Cervical Chylous Fistula After Lymphadenectomy for Differentiated Thyroid Carcinoma: Anatomy, Risk Factors, and Management Strategies—A Narrative Review
- 1Department of Surgery, Iuliu Haţieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
- 24th Surgical Clinic, CF Hospital Cluj-Napoca, 400015 Cluj-Napoca, Romania
Abstract
Background: Cervical chylous fistula is a rare but potentially severe complication of laterocervical lymphadenectomy associated with thyroidectomy for thyroid carcinoma with lateral lymph node metastases. It occurs predominantly during level IV dissection in the proximity of the jugulo-subclavian confluence. Injury to the thoracic duct or the right lymphatic duct can generate persistent lymphorrhagia, leading to severe electrolyte imbalances, hypoproteinemia, and lymphopenia. The anatomical variability of the terminal portion of the thoracic duct justifies a comprehensive analysis of prevention and management strategies. Methods: A structured narrative analysis of data on thoracic duct anatomy, cervical compartment classifications, and therapeutic options was performed using a database search paired with citation tracking. Intraoperative identification techniques, ligation methods, and conservative and interventional strategies were critically evaluated. Results: Chylous fistula is mainly associated with left lower lateral compartment dissection (level IV) and cervical reinterventions. Daily drainage output is the central criterion for therapeutic decision-making, operationalized here through a comparative matrix and a stepwise algorithm. Low-output fistulas frequently respond to conservative treatment (hypolipidemic diet, medium-chain triglycerides, octreotide, or negative pressure). High-output fistulas require surgical reintervention with thoracic duct ligation (potentially associated with tissue adhesives or muscle flaps), video-assisted thoracoscopy, or percutaneous embolization. Conclusions: Prevention through systematic anatomical identification of the thoracic duct during level IV dissection, intraoperative verification of its integrity, and the application of a flow-based therapeutic algorithm drastically reduce morbidity and optimize the management of cervical chylous fistula.
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BibTeX
@article{fabian2026cervical,
title = {{Cervical Chylous Fistula After Lymphadenectomy for Differentiated Thyroid Carcinoma: Anatomy, Risk Factors, and Management Strategies—A Narrative Review}},
author = {Ovidiu Fabian and Emilia Maria Pătruţ and Flaviu Mureşan and Sergiu Neciu and Gabriel Emil Petre},
journal = {Journal of Clinical Medicine},
year = {2026},
month = oct,
doi = {10.3390/jcm15207784},
url = {https://www.mdpi.com/2077-0383/15/20/7784},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Cervical Chylous Fistula After Lymphadenectomy for Differentiated Thyroid Carcinoma: Anatomy, Risk Factors, and Management Strategies—A Narrative Review
AU - Ovidiu Fabian
AU - Emilia Maria Pătruţ
AU - Flaviu Mureşan
AU - Sergiu Neciu
AU - Gabriel Emil Petre
PY - 2026
DA - 2026/10/01
JO - Journal of Clinical Medicine
DO - 10.3390/jcm15207784
UR - https://www.mdpi.com/2077-0383/15/20/7784
AB - Background: Cervical chylous fistula is a rare but potentially severe complication of laterocervical lymphadenectomy associated with thyroidectomy for thyroid carcinoma with lateral lymph node metastases. It occurs predominantly during level IV dissection in the proximity of the jugulo-subclavian confluence. Injury to the thoracic duct or the right lymphatic duct can generate persistent lymphorrhagia, leading to severe electrolyte imbalances, hypoproteinemia, and lymphopenia. The anatomical variability of the terminal portion of the thoracic duct justifies a comprehensive analysis of prevention and management strategies. Methods: A structured narrative analysis of data on thoracic duct anatomy, cervical compartment classifications, and therapeutic options was performed using a database search paired with citation tracking. Intraoperative identification techniques, ligation methods, and conservative and interventional strategies were critically evaluated. Results: Chylous fistula is mainly associated with left lower lateral compartment dissection (level IV) and cervical reinterventions. Daily drainage output is the central criterion for therapeutic decision-making, operationalized here through a comparative matrix and a stepwise algorithm. Low-output fistulas frequently respond to conservative treatment (hypolipidemic diet, medium-chain triglycerides, octreotide, or negative pressure). High-output fistulas require surgical reintervention with thoracic duct ligation (potentially associated with tissue adhesives or muscle flaps), video-assisted thoracoscopy, or percutaneous embolization. Conclusions: Prevention through systematic anatomical identification of the thoracic duct during level IV dissection, intraoperative verification of its integrity, and the application of a flow-based therapeutic algorithm drastically reduce morbidity and optimize the management of cervical chylous fistula.
SN - 2077-0383
ER -