1
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Farrow H, Pickering OJ, Gossage JA, Pucher PH. Impact of thoracic duct resection during radical esophagectomy on oncological and survival outcomes: Systematic review. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:107271. [PMID: 37979459 DOI: 10.1016/j.ejso.2023.107271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 10/14/2023] [Accepted: 11/08/2023] [Indexed: 11/20/2023]
Abstract
Practice is variable in the inclusion or exclusion of the thoracic duct (TD) as part of the resected specimen and associated lymphadenectomy in radical esophagectomy for esophageal cancer. While some surgeons believe that the removal of TD-associated nodes may improve radicality and survival, others suggest this represents systemic disease and resection may increase morbidity without survival benefit. A systematic review was performed up to March 2023 using the search terms 'esoph∗' AND 'thoracic duct' for relevant articles which compared thoracic duct preservation (TDP) to resection (TDR) in esophagectomy for esophageal cancer. Included studies were required to report relevant oncological outcomes including at least one of overall survival (OS), disease free survival (DFS) and nodal yield. Seven cohort studies were included in data synthesis, including data for 5926 patients. None of the reported studies were randomised controlled trials. All studies originated from Japan or South Korea with almost exclusively squamous cell-type cancer. Nodal yield was higher in TDR groups. TDR was equivalent or inferior to TDP with reference to clinical outcomes (length of stay, morbidity, mortality). A single study reported increased OS in the TDR group while the remaining studies reported no significant difference. Overall study quality was moderate to poor. While an increased nodal yield may be associated with TDR, this may also be associated with higher morbidity, and currently available data does not suggest any survival benefit.
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Affiliation(s)
- Harry Farrow
- Department of General Surgery, Queen Alexandra Hospital, University Hospital Portsmouth NHS Trust, Portsmouth, UK
| | - Oliver J Pickering
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - James A Gossage
- Department of Surgery, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
| | - Philip H Pucher
- Department of General Surgery, Queen Alexandra Hospital, University Hospital Portsmouth NHS Trust, Portsmouth, UK; Division of Surgery, Imperial College London, London, UK; Department of Pharmacology and Biosciences, University of Portsmouth, Portsmouth, UK.
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2
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Schafrat PJM, Henckens SPG, Hagens ERC, Eshuis WJ, Gisbertz SS, Laméris W, van Berge Henegouwen MI. Clinical implications of chyle leakage following esophagectomy. Dis Esophagus 2023; 36:doac047. [PMID: 35830862 PMCID: PMC9885733 DOI: 10.1093/dote/doac047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 05/19/2022] [Accepted: 06/14/2022] [Indexed: 02/02/2023]
Abstract
The clinical consequences of chyle leakage following esophagectomy are underexposed. The aim of this study was to investigate the clinical implications of chyle leakage following esophagectomy. This retrospective study of prospectively collected data included patients who underwent transthoracic esophagectomy in 2017-2020. Routinely, the thoracic duct was resected en bloc as part of the mediastinal lymphadenectomy. Chyle leakage was defined as milky drain fluid for which specific treatment was initiated and/or a triglyceride level in drain fluid of ≥1.13 mmol/L, according to the Esophagectomy Complications Consensus Group (ECCG) classification. Primary endpoints were the clinical characteristics of chyle leakage (type, severity and treatment). Secondary endpoints were the impact of chyle leakage on duration of thoracic drainage and hospital stay. Chyle leakage was present in 43/314 patients (14%), of whom 24 (56%) were classified as severity A and 19 (44%) as severity B. All patients were successfully treated with either medium chain triglyceride diet (98%) or total parental nutrition (2%). There were no re-interventions for chyle leakage during initial admission, although one patient needed additional pleural drainage during readmission. Patients with chyle leakage had 3 days longer duration of thoracic drainage (bias corrected accelerated (BCa) 95%CI:0.46-0.76) and 3 days longer hospital stay (BCa 95%CI:0.07-0.36), independently of the presence of other complications. Chyle leakage is a relatively frequent complication following esophagectomy. Postoperative chyle leakage was associated with a significant longer duration of thoracic drainage and hospital admission. Nonsurgical treatment was successful in all patients with chyle leakage.
