Abstract / Summary
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.