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NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #17
Carol Rees Parrish, R.D., MS, Series Editor When Chyle Leaks:
Nutrition Management Options
Chylous leakage from the lymphatic system is a complex problem usually resulting
from injury or abnormality of the thoracic duct. Although rare, when such leaks occur,
they are often difficult to manage and correct. Nutrition therapy plays a major role in
the conservative treatment of chyle leaks. This article will review the process of fat
digestion and absorption, review selected references reporting nutrition interventions,
discuss nutrition options for the treatment of a chyle leak, and provide information to
implement such therapy.
INTRODUCTION
the remaining 15% of cases (2). The incidence of chyle Chyle is an alkaline, milky, odorless fluid that pro- leaks varies depending on the underlying cause. The
vides about 200 kcal/liter. It contains greater than incidence after radical neck dissection is 1–2.5% (3); 30 g/L of protein, 4–40 g/L of lipid (mostly triglyc- after cardiothoracic surgery 0.2–1% (2). eride) and cells consisting primarily of lymphocytes (1).
Chyle leaks are a rare complication; they can occur for a DIAGNOSIS
variety of reasons after injury to the intra-abdominallymphatics (Table 1). Leakage may manifest as a chy- The diagnosis of a chyle leak is often subjective, and lothorax or chylous effusion (thoracic cavity); chylous diagnostic criteria may vary. To confirm that a fluid is ascites (peritoneal cavity); chylopericardium (cardiac chylous, the lipid content should be greater than that of cavity) or as an external draining fistula. Approximately plasma and the protein should be more than half of that 60% of chyle leaks are due to lymphoma; 25% due to of plasma (1). A milky appearance of the drainage trauma (iatrogenic or penetrating); other causes make up fluid is often the initial clue. One simple method sev-eral authors advocate is to restrict enteral fat intake; ifthe drainage becomes clear and/or decreases, it can be Stacey McCray RD, Nutrition Support Specialist Con-sultant, and Carol Rees Parrish RD, MS, Nutrition assumed that a chyle leak is present (3,4). Others eval- Support Specialist, University of Virginia Health uate the drainage fluid for characteristics such as System, Digestive Health Center of Excellence, triglyceride content, alkaline pH, and presence of fat, PRACTICAL GASTROENTEROLOGY • MAY 2004
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• Mechanisms that enhance the rate of blood capillary Potential Causes of Chyle Leak
filtration such as elevated capillary pressure or per-meability; • Decreased plasma colloid osmotic pressure; and • Increased interstitial fluid colloid osmotic pressure.
In addition, water taken by mouth can increase the After LCF is ingested and delivered into the proxi- mal small bowel, bile salts are released into the lumen creating micelles with the fat particles dissolving the hydrophobic LCF in the aqueous small bowel environ- ment. The formation of micelles increases the surface area of LCF allowing easier access to pancreatic Used with permission from the University of Virginia Health System enzymes for hydrolysis. Pancreatic lipase is the primary Nutrition Support Traineeship Syllabus (18) enzyme involved in the breakdown of LCF. Micellestransport fatty acids and monoglycerides to the intesti- specific gravity, cholesterol/triglyceride ratio, or lym- nal villi where they are absorbed across the intestinal phocyte count to confirm the diagnosis (2,5,6). More mucosa. Absorption of fat takes place primarily in the complete reviews of the etiology and diagnosis of proximal jejunum. Of note, bile salts are not absorbed at chyle leaks are available elsewhere (7–9).
this point, but continue down the intestine to the ileumwhere they are reabsorbed and returned to the liver viaenterohepatic circulation. This process of recycling bile A BRIEF REVIEW OF FAT DIGESTION
salts is required for adequate bile flow to continue.
AND ABSORPTION
Ninety percent of bile salts are recycled in this fashion, The majority of dietary fat is in the form of long chain fats making for a very efficient and conservative system.
