Introduction: Chyle leak(CL) is a relatively common complication after pediatric liver transplantation(LT). We aimed to evaluate the incidence, risk factors and management of chyle leaks among paediatric recipients in our unit.
Materials and Methods: Retrospective analysis of data of paediatric(≤16 years) recipients from August 2010 to August 2018 was done. Preoperative, intraoperative and postoperative parameters (CL management including interventions, morbidity & mortality) were recorded. Patients with CL were compared to the rest of the children without CL(noCL group).
Results: Forty two(13.9%) of 301 pediatric recipients developed CL. Among patients with CL, median age was 2 years(4 mon–12 years) and 17 were female. Median weight was 9.2kg(5–39kg). The commonest indication for transplant was cholestatic liver disease(n=30, 71.4%) among which non-biliary atresia cholestatic disease were 13. Living donor LT was done in 37 patients (1 right lobe, 4 left lobe, 32 left lateral section(LLS) grafts). Five patients received split deceased donor LLS grafts. Median graft weight was 277g(173–593g) and median graft recipient weight ratio(GRWR) was 2.39%(0.78–4.74%).
CL manifested at a median of 8 days(5-45 days) from LT and persisted for a median of 7.5 days(2-30 days). Median drain fluid triglyceride level was 185.5 mg/dL(111-363 mg/dL). CL presented as chylous ascites in 34 patients, chylothorax in 6 patients and as both in 2 patients. On diagnosis of CL, fat restricted diet was instituted for all patients. Subcutaneous octreotide injections were additionally administered in 10 pateints. Thirteen(30.95%) children required percutaneous drainage of chylous collections (8 thoracocenteses). Median hospital stay was 21.5 days(10-57 days) and 20 patients(47.62%) had morbidity of ≥3A(Clavien Dindo). There was no surgical mortality among these patients.
Age, sex, body weight, graft weight and GRWR were comparable between CL and noCL groups. Cholestatic liver disease(non-biliary atresia) was significantly more common in the CL group (35.7% vs 20%, p=0.03). Hospital stay was similar between groups. Ninety day mortality was significantly lower in CL group (0% vs 9.7%, p=0.033); however, CL was not a risk factor for 90 day mortality on multivariate analysis.
Patients with prolonged CL(>7 days) had significantly more incidence of chylothorax (35% vs 5.8%,p=0.03)  when compared to those with short duration CL(<7 days). Octreotide requirement (68% vs 17%, p=0.005) and percutaneous drainage (70.5% vs 17.6%, p=0.005)  were significantly more common in prolonged CL. Similarly, ICU and hospital stay and morbidity ≥3A were significantly higher in patients with prolonged CL.
Conclusion: CL is a fairly common complication among pediatric recipients and can be safely and effectively managed with early identification and management with fat restricted diet and octreotide. CL presenting as chylothorax more commonly requires additional intervention for resolution and increases morbidity.