Right-sided chyle leaks, an institutional experience of over 4,000 neck dissections and scoping review of incidence and management
Original Article

Right-sided chyle leaks, an institutional experience of over 4,000 neck dissections and scoping review of incidence and management

Rachel Braude1,2 ORCID logo, Leba Sarkis1,2, Michael Zhang1, Carsten Palme1,2

1Department of Otolaryngology, Head and Neck Surgery, Chris O’Brien Lifehouse, Sydney, NSW, Australia; 2Sydney Medical School, University of Sydney, Sydney, NSW, Australia

Contributions: (I) Conception and design: All authors; (II) Administrative support: All authors; (III) Provision of study materials or patients: L Sarkis, C Palme; (IV) Collection and assembly of data: R Braude; (V) Data analysis and interpretation: R Braude, M Zhang; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Rachel Braude, MD. Department of Otolaryngology, Head and Neck Surgery, Chris O’Brien Lifehouse, 119-143 Missenden Rd, Camperdown, NSW 2050, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia. Email: rachel.braude@health.nsw.gov.au.

Background: Right-sided chyle leaks are an uncommon but potentially severe complications in neck surgery. While the prevalence of chyle leaks on the left side of the neck, often resulting from damage to the thoracic duct, is well-documented, there is limited literature addressing right-sided chyle leaks. This study aims to highlight the prevalence of right-sided chyle leaks in a high-volume Head and Neck unit, provide an overview of the anatomy and variations of the lymphatic system in the right side of the neck, and conduct a scoping review of the literature with regard to its prevalence and management.

Methods: A retrospective analysis was conducted of right-sided neck dissections performed at the Sydney Head and Neck Cancer Institute between 2014 and 2023. Patient charts were individually examined to determine the local prevalence of postoperative right-sided chyle leaks. A scoping review of existing scientific literature was performed to identify the existing prevalence and management regimes of right-sided chyle leaks.

Results: Among 4,547 right-sided neck dissections performed during the study period, five cases of right-sided chyle leaks were identified (0.11% prevalence), with two (40%) of these cases consisting of high-volume leaks which required a return to theatre. The scoping review identified 14 publications for inclusion, these reported an incidence of chyle leaks ranging from 0.75% to 8.9%.

Conclusions: High volume right-sided chyle leaks occur infrequently and may be due to the presence of anastomosis between the right and left sided thoracic ducts. It is imperative that Head and Neck surgeons remain vigilant in lymphatic duct ligation in both right and left-sided neck dissections.

Keywords: Chylous fistula; neck dissection; thoracic duct; postoperative complications

Received: 01 August 2024; Accepted: 14 January 2025; Published online: 10 April 2025.

doi: 10.21037/ajo-24-45

Introduction

Damage to the lymphatic system of the neck is an uncommon but severe complication of neck surgery, occurring in 2–8% (1) of cases. Neck dissection is one of the most common procedures performed in head and neck surgery, and due to the complex anatomy and need for comprehensive dissection, injury to the lymphatic system on either side can occur. This can result in a postoperative chyle leak with significant morbidity including malnutrition, dehydration, and electrolyte disturbances due to the loss of fat, protein and lymphocytes (1,2). Delayed wound healing, wound breakdown and fistula formation can occur with the localised inflammatory response potentially resulting in major morbidity or mortality (1,2). In the cases where free flap reconstruction is required for major head and neck ablations the ramifications of a chyle leak are magnified, with an increased risk of flap-related complications and prolonged admission, which themselves also confer significant morbidity.

Chyle leak secondary to injury of the thoracic duct on the left side of the neck is well documented (3), however, there is a paucity in the literature pertaining to right-sided chyle leaks. The right lymphatic duct drains the right side of the head and neck, the right thorax, and the right arm (4). It is less discernible than the thoracic duct, often has multiple tributaries and there is significant anatomical variation between individuals, making it more prone to injury. To further complicate matters, the thoracic duct which typically terminates on the left, can terminate on the right in an estimated 1–5% of individuals (5). Therefore, a thorough knowledge of the anatomy of the lymphatic system on the right side of the neck is important to any head and neck surgeon to minimise the likelihood of a chyle leak occurring.