(LCF). Digestion and absorption of LCF is a unique and Once absorbed across the intestinal mucosa, the fatty complicated process involving multiple gastrointestinal acids and monoglycerides are re-esterified into triglyc- functions and the lymphatic system. The process requires erides combining with cholesterol, protein and other sub- gastric lipase, pancreatic lipase, additional enzymes, a stances to form chylomicrons. Chylomicrons enter the suitable intestinal pH—ideally pH 7—(achieved by lymphatic system as chyle via lacteals (lymph vessels in secretion of pancreatic bicarbonate) and bile salts. the villous region). Fat-soluble vitamins are also absorbed Lymph is derived from interstitial fluid that flows into the lymphatic system by this route. The chylomi- into the lymphatics; it is the only means for protein crons then travel through the lymph system and are that has left the vascular compartment to be returned to deposited into the venous blood system over the course of the blood. As a result, the protein content of lymph has several hours after a meal. Chylomicrons are then cleared about the same content as the interstitial fluid. The from the blood stream by the enzyme lipoprotein lipase. amount of protein returned to the blood by the lym- Short and medium chain triglycerides (MCT) are phatics is about one fourth to one half of the circulat- more easily absorbed than LCT. MCT is primarily ing plasma protein. Chylomicrons are returned to the absorbed directly across the intestinal mucosa and blood stream via the thoracic duct, the final common delivered to the portal vein. As the intake of LCT pathway for all lymphatic flow. Ultimately, it enters increases (and hence luminal concentration of LCT the venous system at the junction of the internal jugu- increases) along with MCT intake, a higher percentage lar and subclavian veins. Two to four liters of chyle are of the MCT will also be absorbed via the lymphatic transported through the thoracic duct each day (10).
circulation. Sources, advantages and disadvantages of Any factor that increases interstitial fluid pressure will MCT will be discussed later in this article. PRACTICAL GASTROENTEROLOGY • MAY 2004
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Table 2
Summaries of Selected Chyle Leak References
Low-fat/MCT diet (n = 2)Immediate surgery (n = 1) oesophagectomy for carcinoma(n = 11)Age/gender not reported alone and 1 with repeated pleural aspirations and MCT diet supplements was further restricted to 5% animal fat with 8 tbsp MCT oil. 2–3% EFA in the form of corn oil added.
Adults with postoperative chylothorax Clear liquids / TPNafter esophagogastrectomies (n = 10;7M/3F)Age: 37–81 yrs Lewis procedure w/ chylothorax(n = 23; 19M/4F)Age: 34–73yrs TPN for 4 days without resolution. Day 12, 200 mL olive oil was given via NGT prior to surgery for ligation.
types used), 45% CHO and 15% protein providing 35 kcal/kg and vitamins/minerals followed for 26 weeks and 10 weeks respectively after which a fat free diet was added.
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Ascites resolved in 3/4 patients (2 responded to One patient on the low-fat/MCT diet died from management include: elemental diet, low fat/MCT diet, or TPN Administration of standard TF resulted in a transient increase in drainage in one patient, however, overall the administration of clear liquids, Calogen &/or TF did not result in a significant increase in wound or drawbacks and attendant costs is unjustified 8 pts were managed conservatively; 3 required develop chylothorax after oesophagectomy and there is no significant difference between the conservative or surgical approach Child treated with MCT oil and diet alive at 10 years Drainage of effusion, a low fat diet w/ MCT Patient needing repeated pleural aspirations expired Doil is helpful in some patients; if fluid loss exceeds 1.5 L/day (adults) or 100mL/day in child for >5–7 days, drainage should be stopped; replace all fluid, protein and electrolytes via IV.
Significant decrease in size of right pleural effusion A fat restricted diet using MCT successfully and further thoracentesis for >24 months decreased chylous effusion over a 24-month Nutritional status remained constant.
5 closed with MCT diet alone; 6 with TPN MCT diet should be tried first; if drain 2 pts ultimately required surgical intervention.
production does not decrease, Peptison TF should be tried; TPN as last resort for ~30 days before surgical intervention.