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Affiliation(s)
- Pascale J M Schafrat
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Meibergdreef 9, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
- Amsterdam UMC, location University of Amsterdam, Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Meibergdreef 9, Amsterdam, The Netherlands
| | - Sofie P G Henckens
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Meibergdreef 9, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
- Amsterdam UMC, location University of Amsterdam, Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Meibergdreef 9, Amsterdam, The Netherlands
| | - Eliza R C Hagens
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Meibergdreef 9, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
- Amsterdam UMC, location University of Amsterdam, Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Meibergdreef 9, Amsterdam, The Netherlands
| | - Wietse J Eshuis
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Meibergdreef 9, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
- Amsterdam UMC, location University of Amsterdam, Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Meibergdreef 9, Amsterdam, The Netherlands
| | - Suzanne S Gisbertz
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Meibergdreef 9, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
- Amsterdam UMC, location University of Amsterdam, Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Meibergdreef 9, Amsterdam, The Netherlands
| | - Wytze Laméris
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Meibergdreef 9, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
- Amsterdam UMC, location University of Amsterdam, Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Meibergdreef 9, Amsterdam, The Netherlands
| | - Mark I van Berge Henegouwen
- Amsterdam UMC, location University of Amsterdam, Department of Surgery, Meibergdreef 9, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, The Netherlands
- Amsterdam UMC, location University of Amsterdam, Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Meibergdreef 9, Amsterdam, The Netherlands
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Filz von Reiterdank ICLJ, Defize IL, de Groot EM, Wedel T, Grimminger PP, Egberts JH, Stein H, Ruurda JP, van Hillegersberg R, Bleys RLAW. The surgical anatomy of a (robot-assisted) minimally invasive transcervical esophagectomy. Dis Esophagus 2022; 36:6758199. [PMID: 36222066 DOI: 10.1093/dote/doac072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 07/26/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Transcervical esophagectomy allows for esophagectomy through transcervical access and bypasses the thoracic cavity, thereby eliminating single lung ventilation. A challenging surgical approach demands thorough understanding of the encountered anatomy. This study aims to provide a comprehensive overview of surgical anatomy encountered during the (robot-assisted) minimally invasive transcervical esophagectomy (RACE and MICE). METHODS To assess the surgical anatomy of the lower neck and mediastinum, MR images were made of a body donor after, which it was sliced at 24-μm intervals with a cryomacrotome. Images were made every 3 slices resulting in 3.200 images of which a digital 3D multiplanar reconstruction was made. For macroscopic verification, microscopic slices were made and stained every 5 mm (Mallory-Cason). Schematic drawings were made of the 3D reconstruction to demonstrate the course of essential anatomical structures in the operation field and identify anatomical landmarks. RESULTS Surgical anatomy 'boxes' of three levels (superior thoracic aperture, upper mediastinum, subcarinal) were created. Four landmarks were identified: (i) the course of the thoracic duct in the mediastinum; (ii) the course of the left recurrent laryngeal nerve; (iii) the crossing of the azygos vein right and dorsal of the esophagus; and (iv) the position of the aortic arch, the pulmonary arteries, and veins. CONCLUSIONS The presented 3D reconstruction of unmanipulated human anatomy and schematic 3D 'boxes' provide a comprehensive overview of the surgical anatomy during the RACE or MICE. Our findings provide a useful tool to aid surgeons in learning the complex anatomy of the mediastinum and the exploration of new surgical approaches such as the RACE or MICE.
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Affiliation(s)
| | - I L Defize
- Department of Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - E M de Groot
- Department of Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - T Wedel
- Institute of Anatomy, Center of Clinical Anatomy, Kurt Semm Center for Minimal Invasive and Robotic Surgery, Kiel University, Kiel, Germany
| | - P P Grimminger
- Department of General, Visceral and Transplant Surgery, University Medical Center of Johannes Gutenberg University, Mainz, Germany
| | - J H Egberts
- Department of Surgery, Jewish Hospital, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - H Stein
- Department of Surgical Applications Engineering, Intuitive Surgical, Sunnyvale CA, USA
| | - J P Ruurda
- Department of Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - R van Hillegersberg
- Department of Surgical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - R L A W Bleys
- Department of Anatomy, University Medical Center Utrecht, Utrecht, The Netherlands
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Olotu O, Uchendu N, Holtrop J, Graham I, Buck J. Traumatic contralateral chylothorax in a patient with penetrating neck injury: a case report. J Surg Case Rep 2021; 2021:rjab031. [PMID: 33777349 PMCID: PMC7984847 DOI: 10.1093/jscr/rjab031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 01/25/2021] [Indexed: 11/13/2022] Open
Abstract
Chylothorax is defined as a collection of chyle within the pleural cavity secondary to injury of the thoracic duct. We describe a rare case of a contralateral chylothorax resulting from a penetrating wound to the left lower anterior neck region. A 37-year-old male presented to the emergency room with a penetrating stab wound of the left neck. Upon clinical exam, the wound measured about 3-4 cm with minimal bleeding and no expanding hematoma or other hard sign of vascular injury. Subsequently, his right chest tube output developed a milky appearance with a total volume of 260 cc over 24 h. The specimen was sent for triglyceride analysis and confirmed diagnosis of chylothorax. He was managed with conservative therapy not requiring surgical intervention. The anatomical variations arising in the thoracic duct warrant the consideration of possible chylothorax in both right and left pleural effusions secondary to penetrating trauma.