The aim of this study is to highlight the prevalence of right-sided chyle leaks in a high-volume Head and Neck unit, provide an overview of the anatomy and variations of the right-sided lymphatic system, and conduct a scoping review of the literature with regard to its prevalence and management.

Background

Typical anatomy

The right lymphatic duct is typically located anterior to the anterior scalene muscle in the neck, however, its anatomical formation and presence varies, posing a significant challenge for the surgeon. Most commonly, the right lymphatic duct arises from the convergence of the right jugular, bronchomediastinal, and subclavian lymphatic trunks (5,6). It typically has a short 2 cm course and is less distinct than the left-sided thoracic duct.

The left-sided thoracic duct is typically described as a single duct originating from the cisterna chyli at the L2 vertebral level, ascending through the aortic hiatus into the posterior mediastinum, crossing to the left side of the thorax at the T5 vertebral level, before terminating at the junction of the left subclavian and internal jugular veins (6,7).

The right-sided lymphatic duct is responsible for draining the right side of the head, neck, as well as the right upper extremity and the organs of the right thorax (6,8). The remainder of the body is drained by tributaries which empty into the left-sided thoracic duct. Like the left-sided thoracic duct, the right-sided lymphatic duct also drains into the venous system at the junction of the right internal jugular and subclavian veins; however, it can have multiple tributaries and is often much less discernible than the left.

Histologically, lymphatic ducts are thin-walled vessels containing loose muscle bundles separated by delicate fibroelastic tissue, making them friable and susceptible to injury (9,10). This is further exacerbated by a thin endothelial cell wall often lacking a basement membrane (10). Although this improves permeability, it renders the duct transparent and fragile, making them more prone to intraoperative damage (9,11).

Anatomic variation

Multiple variations in the anatomy of lymphatic drainage pathways have been described. The right-sided lymphatic drainage pathways—right jugular, right bronchomediastinal, right subclavian lymphatic trunks may terminate individually, resulting in the absence of a main right-sided lymphatic duct (5).

Further variation such as right-sided thoracic ducts, anastomotic channels between the right lymphatic duct and left thoracic duct, and even a rare bilateral thoracic duct have also been reported (12). In 1915, Davis (6) performed a cadaveric dissection and subclassified variations of lymphatic drainage pathways into eight types. Types 4, 7 and 8 describe right-sided dominant thoracic ducts with little contribution from the contralateral side. Types 1, 2 and 3 have significant anastomotic channels between the left and right side. Multiple anastomotic pathways exist between the right and left neck lymphatics, which holds clinical significance and suggests both the right lymphatic duct and variations in thoracic duct anatomy may become relevant when performing bilateral neck surgery.

Further variation such as right-sided thoracic ducts, anastomotic channels between the right lymphatic duct and left thoracic duct, and even a rare bilateral thoracic duct have also been reported (12). In 1915, Davis (6) performed a cadaveric dissection and subclassified variations of lymphatic drainage pathways into eight types. These variations include diverse termination patterns of the thoracic duct, such as right-sided dominance, significant anastomotic channels between the left and right sides, and bilateral contributions. These include thoracic ducts that terminate predominantly on the right side with minimal contribution from the opposite side, as well as configurations with extensive anastomotic channels connecting the left and right sides. Multiple anastomotic pathways exist between the right and left neck lymphatics, which holds clinical significance and suggests both the right lymphatic duct and variations in thoracic duct anatomy may become relevant when performing bilateral neck surgery.