One patient was successfully treated with a closed “Early reintervention by a repeat thoracotomy” Eight patients underwent ligation of the major thoracic duct; the procedure was successful in 7/8 patients 61% of patients; a daily chylous output of Ratio of chylous flow to body-weight Patients with mean chyle outflow <10 mL/kg did No change in chyle drainage noted even on TPN, Try MCT nasogastric diet, then TPN if leak does not stop; after 3–4 weeks, then reexploration.
During periods of MCT formula with fat free diet, pt Diets containing MCT as the sole fat source, or low fat diets with MCT may be valuable in Patient with chylothorax did not require thoracentesis the clinical management of patients with chyluria, chylothorax and presumably other PRACTICAL GASTROENTEROLOGY • MAY 2004
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NUTRITIONAL MANAGEMENT
Finally, some suggest introducing a high fat meal in patients in whom the chyle leak is believed to be Goals of Therapy
closed, ensuring closure before removal of drainage The primary goals of nutritional management of chyle tubes (13). For patients requiring surgical repair of chyle leaks, several authors recommended 6-8 oz of a 1. Decrease production of chyle fluid in order to mixture of milk and cream or olive oil given to the avoid aggravating the effusion, ascites or chest tube patient a few hours before surgery in order to clearly identify the leak at the time of operation (7,11,14).
2. Replace fluid and electrolytes; and3. Maintain or replete nutritional status and pre- FAT FREE DIET
For patients who are able to take food by mouth, a very Clinical indicators to assess efficacy of nutrition low fat diet may be tried (see Appendix 1). If the mark- therapy might be: a drastic decrease in chest tube ers outlined to guide therapy improve, then this may be drainage; serial x-rays for clinical improvement of an all that is necessary. It is virtually impossible to eliminate effusion or a decrease in the need for serial taps. How- all fat from the diet; many fruits, vegetables and “fat ever, there are no set guidelines for any of these para- free” products contain traces of fat (designated “fat free” meters. The length of time that nutrition therapy is pur- products may have <0.5 g fat per serving (see Table 3). sued varies in the literature from one to 24 weeks. Such a diet may be difficult to maintain, unless the Unfortunately, prospective, randomized, clinical patient is extremely motivated and compliant. Patients trials are not available regarding the treatment of chyle must be carefully instructed on how to eliminate fat from leaks. All reports in the literature are case studies or the diet and to obtain adequate protein from fat free foods small cohorts of patients reporting a particular author’s or supplements. The use of fat free oral supplements therapeutic management. See Table 2 for a summary of (such as Enlive!® or Resource® Fruit Beverage) may be helpful. See Table 4 for a list of fat free protein sources.
In addition to a lack of clinical trials regarding Nutritional status must be monitored closely; fat-soluble treatment of chyle leaks, there are no accurate defini- vitamin and essential fatty acid supplementation, or sup- tions of what constitutes acceptable 24-hour drainage, plemental nutrition support need to be addressed. A ther- or how long conservative therapy should be under- apeutic vitamin and mineral supplement may be neces- taken before surgical intervention is pursued. Options sary to ensure complete nutritional intake.
