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Nutritional Management in Patients with Chyle Leakage: a Systematic Review

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Nutritional Management in Patients with Chyle Leakage: a Systematic Review European Journal of Clinical Nutrition (2015) 69, 776–780 © 2015 Macmillan Publishers Limited All rights reserved 0954-3007/15 www.nature.com/ejcn ORIGINAL ARTICLE Nutritional management in patients with chyle leakage: a systematic review BR Steven1 and S Carey1,2 BACKGROUND/OBJECTIVES: To investigate all the available evidence assessing the effect of nutrition intervention on patients with chyle leakage and its effectiveness at reducing the need for surgical intervention. SUBJECTS/METHODS: A systematic review was undertaken of all English language studies using MEDLINE, Cinahl and Web of Science from January 1980 to September 2013. Case series were included because of limited available evidence. Exclusion criteria included animal studies, pediatrics and studies without nutritional intervention. Assessment of study quality was included. Because of the heterogeneity of the data, no meta-analysis was performed. RESULTS: Thirty-one articles were identified for analysis, all of which were retrospective case series studies. The data within these studies were greatly limited. A total of 550 subjects were identified from these studies, 72% of whom had a chyle leak successfully resolved without surgical intervention. However, there was no significant difference between the type of dietary intervention and the rate of resolution (χ2 = 11.14, P = 0.08). CONCLUSIONS: Although there is evidence to suggest that nutrition may have a role in the management of patients with chyle leakage, it is not possible to determine which dietary methods are most effective. More research is required before any guidelines for best practice can be established. European Journal of Clinical Nutrition (2015) 69, 776–780; doi:10.1038/ejcn.2015.48; published online 29 April 2015 INTRODUCTION The method of nutritional management commonly recommended Chyle leaks are a rare but potentially life-threatening condition, in among practitioners includes dietary fat restriction to reduce chyle 6 which chyle extravasates from the thoracic duct or one of its major flow, which is theorized to encourage the effusion to heal. This is branches, leading to chylous disorders such as chylothorax, used in conjunction with medium-chain triglyceride (MCT) chylous ascites, chyluria and chylopericardium. The potential supplementation. MCTs bypass the lymphatic system and enter 6 causes of a chyle leak are numerous, but they are typically caused the portal venous system directly. However, no consensus has by malignant neoplasms, specifically lymphoma,1 as well as been reached on the optimum method of management, with invasive surgery or penetrative trauma of the neck, chest or current guidelines being based on retrospective reviews of case abdomen.2–4 reports.11 Chyle is a lymphatic fluid flowing from the lymph channels of In addition to fat-free/low-fat diets and MCT supplementation, 5 the small intestine to the venous blood supply via the thoracic treatment options include enteral feeding, low-fat diets supple- duct.5 It is enriched with ingested dietary fats, specifically long- mented with the essential fatty acids (linoleic and linolenic chain triglycerides (LCT), which are bound to chylomicrons.5,6 acid),10,12 drainage of chyle to relieve pressure,11 pleurodesis,13,14 Postprandially, chyle becomes milky white and greatly increases in total parenteral nutrition (TPN) to provide bowel rest and reduce volume as a result of dietary fat ingestion,7 whereas in a fasted chyle output,11 drug therapy to reduce lymphatic flow15 and state, chyle becomes quite clear and reduces in volume.5 Because invasive surgical intervention to seal the leakage.16 Many of these chyle is a fat-enriched lymphatic fluid, it is rich in protein, fat, methods are often used in conjunction or used progressively as fat-soluble vitamins, lymphocytes, immunoglobulins and more conservative methods fail. electrolytes.4 Loss of this fluid may result in impaired wound Because of the lack of scientific consensus on the optimum healing, electrolyte abnormalities, dehydration, immune suppres- method of nutritional management for patients with a chyle leak, sion, nutritional deficiencies, prolonged hospitalization and the nutritional and medical practice employed varies between occasionally result in patient death.7,8 As many patients with a practitioners, and, as a result, it is unlikely that best patient health chyle leak have recently undergone surgery and/or suffered outcomes are consistently achieved. To consistently achieve severe trauma, they are already at significantly increased better patient health outcomes in those with chyle leakage, nutritional risk with increased protein and energy requirements