Methods

The study is reported according to the PRISMA-ScR reporting guidelines (available at https://www.theajo.com/article/view/10.21037/ajo-24-45/rc). The Sydney Head and Neck Cancer Institute Database was searched for all right-sided neck dissections conducted between January 2014 and April 2023. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013) (13). Approval for use and publication was obtained from the Sydney Local Health District Human Research Ethics Committee at RPA Hospital (HREC Approval No. HREC/RPA/X13-0439). Individual consent for this retrospective analysis was waived. The charts of all patients whose neck dissection was complicated by a right-sided chyle leak were identified to calculate local prevalence, and their charts reviewed to determine management regimes. High output leaks were defined as those with daily volumes exceeding 500 mL (1).

A scoping review of the scientific literature was conducted to determine the prevalence and management regimes of right-sided chyle leaks. A scoping review was deemed suitable to provide a broad overview of the evidence. The methodology and eligibility criteria for this review were established by the authors prior to its commencement.

Search strategy

MEDLINE®, Embase®, PubMed, Google Scholar and Scopus databases were searched using the keywords “chyle leak”, “chyle fistula”, “chylorrhea”, “lymphatic damage”, “neck dissection” and “right-sided”. All research types were included due to the limited nature of right-sided chyle leaks. Those reporting only on left-sided chyle leaks or bilateral neck dissection were excluded. Studies were limited to humans and those published in the English language from 1900 to October 2023. Abstracts were independently reviewed by reviewers to identify papers discussing right-sided chyle leaks, with the full-text articles examined to determine final eligibility for inclusion. The reference list of each full-text article was manually searched for additional eligible studies.

Results

Institutional experience

A total of 4,547 right-sided neck dissections were performed at our institution during the study period, with five cases (0.11%) resulting in a right-sided chyle leak. Of these, three (60%) were high-output leaks, while two (40%) were low-output leaks. Low-output leaks were successfully managed conservatively with dietary modifications, primarily through a low-fat diet. In cases of high-output leaks, initial management with dietary modification was supplemented with further intervention when necessary.

Two patients with high output chyle leaks required surgical exploration. One underwent muscle patch repair following persistent high-output leakage despite conservative measures, while the other was discharged on a specialized low-fat diet consisting of rice, vegetables, and fruit. This structured approach highlights the efficacy of conservative management for low-output leaks and the need for timely surgical intervention in refractory high-output cases. Table 1 provides a summary of clinical details, intervention and outcomes of the 5 patients who sustained a right-sided chyle leak.

Table 1

Right-sided post-operative chyle leaks at our institution

No. Age, years Gender Pathology Surgical intervention Volume of leak Management and outcome
1 50 Male Metastatic melanoma Right superficial parotidectomy and right selective neck dissection levels I–IV Low Low-fat diet
2 35 Female Alveolar rhabdomyosarcoma Open and endoscopic resection sinonasal/orbital/skull base tumour and right neck dissection Low Low-fat diet
3 67 Male Differentiated thyroid cancer Total thyroidectomy, central neck dissection, right neck dissection High Low-fat diet, required return to theatre, continued to have a high output leak, sent home on rice, vegetable, fruit diet
4 52 Male Salivary duct carcinoma Right submandibular gland excision, followed by radical right neck dissection (levels I–V) and resection of right lingual nerve High Low-fat diet
5 26 Male Differentiated thyroid cancer Total thyroidectomy, central neck dissection, bilateral levels IIa, III, IV, Vb neck dissection High Low-fat diet, return to OT day 7 for muscle patch repair

OT, operating theatre.

Literature review

The literature review identified 93 publications (Figure 1). Following removal of duplicates and non-English publications, 64 publications were identified and their abstracts were screened. Sixty full texts were assessed, resulting in 14 publications for inclusion in this review. Table 2 summarises the results from our institution in the broader context of the publications examined in the literature review. This includes 11 case series and 3 case reports. Prevalence was not reported or not applicable in 9 of these publications. In the remaining 5 texts, the prevalence of right-sided chyle leaks ranged from 0.75% to 8.9%, with variability likely reflecting differences in case detection and reporting methodologies.

Figure 1 PRISMA diagram of study selection.