for treatment include nutrition intervention such as: anessentially fat free diet; fat free diet supplemented with MEDIUM CHAIN TRIGLYCERIDES (MCT)
medium chain triglycerides (MCT); specialized enteralfeeding (fat free, MCT based or very low fat); or total Medium chain triglycerides (MCT) are often recom- parenteral nutrition (TPN). Reinfusion of lost chyle in mended in the treatment of chyle leaks. As discussed those patients with external drains has also been advo- previously, MCT is thought to be absorbed directly cated (12). In patients with an external drain, a clini- across the mucosa into the portal circulation and does cally useful trial to help determine enteral candidates not require transport via the lymph system. However, there is evidence that although much MCT is absorbed 1. An NPO period for 24 hours, determining base- directly into the portal blood system, some MCT may line chyle output before initiating TPN, with addition find its way into the lymphatic system and make up part of the lymph fluid, especially in the setting of high 2. Once chyle output is determined, initiate fat MCT intake. In a 1989 report, Jensen, et al, found that free or very low fat oral or enteral feeding and observe lymph fluid contained a significant amount of medium chain fatty acids (20% of triglyceride fatty acids) when 3. Based on results, continue oral/enteral or move PRACTICAL GASTROENTEROLOGY • MAY 2004
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Table 2 (continued)
Summaries of Selected Chyle Leak References
TPN was added in 1 patientNutrition regimen not described in 5 patients (n = 9)No nutrition therapy prior to surgery (n = 2) authors’ institution and 22 previously low-fat/MCT oral diet reported cases (n = 27; 22M/5F) Adults with thoracic duct fistulas (TDF) Group 1: TPN 2500 kcals; actual amount received not reported fistulas (n = 16)Age & gender not provided Used with permission from the University of Virginia Health System Nutrition Support Traineeship Syllabus (18) PRACTICAL GASTROENTEROLOGY • MAY 2004
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Medium chain fatty acids were found in the chyle Study demonstrated MCT absorption by the triglycerides while on the MCT modular diet, but not preferable substrate in patients with chyleleaks. Patient 1 had no postoperative signs of chylous fistula Patient 2 had 2 further surgical interventions; fistula 3 patients underwent surgery; others managed by Treatment of chylothorax is dependent on All chylous fistulas healed in 2–7 days without further Spontaneous closure of fistulae is better Intraoperative chyle leaks were corrected during In all patients, chyle drainage ceased 10–15 days after mineral mixture, folate and multivitaminproved a satisfactory approach in patientswith chylous fistula Resolution of chylothorax was achieved in all but Conservative therapy should be tried for patients with traumatic chylothorax with 50% of surgically treated group had significant emphasis on nutrition support; failure of Only 3 of 12 pts underwent operative intervention All patients with chyle fistulas should receivemedical management initially including an MCT diet followed by TPN if drainage doesnot significantly decrease.
Chylous drainage continued in all patients during the Initial procedure successful in 10/11 patients following surgery for esophageal obstruction Ascites resolved in all patients in authors’ institution Conservative treatment with bowel rest, TPN and in 20/22 previous reports (mean time to resolution: and then a high protein/low-fat/MCT diet is 63 days) TDF healed in 10/11 patients in TPN group; TDF healed “TPN was more successful for the closure of Duration of treatment significantly shorter in TPN group nutrition” decreasing the need for surgery Neither group showed significant weight loss, but the NG group had a significant decrease in serum protein levels 4 of the patients treated with a low-fat diet and wound Operative intervention should be considered care required no further intervention.
early in patients with fistula drainage of 12 patients required further surgical intervention PRACTICAL GASTROENTEROLOGY • MAY 2004
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Nutrient Content Claims About Fat
Examples of Fat Free Protein Sources*
FDA regulations spell out what terms may be used to describe the level of a nutrient in a food and how they can be used.
High Protein Foods
• Free. This term means that a product contains no amount of, or only trivial or “physiologically inconsequential” amounts of, one or more of these components: fat, saturated fat, cho- lesterol, sodium, sugars, and calories. For example, “calorie- free” means fewer than 5 calories per serving, and “sugar- free” and “fat-free” both mean less than 0.5 g per serving.
Synonyms for “free” include “without,” “no” and “zero.” A synonym for fat-free milk is “skim.” • Low. This term can be used on foods that can be eaten fre- quently without exceeding dietary guidelines for one or more of these components: fat, saturated fat, cholesterol, sodium, and calories. Thus, descriptors are defined as follows: Synonyms for low include “little,” “few,” “low source of,” and Source: U. S. Department of Health and Human Services U. S. Food and Drug Administration, FDA Backgrounder May 1999; http://www.cfsan.fda.gov/~dms/fdnewlab.html (accessed 4/4/04).
Fat Free Oral Liquid Supplements
MCT is available as MCT oil or in specialized oral/enteral supplements and contains 8.3 calories per Nutritional Supplement Protein Powders
gram (1 Tb = 15 mL = 115 kcal). Unfortunately, MCT oil is unpalatable and not generally well accepted by patients. MCT oil also tends to be very expensive, a cost not usually covered by insurance if taken orally.