evidence-based clinical practice guidelines need to be established. for wound healing,9 which is only exacerbated by nutrient losses However, with no available systematic reviews and a lack of from chyle leakage. evidence on the matter, this is currently not possible. The aim of The goal of nutritional management in chyle leakage is to this paper was to systematically review all the available evidence encourage healing of the damaged lymphatic vessels, along with assessing the effect of nutritional intervention on people with replacing chylous losses and meeting the patient's nutritional chyle leakage and its effectiveness at reducing the need for needs with adequate kilojoules, fluid, electrolytes and protein.10 surgical intervention. 1School of Clinical Nutrition, University of Sydney, Sydney, New South Wales, Australia and 2Nutrition and Dietetics Department, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia. Correspondence: Dr S Carey, Royal Prince Alfred Hospital, Missenden Road, Camperdown, Sydney, New South Wales 2050, Australia. E-mail: [email protected] Received 7 January 2014; revised 24 August 2014; accepted 23 January 2015; published online 29 April 2015 Systematic review of chyle leaks BR Steven and S Carey 777 SUBJECTS AND METHODS Data analysis Search strategy A meta-analysis was not able to be performed because of the A computerized bibliographic search was performed using Title/Abstract heterogeneous nature of the studies. Because of the nominal nonpara- 2 searches and Medical Subject Headings (MeSHs) where appropriate, of the metric nature of the data, the χ -test was used to compare success rates Medline, Cinahl and Web of Science databases for publications from January between dietary treatment options, using the Statistical Package for Social 1980 to September 2013. Because of the variety of terminology used when Sciences version 17.0 (SPSS Inc, Chicago, IL, USA). Statistical significance describing chyle leaks, a comprehensive search was required to capture all was assumed at Po0.05. relevant articles. Search terms included the following: Chylous ascites (MeSH), chylothorax (MeSH), thoracic duct (MeSH), lymphatic vessels (MeSH) or chyl*, and therapeutics (MeSH), treatment outcome (MeSH), disease progression RESULTS (MeSH), survival analysis (MeSH), enteral nutrition (MeSH), parenteral nutrition A total of 7,198 citations were identified through the primary (MeSH),triglycerides(MeSH),mct,fat*,conservativeormanag*.Exclusions search (2285 from Medline, 4482 from Web of Science and 430 included animal studies, publications reported in another language other than English, studies containing pediatrics, individual case reports, studies without from Cinahl). After screening, 60 full-text articles were considered nutritional intervention, studies that did not report treatment outcomes and for review, 29 of which fell within the exclusion criteria, leaving 31 publications where the full text was not available. The reference lists of all suitable articles for analysis (Figure 1). The reference lists of these included articles were browsed to obtain additional studies. Because of the articles were browsed but did not identify any appropriate limited number of randomized trials, case review studies were included in this publications that were available in full text. systematic review. All of the identified articles were retrospective case series (Table 1). No randomized control trials involving nutritional Data extraction and quality assessment management were available. The highest score for scientific Each article was scored for its scientific quality by two researchers (BRS and quality was 3/11, with the majority of articles scoring 2/11, SC) on a scale of 0–11, using a quality assessment tool adapted from indicating the poor quality of evidence available. Sample size of 17 Heyland et al. Articles were appraised on their use of randomization, each study varied from 3 to 66 participants and from 18 to 89 blinding, intention-to-treat analysis, patient selection, description of years of age. patient outcomes and baseline comparisons for the groups of patients. From these articles, 550 patients having had received nutritional Data extraction was performed by one researcher (BRS). Extracted data fi included study design, participant characteristics, location of effusion, intervention for chyle leakage were identi ed. Reported methods diagnostic method used, drainage output, dietary intervention used, time of dietary intervention included fasting, TPN, enteral nutrition, to resolution and the incidence of surgical intervention. restriction of dietary fat/LCTs and MCT supplemented diets. Records identified through Additional records identified database searching through other sources (n = 7198) (n = 0) Identification Records after duplicates removed (n = 6277) Records screened Records excluded (n
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