Table 2

Scoping review of the literature of right-sided chyle leaks

Study Publication type Total right-sided neck dissections Number of right-sided chyle leaks Prevalence Volume of leak Management
Braude et al., 2025 Original Article 4,547 5 0.1% As per Table 1 As per Table 1
Deshmukh et al., 2021 (14) Case report 1 1 N/A Low Conservative management with ocretreotide and diet. Surgical exploration on day 10 due to persistence. Leak ligated and gel foam used with good effect
Dunlap et al., 2021 (3) Case series 212 3 1.4% N/A N/A
Tenny et al., 2018 (15) Case report 1 1 N/A Low Conservative management with octreotide and diet. Thoracic duct ligation on day 22
Ahn et al., 2015 (16) Case series 231 7 3.0% Low Conservative management with pressure dressings and nutrition followed by octreotide → surgery if failed (1 case)‡
Abraham et al., 2015 (17)† Case series Not reported 6 Not reported 5 low, 1 high Low output leaks healed spontaneously. High output leak managed conservatively with surgery on day 4 with ligation
Dhiwakar et al., 2014 (18) Case series Not reported 1 Not reported Low Conservative management with diet
Harlak et al., 2008 (19) Case report 1 1 N/A Low Conservative management with wound drainage, local pressure dressing, and low fat diet → octreotide → surgical repair on day 16 with sternocleidomastoid muscle flap and fibrin glue
Priego Jiménez et al., 2008 (20) Case report 1 1 N/A High conservative management with diet + octreotide then IV somatostatin and TPN
Roh et al., 2008 (21)† Case series 56 5 8.9% Low Pressure dressings → diet modification → TPN → surgery with gelfoam packing, fistula ligation and pectoralis major muscle flap‡
Nussenbaum et al., 2000 (22) Case series Not reported 2 – 1 low, 1 high Conservative management with nutrition, closed drainage, pressure dressings + diet or TPN → surgery if failed → leak oversewn or ligated with fibrin glue, sternocleidomastoid flap‡
De Gier et al., 1996 (23) Case series 132 1 0.75% Low Dietary modification
Spiro et al., 1990 (24) Case series Not reported 1 Not reported Mixed Conservative management with closed drainage and pressure dressings + diet → surgical ligation‡
Havas et al., 1987 (11) Case series 93 2 2.1% 1 low, 1 high Conservative management with diet for low output case, high output case requiring surgical re-exploration
Crumley & Smith, 1976 (25) Case series Not reported 3 Not reported Low Pressure dressings, two requiring surgical ligation

†, neck dissection for thyroid cancer only. ‡, not specific to left or right-sided leak management. N/A, not applicable; TPN, total parenteral nutrition.

Throughout the included studies, the majority of low-output leaks were managed conservatively using dietary modification, often supplemented with adjunct therapies such as octreotide or somatostatin to reduce lymphatic flow (11,14-16,18-25). Pressure dressings, wound drainage, and negative pressure wound therapy were also employed as supportive measures (16,19,21,22,24,25).

High-output leaks typically necessitated surgical intervention following the failure of conservative approaches. Surgical techniques described in the literature included direct ligation of the leaking duct, the use of muscle flaps (e.g., sternocleidomastoid, omohyoid or pectoralis major), and the application of fibrin glue or gel foam for additional sealing (11,14,15,17,19,21,22,24,25). The timing of surgical intervention varied, with procedures typically performed between 4 and 22 days postoperatively. Thoracic duct ligation via thoracoscopic or transthoracic approaches were employed in a few cases, with reported success rates exceeding 90% (26-29). These findings align closely with the stepwise approach observed at our institution, emphasising the use of conservative measures as a first-line approach and surgical exploration as a last resort.

Discussion

Postoperative right-sided chyle leaks following neck dissection, despite a varied reported prevalence of between 0% to 8.9%, remains a uncommon occurrence. Overall, our institution had a low right-sided chyle leak rate of 0.11%.

Naturally, there exists significant variability in the surgical technique in controlling lymphatic structures, however, there is universal acceptance that prevention of chyle leaks is improved through increased experience, anatomical knowledge, and meticulous technique. Diathermy coagulation leads to unacceptably high leak rates, with options such as silk sutures and thermal sealing devices preferred by some as are ancillary procedures such as using local muscle flaps and sclerosing agents (11,30).

