134 Figure 1. Operative findings. The clear fluid is running from one duct (black arrow). system [4]. It has been reported that more than two terminal ducts exist in 7-20% of cases and one case with a thoracic duct that emptied into the right internal jugular vein was described [4,5]. A rare anatomical variation of the lymphatic trunk, pos- teroinferior to the axillary vein, was supposed to be the cause of the chylous leak after mastectomy [6]. It is very difficult to predict injury to the lymphatic trunks preoperatively or to recognize it during surgery because of its rare occurrence in axillary surgery and the absence of well- known risk factors. Chylous leakage is usually diagnosed by the typical “milky” drainage fluid after surgery and is confirmed by biochemical analysis of the electrolyte, protein, and fat content of the fluid, which, in these cases, are compatible with chyle. Lymphoscin- tigraphy or computed tomography are also helpful for the con- firmation of chyle collection [7]. Nakajima et al. [3] reported that they did not find any char- acteristic risk factors after analysis of four cases, although others mentioned previously the effects of wound seroma or obesity [8]. The initial management of chylous leakage should be conser- vative, including adequate drainage, diet control, and treatment with intravenous octreotide and oral injection of tetracycline hydrochloride [9]. It can also be managed successfully without special dietary control [3]. However, some authors advocate that timely or early re- exploration should be used to manage chylous fistulas, con- sidering the prolongation of the hospital stay and morbidity [2]. Surgical indications can vary depending on the site of the chylous leakage. It is considered when pleural drainage is greater than 1 L per day for more than 5 days in cases of chylothorax Jong Min Baek, et al. or with continuous drainage over 500-600 mL per day without improvement [1,10]. However, an early surgical approach can easily be considered in breast surgery because the risk associ- ated with re-exploration of the superficial chest wall and axilla is not very high. Surgical management consists of direct ligation of the injured lymphatic channel, if it can be seen during exploration, and plugging with gel foam, other packing materials, or with glue or local muscle rotation flaps [2]. Awareness of this unusual complication after breast surgery should make it possible to avoid or recognize the injury to the thoracic duct during surgery. Certain ligations in the deep axillary area can prevent this complication [3]. Thus, we suggest an even more careful dis- section and ligation in cases where the patient has massive axillary metastasis. In addition, a timely surgical approach may represent an alternative, because of its low morbidity and because it avoids delaying subsequent oncologic treatments, even though many cases were treated conservatively. CONFLICT OF INTEREST The authors declare that they have no competing interests. REFERENCES 1. MerriganBA, Winter DC, O’Sullivan GC. Chylothorax. Br J Surg 1997; 84:15-20. 2. Fitz-HughGS, Cowgill R. Chylous fistula. Arch Otolaryngol 1970;91: 543-7. 3. NakajimaE, Iwata H, Iwase T, Murai H, Mizutani M, Miura S, et al. Four cases of chylous fistula after breast cancer resection. Breast Cancer Res Treat 2004;83:11-4. 4. GottliebMI, Greenfield J. Variations in the terminal portion of the human thoracic duct. AMA Arch Surg 1956;73:955-9. 5. ShimadaK, Sato I. Morphological and histological analysis of the tho- racic duct at the jugulo-subclavian junction in Japanese cadavers. Clin Anat 1997;10:163-72. 6. PurkayasthaJ, Hazarika S, Deo SV, Kar M, Shukla NK. Post-mastectomy chylous fistula: anatomical and clinical implications. Clin Anat 2004;17: 413-5. 7. AbdelrazeqAS. Lymphoscintigraphic demonstration of chylous leak after axillary lymph node dissection. Clin Nucl Med 2005;30:299-301. 8. AbeM, Iwase T, Takeuchi T, Murai H, Miura S. A randomized controlled trial on the prevention of seroma after partial or total mastectomy and axillary lymph node dissection. Breast Cancer 1998;5:67-9. 9. CaluweGL, Christiaens MR. Chylous leak: a rare complication after axillary lymph node dissection. Acta Chir Belg 2003;103:217-8. 10. SpiroJD, Spiro RH, Strong EW. Themanagement of chyle fistula. Laryn- goscope 1990;100:771-4. http://ejbc.kr http://dx.doi.org/10.4048/jbc.2012.15.1.133