MCT must be provided in moderation. Too much may cause diarrhea and gastrointestinal distress. Doses of 60–70 grams/day (4–5 tablespoons; ~500–600 calories) spread out throughout the day are generally tolerated.
MCT-containing products contain a high percentage of *Carbohydrate calories may be present in some of these sources MCT, but may also contain LCF as well. Table 5 pro- Used with permission from the University of Virginia Health System vides a summary of selected products containing MCT.
Nutrition Support Traineeship Syllabus (18) Patients following a fat free or diet with MCT oil as the only fat source for any length of time may need to the body and must be received in the diet. Linoleic acid supplement essential fatty acids (EFA) and fat soluble is the primary EFA. Linolenic acid and arachadonic acid vitamins. Essential fatty acid deficiency (EFAD) can are other associated fatty acids that can be produced by begin to occur within as little as five days without provi- the body in the presence of adequate linoleic acid. EFAD sion (16). MCT oil contains negligible, if any, EFA can result in skin lesions, eczema, impaired wound heal- (Mead Johnson’s = 29% C8, 67% C10 and < 4% greater ing, thrombocytopenia, and growth problems. EFA than C10) (http://www.meadjohnson.com/products/ needs can be met by providing approximately 2%–4% of hcp-adult-med/mctoil.html). EFA cannot be produced by PRACTICAL GASTROENTEROLOGY • MAY 2004
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Selected MCT Products*
MCT Oils: Serving size = 2 tablespoons
*This is just a sample of products available on the market Used with permission from the University of Virginia Health System Nutrition Support Traineeship Syllabus (18) total caloric intake (approximately 40–80 kcal) of essen- Fruit Beverage, Enlive!, Boost Breeze—Table 7) com- tial fatty acids per day for a 2000-calorie diet. Linoleic bined with a therapeutic multivitamin/mineral supple- acid is found in vegetable oils, especially those made ment and fat free protein as needed. Although these prod- from safflower, sunflower or corn oil. For EFA content ucts are not meant to be the sole source of nutrition for of selected vegetable oils see Table 6. It may be possible extended periods, they are reasonable to try short-term to replace EFA by topical application of EFA, however, before moving to more expensive enteral formulas or if this is to be continued for a significant length of time, TPN. Simple modifications such as a fat free protein EFA status should be monitored (17).
source and a small amount of safflower oil to meet EFAneeds can be added for short-term use (<2–3 months—nodata to support, but if calories, protein, EFA, vitamins and FAT SOLUBLE VITAMINS (VITAMINS A, D, E, K)
minerals are adequate for this period of time, would not For patients who are unable to take adequate nutrition by expect a nutritional deficiency to add to morbidity).
mouth, enteral nutrition by feeding tube is recom- Although these types of beverages are generally used for mended. Options for enteral feeding formulas include anMCT-based formula, very low fat elemental formula, or Essential Fatty Acid (EFA) Content of Selected
an oral fat free supplement. Table 7 compares several Vegetable Oils (34)
commercial products available. MCT-based formulascontain high levels of MCT and low amounts of LCF.
Very low fat elemental formulas contain low levels of both MCT and LCF. The amount of LCF in these for- mulas allows them to meet essential fatty acid (EFA) needs and fat-soluble vitamin needs. However, LCF in levels higher than needed (2%–4% of total calories) may contribute to increased chyle output. Also, as mentioned previously, high levels of MCT may find their way to the lymph system and contribute to chyle output. Finally, these formulas are often very expensive, although not as expensive or risky as parenteral nutrition.