Reflecting on our institutional practice, there exists variance between individual surgeons. During neck surgeries, particularly those involving dissection of level IV, care is taken to identify and ligate lymphatic structures individually. Method of ligation is varied, with haemostatic clips (e.g., LigaClips), ligating ties, or tissue sealant devices (e.g., LigaSure Exact) being preferred. The sole use of diathermy and bipolar devices in level IV is generally avoided. The Cernea manoeuvre (31) is also widely performed to ensure there is no lymphatic leak. This technique involves using a Valsalva manoeuvre and Trendelenburg positioning. By disconnecting the ventilator to lower intrathoracic venous pressure and applying abdominal pressure, chyle is propelled into the cervical thoracic duct, allowing for detailed inspection with magnification and prompt ligation of leaking lymphatic vessels (31). The manoeuvre can then be repeated to ensure success of ligation. If required, a simple flap rotation using adjacent strap muscles or sternocleidomastoid sutured to the prevertebral fascia to reinforce the ligated lymphatic vessel.

Following closer discussion and examination of the cases in question, we postulate that high-volume right-sided chyle leaks could be explained by the numerous anastomotic channels that exist between the right and left neck lymphatic system as documented by Davis (6). One patient of note underwent a bilateral comprehensive neck dissection for differentiated thyroid cancer, experienced a persistent right high-volume leak. He was initially managed with a low-fat diet, which was unsuccessful. Surgical exploration was thus required, and a muscle patch with tissue sealants was utilised. A local pressure dressing was applied and changed frequently to ensure there was no extended loss of pressure. The high-volume leak settled after 10 days of therapy.

In this particular patient’s case, a left-sided comprehensive neck dissection was performed first, and the thoracic duct was identified and ligated. We theorise that ligation may have led to the opening of collateral channels, which in turn caused the diversion of chyle from the left side to the right side of the neck (32,33). Pomerantz et al. [1963] (32) evaluated clinical studies of patients undergoing neck dissection and experimental canine studies to examine the impact of thoracic duct ligation on the diversion of chyle with the formation of collateral lymphatic channels. This supports our theory that collateral shunting may contribute to significant right-sided chyle leaks after acute ligation of the thoracic duct during neck dissection. What further complicates the matter is that the surgical bed in level IV then becomes filled with lymphatic fluid from multiple source vessels, making identification and ligation of a single causative tributary challenging to accomplish for the surgeon.

Review and comparison to the literature

Our institution’s reported prevalence is lower than that found in the literature, with only one study reporting a lesser rate of 0% (34). We postulate that such variability may be related to differences in volume of cases, surgical technique, and postoperative monitoring. Roh et al. [2008] (21) reported a significantly higher rate of right-sided chyle leaks of 8.9%. The authors hypothesised their higher incidence of postoperative chyle leaks was due to their closer monitoring. Their reported outcomes from the right-sided leaks were generally less severe and resolved with simple medical management.

Management of right-sided chyle leaks

A postoperative leak is often noticed by a sudden increase in drain output following commencement of feeds. Confirmation can be achieved by confirming the presence of chylomicrons or a drain fluid triglyceride level >100 mg/dL (3,35). The management depends on whether the leak is low or high output (>500 mL/day) (1).

Management of right-sided chyle leaks typically follows a stepwise approach, beginning with non-surgical, non-pharmacological measures. Dietary modification, including the use of medium-chain triglycerides, is the mainstay of treatment for low-volume leaks (<500 mL/day) (1,14,22). In our unit, 60% of patients were successfully managed with this form of dietary modification alone. This approach effectively reduces chyle production by bypassing the lymphatic system, with total parenteral nutrition (TPN) reserved for persistent cases (1). Adjunctive measures, such as compression dressings or negative pressure wound therapy, are sometimes employed in refractory cases to aid in resolution (36,37).

