In addition, half of the 4 liters of lymph draining through the cisterna chyli and thoracic duct originates from the intestinal and hepatic lymphatics. The cisterna chyli is found on the posterolateral edge to the right of the aorta at the level of vertebral bodies T12, L1, L2, and L3 as lymphatics from the mesentery, intercostals, and lumbar regions coalesce in the retroperitoneal space. At approximately L1, the cisterna chyle ascends, becoming the thoracic duct. The duct then enters the posterior mediastinum, crosses at T4 into the left retropleural space, and continues in a cephalad direction. Fistulas arising in the neck are easier to access and identify than those that occur in the abdomen or thorax.
Nutritional intervention remains the mainstay of nonoperative treatment.
Medium chain triglycerides are absorbed directly from the gut into the portal venous circulation. TPN affords full caloric and nitrogenous support while allowing for bowel rest. Bowel rest achieves a decrease in chyle flow allowing for healing to occur. A period of observation from one to several weeks should be allowed before determining whether these therapies are successful. In patients where accumulation of chyle leads to significant problems such as shortness of breath and lung collapse, the use of drainage through a thoracostomy tube or paracentesis may be necessary despite the obvious adverse effects that this form of therapy may produce.