chylous leakage can result from damage to the thoracic duct or its branches after surgical procedures of various types , such as neck or thoracic surgery . although the majority of chylous leakage cases after breast surgery are managed conservatively , we chose to do a re - operation because of the presence of a high chyle output . herein , we reported our experience of a case of chylous leakage after axillary lymph node dissection , that was treated surgically . a 38-year - old woman with invasive ductal carcinoma in the left breast underwent a modified radical mastectomy . the surgical procedure was uneventful and two suction drains were left at the mastectomy site and axilla , in a routine manner . analysis of the fluid was compatible with chyle ( milky color , protein , 3,400 mg / dl ; triglycerides , 784 mg / dl ; total cholesterol , 61 mg / dl ; and lymphocyte dominance ) . initially , we tried conservative management with closed suction drainage , a compressive bandage , and limitation of oral intake ; however , the daily output of the drain increased to 700 ml by the seventh postoperative day . therefore , we re - explored the axilla and observed that the clear fluid was running from a single duct located just below the lateral pectoral bundle branch ( figure 1 ) . we ligated the duct and reinforced the suspicious site 3 - 4 cm below the duct using a mass ligature . after the re - exploration , the daily output of the drain decreased to 80 ml , although it remained slightly milky in nature . the pathology report confirmed a 1.5-cm , poorly differentiated invasive ductal carcinoma and one metastatic lymph node of 15 lymph nodes evaluated . chylous leakage seldom occurs after axillary surgery because the axilla is anatomically remote from the thoracic duct . the reported incidence of chylous leakage after neck surgery is 1 - 3% and its incidence after surgery for breast cancer is ~0.5% . to prevent and control this complication , it is important to determine the location of the chyle leakage . the anatomy of the thoracic duct is well documented and there are numerous variations in the pattern and site of the thoracic duct in the venous system . 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 . a rare anatomical variation of the lymphatic trunk , posteroinferior to the axillary vein , 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 . nakajima et al .   reported that they did not find any characteristic risk factors after analysis of four cases , although others mentioned previously the effects of wound seroma or obesity . the initial management of chylous leakage should be conservative , including adequate drainage , diet control , and treatment with intravenous octreotide and oral injection of tetracycline hydrochloride . however , some authors advocate that timely or early re - exploration should be used to manage chylous fistulas , considering the prolongation of the hospital stay and morbidity . it is considered when pleural drainage is greater than 1 l per day for more than 5 days in cases of chylothorax or with continuous drainage over 500 - 600 ml per day without improvement . however , an early surgical approach can easily be considered in breast surgery because the risk associated 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 . awareness of this unusual complication after breast surgery should make it possible to avoid or recognize the injury to the thoracic duct during surgery . thus , we suggest an even more careful dissection 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 .
chylous leakage is an extremely rare complication of surgery for breast cancer . 
 we experienced a case of chylous leakage after axillary lymph node dissection . a 38-year - old woman with 
 invasive ductal carcinoma in the left breast underwent a modified radical mastectomy after four cycles of neoadjuvant chemotherapy . 
 the postoperative serosanguinous drainage fluid became " milky " on the fourth postoperative day . after trying conservative management , 
 we re - explored the axilla and ligated the lymphatic trunk . 
 although the success of many cases supports conservative management , timely surgical intervention represents an alternative in cases where leakage persists or where the output is high .