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Page 2 of 11 Drobot et al. Plast Aesthet Res 2021;8:30 https://dx.doi.org/10.20517/2347-9264.2021.19

Keywords: Chyle leakage, breast cancer, axillary lymph node dissection, lymphangiography, lymphatic
embolization, supermicrosurgery, lymphaticovenular anastomosis, treatment algorithm

INTRODUCTION
Chyle is a milky substance derived from the intestines during digestion and then carried by the lymphatic
[1]
system . Usually, it enters the venous system at the level of the left brachiocephalic vein. During surgery,
iatrogenic injuries to the thoracic duct could lead to chylous leakage, especially due to aberrant anatomy .
[2]
Chyle leakage rarely occurs secondary to axillary surgery and little guidance exists regarding its
management . This iatrogenic complication may cause high physiological morbidity, high mental burden,
[3-5]
prolonged treatment, and delayed primary oncologic treatment. The current therapy focuses mainly on
reducing flow in the thoracic duct . Our case shows that chyle leakage may include a peripheral component
[6]
in addition to the central one. We demonstrated that lymphaticovenular anastomosis (LVA) can reduce
peripheral component flow, therefore decreasing the total chyle leakage.

CASE REPORT
A 43-year-old woman, with a history of diabetes type 1 and bilateral breast augmentation, presented with a
lump in the lateral aspect of her left breast. Mammography and breast US showed a mass, 1.8 cm in
diameter without suspected axillary lymph nodes. Ultrasound-guided biopsy showed invasive duct
carcinoma. Immunohistochemical evaluation showed ER , PR , HER , Ki 10%-15%. MRI imaging showed
+
+
2-
two not enlarged axillary lymph nodes with moderate cortical thickness and did not show any additional
breast lesions.
Breast conservative surgery and sentinel lymph nodes biopsy were performed. Intraoperative histological
examination of the lymph nodes was positive for macro metastasis. Axillary lymph node dissection (Level 1-
2 nodes) was performed. It was an uneventful operation that ended with the placement of an axillary
+
suction drain. Definitive histology revealed metastases (pN ) in 16 out of 20 removed lymph nodes.
Following those findings, initiation of chemotherapy was suggested.

By the end of Postoperative Day 1 (POD), the drain collected 500 mL of a milky fluid [Figure 1]. Analysis of
the milky fluid was compatible with chyle (triglycerides 2200 mg/dL). The chyle leakage was stable
(400-500 mL/day) in the following days [Figure 2]. On POD 5, in a wound revision, tiny suspected leaking
lymphatic ducts were ligated. At first, the leakage decreased, but soon stabilized again at 500 mL per day.
The drained fluid became more lucid, and the triglycerides decreased to 220 mg/dL. On POD 8, with the
aim of reducing chylous output, a conservative treatment of octreotide and medium-chain triglycerides
(MCT) diet was initiated. Without reduction of chyle volume leakage, on POD 10, she was admitted to
another medical center, and a treatment with fasting and partial parental nutrition was initiated. On POD
12, a central vein port was inserted for treatment with total parenteral nutrition (TPN). On POD 24, the
patient was diagnosed as positive for COVID-19; she had no respiratory symptoms during the whole
therapeutic course. On POD 26, the patient could no longer bare the TPN treatment and ceased its use for
the following 8 days.

On POD 30, the patient presented with a dehiscence of the operated wound with lymphatic fluid leakage
through it. The treatment included wound debridement and skin suturing. Chyle leakage output increased
significantly in the following days.