Postesophagectomy chylothorax: incidence, risk factors, and outcomes

Treatment options in patients with chylothorax

BACKGROUND

Chylothorax arises when lymphatic fluid (chyle) accumulates in the pleural cavity because of leakage from lymphatic vessels. It is most commonly seen after thoracic surgery (in 0.5% to 1% of cases) and in association with tumors. No prospective or randomized trials have yet been performed to evaluate the available treatment options.

METHOD

This review is based on a selective search of the PubMed database for pertinent publications from the years 1995 to 2013. Emphasis was laid on articles that enabled a comparative assessment of treatment options.

RESULTS

Initial conservative treatment (e.g., parenteral nutrition or a special diet) succeeds in 20% to 80% of cases. When such treatment fails, the standard approach up to the present has been to treat surgically, e.g., with ligation of the thoracic duct, pleurodesis, or a pleuroperitoneal shunt. The success rates of such procedures have ranged from 25% to 95%. Most of the patients undergoing such procedures are severely ill; complication rates as high as 38% have been reported, with mortality as high as 25%. In more recent publications, however, morbidity and mortality were lower. Interventional radiological treatments, such as percutaneous thoracic duct embolization or the percutaneous destruction of lymphatic vessels, succeed in about 70% of cases and lead to healing in up to 80% of cases, even after unsuccessful surgery. The complication rate of percutaneous methods is roughly 3%.

CONCLUSION

Interventional radiological procedures have now taken their place alongside conservative treatment and surgery in the management of chylothorax, although they are currently available in only a small number of centers.

Chylothorax after esophagectomy for cancer: impact of the surgical approach and neoadjuvant treatment: systematic review and institutional analysis

BACKGROUND

Esophagectomy is a challenging operation with considerable potential for postoperative complications, including chylothorax.

METHODS

Because no randomized controlled trial or metaanalysis is available to clarify the incidence of chylothorax in esophageal cancer surgery, the authors analyzed their own institutional data for 1,856 patients and performed a systematic review using the MEDLINE database (9,794 patients) to identify risk factors, compare success rates of therapeutic approaches, and investigate long-term outcomes.

RESULTS

The overall institutional chylothorax rate was 2 % (n = 39). Reoperation was performed for 69 % of the patients. No significant difference was noted between the transthoracic and transhiatal approaches. Regression analysis showed neoadjuvant treatment (odds ratio [OR], 0.302; p = 0.001) and tumor type (OR, 0.304; p = 0.002) to be independent risk factors. The systematic review included 12 studies. Chylothorax occurred for 2.6 % of the patients. Treatment favored reoperation in five studies (70-100 %) and a conservative approach in four studies (58-72 %), with equal mortality rates. No significant difference was found between the transthoracic and transhiatal approaches.

CONCLUSION

Chylothorax rates are low in high-volume centers (2-3 %). No significant difference was noted between the transthoracic and transhiatal approaches. Neoadjuvant treatment and tumor type were shown to be independent risk factors. Treatment concept (reoperation vs conservative treatment) did not affect long-term survival.

[Management of postoperative complications following esophagectomy]

Complications following esophagectomy significantly affect the outcome, including perioperative mortality, costs and survival. Pulmonary complications and anastomotic leaks still remain the most serious complications and early recognition and appropriate initial treatment are essential. Mortality associated with esophageal leaks is decreasing due in part to the increased use of computed tomography (CT) scanning and endoscopy for diagnosis and subsequent appropriate multidisciplinary therapy. In this respect, it is critically important to differentiate between leaks and conduit necrosis, and endoscopic examination is the best method for making this assessment. Endoscopic and interventional radiology techniques are being applied increasingly for detection of intrathoracic leaks but appropriate patient selection is important. Adequate external drainage of the leak and prevention of further contamination are the primary therapeutic goals. The spectrum of therapeutic options ranges from simple conservative treatment for smaller, well drained leaks, interventional placement of drains, to endoscopic intervention with closure of the fistula or placement of stents and reoperation or discontinuity resection for conduit necrosis.

Chyluria after ligation of the thoracic duct: a rare complication after thoracoscopic-assisted esophagectomy for esophageal cancer

Chyluria is leakage of lymphatic fluid into the urine, following trauma to or obstruction of the lymphatic system. We herein report a rare case of chyluria after esophagectomy for esophageal cancer. A 69-year-old male complaining of epigastric pain and reflux symptoms was diagnosed with advanced esophageal cancer and regional lymph node metastases. After receiving neoadjuvant chemotherapy to control the regional lymph node metastases, the patient underwent transthoracic excision of the esophagus assisted by thoracoscopy, with excision of the azygos vein and thoracic duct, esophagostomy and tube gastrostomy. On postoperative day 22, the urine appeared ivory white in color, and urine tests showed a high triglyceride level, thus confirming the diagnosis of chyluria. The chyluria decreased temporarily after switching the patient from enteral nutrition (EN) to parental nutrition, but it emerged again after the resumption of EN. Lymphangiography at that stage showed the flow of lipiodol into the pelvis of the left kidney. Resolution of the chyluria was noted after lymphangiography. He underwent esophageal reconstruction with a gastric tube through an anterior mediastinal route, and was discharged 36 days after the second operation. He was thereafter followed up at the outpatient clinic with radiotherapy.

Anesthetic management for esophageal resection

Surgical resection remains a standard treatment option for localized esophageal cancer. Surgical approaches to esophagectomy include transhiatal and transthoracic techniques as well as minimally invasive techniques that have been developed to reduce the morbidities associated with laparotomy and thoracotomy incisions. The perioperative mortality for esophagectomy remains high with cardiopulmonary and anastomotic complications as the most frequent and serious morbidities. This article reviews the management of patients presenting for esophagectomy, with a focus on evidence-based anesthetic and perioperative approaches for improving outcomes.