Persistent Chyle Leak Post Mastectomy with Axillary Clearance: An Experience with Conservative Treatment vs Surgical Management Volume 55- Issue 5

Ashvirni Gilbeth*

• General Surgery Doctor in Putrajaya Hospital, Wilayah Persekutuan Putrajaya, Malaysia

Received: March 23, 2024; Published: April 03, 2024

*Corresponding author: Ashvirni Gilbeth, General Surgery Doctor in Putrajaya Hospital, Wilayah Persekutuan Putrajaya, Malaysia

DOI: 10.26717/BJSTR.2024.55.008775

Abstract PDF

Chylous fistula, a complication related to thoracic duct injury or its branches, may develop following neck or thoracic abdominal surgery. Chyle is a milky fluid made up of emulsified fats (long chain triglycerides) and lymph derived from the absorption of fats from the small intestine into the lymphatic system. However, chyle leak after mastectomy with axillary clearance is an unusual phenomenon. Seroma formation and chronic lymphoedema of the upper limb are far more common. The reported incidence of chylous fistula after breast cancer surgery is less than 0.5%. It may delay wound healing, extend hospitalization, impair the immune system, and affect the initiation of adjuvant therapy. Although rare, it is important that all breast surgeons should be aware that a chylous fistula can develop after axillary dissection and its available treatment options. As this is a rare complication there is a paucity of evidence in its management strategies. The aim in this systematic review is to conduct a qualitative and/or quantitative synthesis of the literature and provide more robust recommendations for its management (conservative vs surgical modalities) to minimize the gap of knowledge though this study [1-5].

• To investigate the treatment of post operative chyle leak after mastectomy.

• To study the risk factors for the occurrence of post operative chyle leak in patients that underwent mastectomy.

• To evaluate the permissible length of conservative treatment before progressing to surgical options

• To compare the numerous proposed conservative and surgical options to stop chyle leak.

Patient

Patients that undergone mastectomy and developed chyle leak post operatively

Intervention

The feasibility of treating patients conservatively.

Comparison

To progress to surgical management once conservative treatment fails.

Outcome

To study the complete resolution of chyle leak with the available treatment options (complications, prognosis).

Searches

Embase, MEDLINE and Web of Science were searched up to 01/11/22 for articles published in English.

Embase: ('chyle leak':ab, ti OR 'chyle leaks':ab, ti OR 'chyle leakage':ti OR 'chylothorax':ti OR 'thoracic duct':ti) AND ('mastectomy':ab, ti OR 'nipple sparing surgery with axillary clearance':ab

MEDLINE (PubMed): ((chyle leak[title/abstract]) OR chyle leaks[title/abstract]) OR (chyle leakage[title]) OR (chylothorax[title]) OR (thoracic duct[title])) AND ((mastectomy[title/abstract])

Web of Science: TS=("mastectomy" OR "chyle leak post mastectomy" OR "breast resection" OR "chyle leak post mastectomy")

Case reports were examined for procedure type, duration of leak and treatment strategy. Nevertheless, we will contact the corresponding author, by e-mail, for missing data that is needed for the systematic review. The references of systematic reviews that come up in the search will also be searched manually [5-10].

Types of Study to be Included.

Inclusion Criteria: Randomised controlled trials, cohort studies, retrospective reviews, cross-sectional studies.

Exclusion Criteria: case reports, case series (<20 patients), systematic reviews, editorials, conference abstracts, studies where full text not in English, studies that were not specific to chyle leaks after mastectomy. The trend in the management of chyle leak following mastectomy with axillary clearance are identified as follows:

1. Primary outcome: chylous leakage

2. Secondary Outcome:

Side affected.

Type of surgery.

Level of axillary clearance - level 1-3.

Age

Drain output - mls in first 24hrs, then average mls/24hrs overstay.

Management

Complications from procedure

Mortality rate

Measures of Effect

Primary outcome was the chyle leak rate, defined as the presence of milky, non-infectious discharge through the abdominal drain with triglyceride levels higher than 1.3 mmol/L and lower cholesterol levels than blood, was defined as chylous ascites.

Data Analysis

The data will be reviewed independently by two reviewers and demographic characteristics of the data set will be assessed. The level of axillary clearance, the status of the lymph nodes taken (metastatic or benign) and the number sampled, the diagnostic tool used, the date any chylous leak noted, initial management, chylous output, secondary management, and time of resolution will be assessed. Comparison with separate groups of those that need secondary surgical management and with those who has been treated successfully conservatively.