One inexpensive option that we have found useful in Used with permission from the University of Virginia Health System patients able to take oral nutrition is to use a modified reg- Nutrition Support Traineeship Syllabus (18) imen of fat free liquid nutritional supplement (Resource PRACTICAL GASTROENTEROLOGY • MAY 2004
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Comparison of Very Low Fat Enteral Formulas and Oral Supplements*
Fat Free Oral Supplements**
*Information gathered from manufacturers websites and 800# customer service **Not meant to be sole source of nutrition; will need addition of some nutrients Used with permission from the University of Virginia Health System Nutrition Support Traineeship Syllabus (18) oral supplementation, with some additions, they can also trials are lacking, hence clear guidelines for nutritional be part of a fat free enteral regimen. This regimen pro- management are not available. Treatment and monitor- vides only enough LCF to meet EFA needs. It is also cost ing is empiric in many cases, but the treatment may be effective and easy for patients to obtain. problematic due to expense, palatability, compliance, Total parenteral nutrition (TPN) is sometimes used insurance coverage and unclear endpoints. Presented in the treatment of chyle leaks. Due to the risks and here are options for the clinician to try before resorting complications associated with TPN, including to parenteral nutrition. See Table 8 for a summary of increased infectious complications, gastrointestinal guidelines for patients with chyle leaks.
atrophy, and increased cost, TPN should be reservedfor situations where other options have failed. Par-enteral lipids are phospholipids designed for intra- References
venous infusion. They are delivered directly into the 1. Steward W, Hunter WA, O’Byrne, Snowden J. Chemotherapy blood stream and as a result do not pass through the and haemopoietic stem cell transplantation. In: Intestinal failure.
lymph system as chyle. Therefore, IV lipids are not Nightingale J (ed). Greenwich Medical Media Limited, London,2001:73.
contraindicated in patients with chyle leaks. 2. Kozar R, Cipolla J. Chylothorax. Available online at: http://www.
emedicine.com/med/topic381.htm. Accessed January 30, 2004.
3. de Gier HH, Balm AJM, Bruning PF, et al. Systemic approach to the treatment of chylous leakage after neck dissection. Head & CONCLUSION
4. Gregor RT. Management of chyle fistulization in association with Chyle leaks are infrequent complications seen in the neck dissection. Otolaryngol Head Neck Surg, 2000;122:434- clinical setting. However, because of the direct effect oral or enteral nutrition plays, this complication can be 5. Orringer MB, Bluett M, Deeb M. Aggressive treatment of chy- lothorax complicating transhiatal esophagectomy without thora- challenging for the clinician. Evidenced-based clinical cotomy. Surgery, 1988;104:720-726.
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Summary Guidelines in the Nutritional Management of Chyle Leaks
Adequate protein intake
• Chyle contains significant amounts of protein (22–60 g/L) • Recommendations for protein intake should account for such losses if an external drain is present or with repeated chylous fluid “taps” • Adequate intake may be a challenge for patients on a fat free oral diet Essential fatty acid deficiency (EFAD)
• 2%–4% of total calories from EFA required to avoid EFAD • May occur within 1-3 weeks of a fat free diet • Diagnosis: triene to tetraene ratio of >0.4 &/or physical signs of EFAD (see section on MCT oil for more details) • IV fat emulsion may be required if a patient is unable to tolerate any oral/enteral fat or if it is unwise to try adding oral/enteral fat • MCT oil does not provide significant EFA Fat soluble vitamins
• Fat soluble vitamins are also carried by the lymphatic system • A multivitamin with minerals is generally recommended for patients on a restricted oral or enteral regimen • Water soluble forms of vitamins A, D, E, and K may be better utilized Used with permission from the University of Virginia Health System Nutrition Support Traineeship Syllabus (18) 6. Pabst TS, McIntyre KE, Schilling JD. Hunter GC, Bernhard VM.
support in patients with low volume chylous fistula following Management of chyloperitoneum after abdominal aortic surgery.
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23. Celona-Jacobs N, et al. Improvement of chylous pleural effusion 9. Aalami OO, et al. Chylous ascites: a collective review. Surgery, using a restricted fat diet and medium chain triglycerides in a patient with congenital lymphangiectasia. Nutr Clin Pract, 10. Wengen DF, et al. Complications of radical neck dissection. In: The Neck. Diagnosis and Surgery. Shockley WW, Phillsbury III, 24. Dougenis D, Walker WS, Cameron EWJ, Walbaum PR. Man- agement of chylothorax complicating extensive esophageal resec- 11. Robinson CLN. The management of chylothorax. Ann Thorac tion. Surg Gynecol & Obstet, 1992;174:501-506.
