the mass. At the completion of the dissection, a small chyle leak was recognized and the thoracic duct was identified, ligated, and oversewn. Valsalva maneuvers repeatedly induced by the anesthetist on multiple occasions demonstrated that the thoracic duct leak was successfully closed. Further inspection before closure of the wound revealed adequate hemostasis and no drainage from the thoracic duct. A 1⁄2 inch drain was placed. The immediate postoperative course was unremarkable and by the third hospital day the patient was tolerating a full oral diet. On postoperative day 4, a moderate quantity of milky fluid appeared from the drain site, and 15 mL was sent to Biochemistry and Microbiology for analysis. A new pressure dressing was applied, but the drainage continued to progress. His diet was changed to a zero-fat diet consisting of clear fluids, fruit, and Vital Resource Fruit Beverage. Biochemical analysis revealed a triglyceride level of 9.64 mmol/L in the aspirate. The sample sent to the microbiology laboratory grew coagulase-negative Staphalococcus aureus. The infection was successfully treated with a 10-day course of cloxacillin. During the next 15 days, the patient continued to have soaking through his pressure dressings despite daily changes. On hospital day 18, subcutaneous Octreotide 100 g three times daily was started to decrease the chyle output before starting the patient on total parenternal nutrition (TPN). Within 24 hours, the chyle fistula stopped draining completely. After several days without drainage, the patient was started on a full oral diet with no recurrence of the chyle leak. He received a total of 8 days of Octreotide treatment before being discharged home in good condition.