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Affiliation(s)
- Olumide Olotu
- St. George's University, School of Medicine, True Blue, Grenada
| | - Nneka Uchendu
- Wayne State University, School of Medicine, Detroit, MI, USA
| | - John Holtrop
- Department of Surgery, Ascension St. John Hospital, Detroit, MI, USA
| | - Isabella Graham
- St. George's University, School of Medicine, True Blue, Grenada
| | - Joseph Buck
- Department of Surgery, Ascension St. John Hospital, Detroit, MI, USA
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5
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The presence of metastatic thoracic duct lymph nodes in Western esophageal cancer patients. Ann Thorac Surg 2021; 113:429-435. [PMID: 33676903 DOI: 10.1016/j.athoracsur.2021.02.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 02/04/2021] [Accepted: 02/22/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND The thoracic lymphadenectomy during an esophagectomy for esophageal cancer includes resection of the thoracic duct (TD) compartment containing the thoracic duct lymph nodes (TDLN). However, the role of TD compartment resection is still a topic of debate since metastatic TDLNs have only been demonstrated in squamous cell carcinomas in Eastern esophageal cancer patients. Therefore, the aim of this study was to assess the presence and metastatic involvement of TDLNs in a Western population, in which adenocarcinoma is the predominant type of esophageal cancer. METHODS From July 2017 to May 2020 all consecutive patients undergoing an open or robot-assisted transthoracic esophagectomy with concurrent lymphadenectomy and resection of the TD compartment in the University Medical Center Utrecht, The Netherlands and the Città della Salute e della Scienza University Hospital in Turin, Italy were included. The TD compartment was resected en bloc and was separated in the operation room by the operating surgeon after which it was macro- and microscopically assessed for (metastatic) TDLNs by the pathologist. RESULTS A total of 117 patients with an adenocarcinoma (73%) or squamous cell carcinoma (27%) of the esophagus were included. In 61 (52%) patients TDLNs were found, containing metastasis in 9 (15%) patients. No major complications related to TD compartment resection were observed. CONCLUSIONS This is the first study to demonstrate the presence of metastatic TDLNs in adenocarcinomas of the esophagus. This result provides a valid argument to routinely extend the thoracic lymphadenectomy with resection of the TD compartment during an esophagectomy for esophageal cancer.
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Lourensz K, Loh D, Burton P. Post-oesophagectomy chyle leak presenting as a pleuro-enteral lymphatic shunt via the gastric conduit. ANZ J Surg 2021; 91:E652-E653. [PMID: 33650750 DOI: 10.1111/ans.16696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 01/27/2021] [Accepted: 02/11/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Kaleb Lourensz
- Department of Surgery, Monash University, Melbourne, Victoria, Australia.,Oesophago-Gastric and Bariatric Unit, Department of General Surgery, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Damien Loh
- Department of Surgery, Monash University, Melbourne, Victoria, Australia.,Oesophago-Gastric and Bariatric Unit, Department of General Surgery, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Paul Burton
- Department of Surgery, Monash University, Melbourne, Victoria, Australia.,Oesophago-Gastric and Bariatric Unit, Department of General Surgery, The Alfred Hospital, Melbourne, Victoria, Australia
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7
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Kingma BF, Read M, van Hillegersberg R, Chao YK, Ruurda JP. A standardized approach for the thoracic dissection in robotic-assisted minimally invasive esophagectomy (RAMIE). Dis Esophagus 2020; 33:6006409. [PMID: 33241307 DOI: 10.1093/dote/doaa066] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 05/12/2020] [Accepted: 05/22/2020] [Indexed: 12/11/2022]
Abstract
Robot-assisted minimally invasive esophagectomy (RAMIE) is increasingly being adopted as the preferred surgical treatment for esophageal cancer, as it is superior to open esophagectomy and a good alternative to conventional minimally invasive esophagectomy. This paper addresses the technical details of the thoracoscopic phase of RAMIE, including the operating room set-up, patient positioning, port placement, and surgical steps.