25. Dugue L, et al. Output of chyle as an indicator of treatment for 12. Myers EN, et al. Management of chylous fistulas. Laryngoscope, chylothorax complicating oesophagectomy. Br J Surg, 1998;85: 13. Spain DA, McClave SA. Chylothorax and chylous ascites. In: 26. Hashim SA, et al. Treatment of chyluria and chylothorax with Gottschlich MM, Furhman MP, Hammond KA, Holcomb BJ, medium-chain triglyceride. N Eng J Med, 1964;270(15):756-761.
Seidner DL, eds. The science and practice of nutrition support: a 27. Kassel RN, Havas TE, Gullane PJ. The use of topical tetracycline case-based core curriculum. Dubuque, IA: Kendall/Hunt Pub- in the management of persistent chylous fistulae. J Otolaryngol, 14. Golden P, et al. Chylothorax in blunt trauma: a case report. Am J 28. Kostiainen S, Meurala H, Mattila S, Appelqvist P. Chylothorax, Crit Care, 1999; 8(3): 189-192.
Clinical experience in nine cases. Scand J Thor Cardiovasc Surg, 15. Jensen GL, Mascioli EA, Meyer LP, et al. Dietary modification of chyle composition in chylothorax. Gastroenterology, 1989; 29. Lucente FE, Diktaban T, Lawson W, Biller HF. Chyle fistula management. Otolaryngol Head Neck Surg, 1981;89:575-578.
16. Baumgartner T. Parenteral Macronutrition. In: Baumgartner T 30. Martin IC, et al. Medium chain triglycerides in the management (ed.). Clinical Guide to Parenteral Micronutrition; Fujisawa of chylous fistulae following neck dissection. Br J Maxillofac 17. Miller DG, et al. Cutaneous application of safflower oil in pre- 31. Marts BC, et al. Conservative versus surgical management of venting essential fatty acid deficiency in patients on home par- chylothorax. Am J Surg, 1992;164:532-535. 32. Ramos W, Faintuch J. Nutritional Management of thoracic duct 18. Parrish CR, Krenitsky J, McCray S. University of Virginia Health fistulas. A comparative study of parenteral versus enteral nutri- System Nutrition Support Traineeship Syllabus. Available through the University of Virginia Health System Nutrition Ser- 33. Spiro JD, Spiro RH, Strong EW. The management of chyle fis- vices in January 2003. E-mail Linda Niven at ltn6m@ tula. Laryngoscope, 1990; 100:771-774.
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20. Al-Khayat M, Kenyon GS, Fawcett HV, Powell-Tuck J. Nutrition PRACTICAL GASTROENTEROLOGY • MAY 2004
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Appendix 1
Foods Very Low in Fat (FF = Fat Free)
• Plain fresh, frozen or canned vegetables • Vegetables in butter, cream sauce, cheese • FF bread, FF crackers, FF cold cereals (no nuts), FF rice cakes, FF bagels, FF pasta, rice • FF air popped popcorn, FF potatoes, sweet potatoes, yams • EggBeaters or egg substitute, egg whites • Beans—black, pinto, kidney, white, garbanzo, lentils, • FF dairy products, including: milk, cheese, sour cream, cream cheese, cottage cheese, yogurt, frozen yogurt, ice cream, Dannon FF Light n’ Fit Smoothie, Yoplait Nouriche • Fruit juices/nectars, fruit beverages, Lemonade • Beverages made with low fat or full fat • Chewing gum, hard mints, jelly candy, gummy candy, licorice • FF frozen juice bars / FF Popsicles, sorbet, Italian ice • FF salad dressing, ketchup, barbeque sauce, mustard, soy sauce, hot sauce, FF salsa, relish, syrup • Low fat or regular mayonnaise, regular *Fat content may vary based on product & brand; read labels to confirm the fat content of a specific item.
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