Pharmacological measures such as octreotide, a somatostatin analogue, have shown efficacy in reducing lymph flow and are commonly used as an adjunct to dietary interventions (38). Although generally effective, octreotide alone may not resolve all cases (38-40) and is often avoided when a free flap has been placed. The use of other topical agents such as OK-432 and tetracycline has been described at time of initial surgery, however the literature suggests that this approach has gone out of favour due to its potential to complicate future surgeries (21,41).

For high-volume leaks or those refractory to conservative measures, surgical intervention remains the definitive treatment. In the initial instance, a transcervical approach involving direct ligation of the leaking duct and the use of adjuncts such as fibrin glue or muscle flaps is considered the gold standard (42). High caloric feeds to promote increased chyle leak immediately before returning to theatre may also aid in identification of the leak site. Should a trans-cervical approach be unsuccessful, then video-assisted thoracoscopic surgery (VATS) with transthoracic ligation of the thoracic duct offers a minimally invasive alternative (43,44) with a greater than 90% reported success rate however most of this data relates to left sided leaks (45,46).

Thoracic duct or lymphatic embolisation can additionally be achieved using uni- or bipedal lymphangiography (26,27). This technique was first described by Cope [1998] (26) and allows for identification of the chyle leak site. The thoracic duct or otherwise affected lymphatic vessel is then catheterised percutaneously and closed using tissue glue, coils or a combination of both (27,28). In a 2004 review, Cope (27), reported a success rate of 70%. A more recent retrospective study by Ushinsky et al. (29) reported a success rate of greater than 90%. This study incorporated the use of retrograde ultrasound-guided embolisation in difficult cases.

This stepwise approach emphasises the importance of tailoring management to the severity of the leak, with most right-sided chyle leaks responding well to non-surgical measures and surgical intervention reserved for high-output or refractory cases. This aligns with the findings from our institutional experience and the broader literature.

Limitations

While this review offers valuable insights into right-sided chyle leaks, it has several limitations. Due to the paucity of literature on right-sided chyle leaks, we included diverse study types, which may affect the consistency and rigour of findings. Variability in reported prevalence rates, incomplete data, and the inclusion of studies with differing quality further impact the reliability of the conclusions. Addressing these limitations in future research could improve the robustness and applicability of reviews in this area.

Conclusions

Right-sided chyle leaks remain uncommon. Our institutional experience indicates a prevalence of 0.11%, with the literature reporting between 0–8.9%. We hypothesise that high-volume chyle leaks in bilateral comprehensive neck dissections may occur secondary to shunting from the left-sided thoracic duct to the right-sided lymphatic duct, owing to significant anastomoses between the two structures. Head and Neck Surgeons should continue to be vigilant intraoperatively in the identification and ligation of potential lymphatic structures, remain cognisant of the variable anatomy in this region, and employ a graded approach when managing right-sided chyle leaks.

Acknowledgments

Our abstract has been accepted for presentation at the RACS 92nd Annual Scientific Congress Conference in Christchurch, New Zealand, taking place between the 6th to the 10th May, 2024.

Footnote

Reporting Checklist: The authors have completed the PRISMA-ScR reporting checklist. Available at https://www.theajo.com/article/view/10.21037/10.21037/ajo-24-45/rc

Data Sharing Statement: Available at https://www.theajo.com/article/view/10.21037/ajo-24-45/dss

Peer Review File: Available at https://www.theajo.com/article/view/10.21037/ajo-24-45/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://www.theajo.com/article/view/10.21037/ajo-24-45/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). Approval for use and publication was obtained from the Sydney Local Health District Human Research Ethics Committee at RPA Hospital (HREC Approval No. HREC/RPA/X13-0439). Individual consent for this retrospective analysis was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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doi: 10.21037/ajo-24-45
Cite this article as: Braude R, Sarkis L, Zhang M, Palme C. Right-sided chyle leaks, an institutional experience of over 4,000 neck dissections and scoping review of incidence and management. Aust J Otolaryngol 2025;8:14.

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