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Affiliation(s)
- B F Kingma
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - M Read
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.,Department of Surgery, The University of Melbourne (St Vincent's Hospital), Melbourne, Australia
| | - R van Hillegersberg
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Y K Chao
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linko, Chang Gung University, Taoyuan, Taiwan
| | - J P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
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8
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Yang YH, Park SY, Kim DJ. Chyle Leakage after Esophageal Cancer Surgery. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 53:191-199. [PMID: 32793451 PMCID: PMC7409880 DOI: 10.5090/kjtcs.2020.53.4.191] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 05/25/2020] [Indexed: 02/06/2023]
Abstract
Surgeons recommend dissecting lymph nodes in the thorax, abdomen, and neck during surgery for esophageal cancer because of the possibility of metastasis to the lymph nodes in those areas through the lymphatic plexus of the esophageal submucosal layer. Extensive lymph node dissection is essential for accurate staging and is thought to improve survival. However, it can result in several complications, including chyle leakage, which refers to continuous lymphatic fluid leakage and can occur in the thorax, abdomen, and neck. Malnutrition, fluid imbalance, and immune compromise may result from chyle leakage, which can be potentially life-threatening if it persists. Therefore, various treatment methods, including conservative treatment, pharmacological treatment such as octreotide infusion, and interventions such as thoracic duct embolization and surgical thoracic duct ligation, have been applied. In this article, the risk factors, diagnosis, and treatment methods of chyle leakage after esophagectomy are reviewed.
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Affiliation(s)
- Young Ho Yang
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Seong Yong Park
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Dae Joon Kim
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Korea
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9
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Editorial. Ann Anat 2020; 229:151441. [DOI: 10.1016/j.aanat.2019.151441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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10
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van Boxel GI, Kingma BF, Voskens FJ, Ruurda JP, van Hillegersberg R. Robotic-assisted minimally invasive esophagectomy: past, present and future. J Thorac Dis 2020; 12:54-62. [PMID: 32190354 DOI: 10.21037/jtd.2019.06.75] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Esophagectomy for cancer of the esophagus is increasingly performed using minimally invasive techniques. After the introduction of minimally invasive esophagectomy (MIE) in the early 1990's, robotic-assisted techniques followed after the turn of the millennium. The advent of robotic platforms has allowed the development of robotic-assisted minimally invasive esophagectomy (RAMIE) over the past 15 years. Although recent trials have shown superior peri-operative morbidity and quality of life compared to open esophagectomy, no randomized trials have compared RAMIE to conventional MIE. This paper summarizes the current literature on RAMIE and provides an overview of expected future developments in robotic surgery.
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Affiliation(s)
- Gijsbert I van Boxel
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - B Feike Kingma
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Frank J Voskens
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Jelle P Ruurda
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
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Schurink B, Mazza E, Ruurda JP, Roeling TA, Steenhagen E, Bleys RL, van Hillegersberg R. Low-Fat Tube Feeding After Esophagectomy Is Associated With a Lower Incidence of Chylothorax. Ann Thorac Surg 2019; 108:184-189. [DOI: 10.1016/j.athoracsur.2019.02.056] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 01/30/2019] [Accepted: 02/20/2019] [Indexed: 12/22/2022]
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12
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Affiliation(s)
- Sufeng Chen
- Departments of Thoracic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200333, China.,Department of Oncology, Shanghai Medical College of Fudan University, Shanghai 200333, China
| | - Yue Zhao
- Departments of Thoracic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200333, China.,Department of Oncology, Shanghai Medical College of Fudan University, Shanghai 200333, China
| | - Haiquan Chen
- Departments of Thoracic Surgery, Fudan University Shanghai Cancer Center, Shanghai 200333, China.,Department of Oncology, Shanghai Medical College of Fudan University, Shanghai 200333, China
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