Data Synthesis

Risk ratio (RR) of dichotomous outcomes (i.e., chyle leak, overall morbidity, and anastomotic leak) and mean difference (MD) along with their variances of continuous outcomes will be studied. The heterogeneity will be estimated using the Cochrane’s Q test and I² statistic and explored by using meta-regression. Publication bias will be assessed by Funnel plot and Egger test. A two-sided P-value < 0.05 considered to indicate significance.

Data Extraction

Data relating to multiple outcomes will then be extracted from the studies selected for inclusion, pertaining to side, age, type of surgery, level of axillary clearance (if applicable), drain output, subsequent management, length of stay, complications, and mortality.

Risk of Bias Assessment

As the study revolves around case reports, most of the data collected will be subjective and anecdotal. Hence, risk of bias assessment will not be necessary, other than to recognize the limitations within the methodology.

Ethical Approval

No ethical approval will be subjected as systematic reviews do not involve human participants, collecting new data or conducting primary research.

Subgroup Analysis

A subgroup analysis of those that require surgical management and those that are managed conservatively may be conducted.

My aim to complete the research should be in a time frame of 6 months (Dec 2023- May 2024). The breakdown of the tasks are as follows:

A. September 2023- December 2023

• Establish research question.

• Complete the research protocol.

• Formulate research strategy.

B. December 2023- March 2024

• Establish research design.

• To register the protocol with PROSPERO

• Scoping for data via many of the search tools

• Formulate and write up data analysis.

• Collaborate with other co reviewers.

C. March 2024- May 2024

• Establish the first and second draft of the systematic review.

• Proofread and to commit final checks to the dissertation.

• Write up the dissertation and submit the assignment.

There are a few constraints that could be anticipated from conducting this research which are.

• Lack of resources/literatures

• Time constraints

• Potential problem with programming tool (STATA, SPSS)

• Falling sick

• Financial constraints

• The alternatives that could be taken to minimize interruptions are.

• To prioritize the workflow of the research

• Identify electronic library resources that are needed.

• Identify support needed to access programming tools.

• Personnel that are unwell to stay home and to work remotely.

• Identify the research component which needs more time to be completed.

• Consider reaching out to funding agency program managers (Table 1).

Table 1:

1. Donkervoort SC, Roos D, Borgstein PJ (2006) A case of chylous fistula after axillary dissection in breast-conserving treatment for breast cancer. Clin Breast Canc 7(2): 171e2.
2. Sakman G, Parsak CK, Demircan O (2007) A rare complication in breast cancer sur- gery: chylous fistula and its treatment. Acta Chir Belg 107(3): 317e9.
3. Abdelrazeq AS (2005) Lymphoscintigraphic demonstration of chylous leak after axillary lymph node dissection. Clin Nucl Med 30(5): 299e301.
4. Al-Ishaq Z, Gupta S, Collins MA, Sircar T (2018) Chyle leak following an axillary sentinel lymph node biopsy for breast cancer in a patient with superior vena caval thrombosisea case report and review of the literature. Ann R Coll Surg Engl 100(6): e147e9.
5. Baek JM, Lee JA, Nam YH, Sung GY, Lee DS, et al. (2012) Chylous leakage: a rare complication after axillary lymph node dissection in breast cancer and surgical management. J Breast Canc 15(1): 133e4.
6. Caluwe GLF, Christiaens MR (2003) Chylous leak: a rare complication after axillary lymph node dissection. Acta Chir Belg 103(2): 217e8.
7. Chan AC, Sarojah A (2013) Chylous leakage post mastectomy and axillary clearance: clinical aspect, causes and review of literature. Med J Malaysia 68(3): 262e3.
8. Chow WTH, Rozen WM, Patel NG, Ramakrishnan VV (2015) Chyle leak after axillary lymph node dissection. J Plast Reconstr Aesthetic Surg 68(5): e105e6.
9. Cong M, Liu Q, Zhou W, Zhu J, Song C, et al. (2008) Six cases of chylous leakage after axillary lymph node dissection. Oncol Res Treat 31(6): 321e4.
10. Daggett JD, Watt AW, Smith PD (2016) Chyle leak following right axillary lymph node dissection: a case report and review of current literature. Int J Surg Case Rep 20: 68e73.