Incidence and management of chyle leakage after esophagectomy

The Near-Infrared Visualization and Preemptive Ligation of the Thoracic Duct Effectively Reduce the Chyle Leak Incidence After Minimally Invasive Esophagectomy

OBJECTIVE

The aim of the present study is to assess the effectiveness of indocyanine-green (ICG)-guided lymphography (ICG-Lg) in reducing the incidence of chyle leak (CL) after esophagectomy.

BACKGROUND

Chylothorax may severely impact esophageal cancer surgery, and the pre-emptive ligation of the thoracic duct (TD) is the most widespread control of this complication. Intraoperative ICG-Lg has been recently embedded in minimally invasive esophagectomy to facilitate TD detection and pre-emptive ligation.

METHODS

This retrospective analysis included consecutive patients who underwent minimally invasive Ivor Lewis esophagectomy for cancer at a tertiary referral center between January 2018 and August 2023. Patients were routinely submitted to extended lymphadenectomy with TD ligation and removal. All patients treated after January 2021 underwent ICG-Lg for TD identification and ligation (ICG group) and compared with the previous series (no-ICG group). The primary outcome was the incidence of postoperative CL, while univariate and backward stepwise multivariate logistic regression models were performed to identify associated factors.

RESULTS

After including 320 patients, 151 (ICG group) were submitted to ICG-Lg before the pre-emptive TD ligation. Both groups presented similar characteristics, except for neoadjuvant therapy ( P <0.001) and preoperative comorbidities ( P =0.045). Intraoperative ICG-Lg significantly reduced the incidence of postoperative CL (11.8% vs 4.6%, P =0.026) and was significantly associated with shorter median length of hospital stay (13 vs 9 d, P =0.006). However, CL after ICG-Lg was more likely to require repairing reoperation ( P =0.050).

CONCLUSIONS

Intraoperative ICG-Lg demonstrated significantly lower rates of CL after total minimally invasive esophagectomy and, therefore, it should be routinely embedded in the standardized surgical technique of high-volume centers for esophageal cancer.

Risk Factors and Treatment of Chylothorax After Minimally Invasive Esophagectomy for Esophageal Cancer

Background Postoperative chylothorax is a rare but life-threatening complication of esophagectomy. However, due to its rarity, researching the risk factors and selecting appropriate treatment options has been limited. Methods This study included 727 patients with esophageal cancer who underwent minimally invasive esophagectomy at our hospital. To detect the risk factors for chylothorax, we divided the patients into two groups, with and without postoperative chylothorax. We then compared patient characteristics, tumor-specific variables, and operative details. Subsequently, we analyzed the peri-treatment characteristics and outcomes for the three distinct treatment options we had chosen: surgery, conversion (the group that finally underwent surgery after unsuccessful conservative treatment), and conservative. Results Of the 727 patients, 18 (2.5%) developed a chylothorax. The mean BMI was lower (20.3 vs. 21.9, p=0.057), and more cases of thoracic duct resection were found in the chylothorax group (33.3% vs. 6.2%, p=0.001), with statistical significance. Multivariate analysis identified thoracic duct resection as a risk factor (adjusted odds ratio, 6.83). The drainage volume two days after chylothorax was higher in the surgery group, although the difference was not statistically significant (surgery group, 1,405 ml vs. conversion group, 260 ml vs. conservative group, 310 ml; p=0.073). The surgery group had the shortest median postoperative hospital days among these groups (21.5 as compared to 102 and 25.0 days in the conversion and conservative groups, respectively; p<0.001). None of the patients died during their hospital stays. Conclusion Thoracic duct resection during the initial minimally invasive esophagectomy was an independent risk factor for chylothorax. If drainage volume does not decrease on the second day, early surgery may lead to earlier discharge.

Octreotide's role in the management of post-esophagectomy chylothorax

The use of octreotide in managing intrathoracic chyle leak following esophagectomy has gained popularity in the adult population. While the benefits of octreotide have been confirmed in the pediatric population, there remains limited evidence to support its use in the adults post-esophagectomy. Thus, we performed a single-institution cohort study to characterize its efficacy. The study was performed using a prospective, single-center database, from which clinicopathologic characteristics were extracted of patients who had post-esophagectomy chyle leaks. Kaplan-Meier and multivariable Cox regression analyses were performed to investigate the effect of octreotide use on chest tube duration (CTD), hospital length of stay (LOS), and overall survival (OS). In our cohort, 74 patients met inclusion criteria, among whom 27 (36.5%) received octreotide. Kaplan-Meier revealed no significant effect of octreotide on CTD (P = 0.890), LOS (P = 0.740), or OS (P = 0.570). Multivariable Cox regression analyses further corroborated that octreotide had no effect on CTD (HR = 0.62, 95% confidence interval [CI]: 0.32-1.20, P = 0.155), LOS (HR = 0.64, CI: 0.34-1.21, P = 0.168), or OS (1.08, CI: 0.53-2.19, P = 0.833). Octreotide use in adult patients with chyle leak following esophagectomy lacks evidence of association with meaningful clinical outcomes. Level 1 evidence is needed prior to further consideration in this population.

Outcomes of Chylothorax Nonoperative Management After Cardiothoracic Surgery: A Systematic Review and Meta-Analysis

INTRODUCTION

Chylothorax after thoracic surgery is a severe complication with high morbidity and mortality rate of 0.10 (95% confidence interval [CI] 0.06 - 0.02). There is no agreement on whether nonoperative treatment or early reoperation should be the initial intervention. This systematic review and meta-analysis aimed to evaluate the outcomes of the conservative approach to treat chyle leakage after cardiothoracic surgeries.

METHODS

A systematic review was conducted in PubMed®, Embase, Cochrane Library Central, and LILACS (Biblioteca Virtual em Saúde) databases; a manual search of references was also done. The inclusion criteria were patients who underwent cardiothoracic surgery, patients who received any nonoperative treatment (e.g., total parenteral nutrition, low-fat diet, medium chain triglycerides), and studies that evaluated chylothorax resolution, length of hospital stay, postoperative complications, infection, morbidity, and mortality.

CENTRAL MESSAGE

Nonoperative treatment for chylothorax after cardiothoracic procedures has significant hospital stay, morbidity, mortality, and reoperation rates.

RESULTS

Twenty-two articles were selected. Pulmonary complications, infections, and arrhythmia were the most common complications after surgical procedures. The incidence of chylothorax in cardiothoracic surgery was 1.8% (95% CI 1.7 - 2%). The mean time of maintenance of the chest tube was 16.08 days (95% CI 12.54 - 19.63), and the length of hospital stay was 23.74 days (95% CI 16.08 - 31.42) in patients with chylothorax receiving nonoperative treatment. Among patients that received conservative treatment, the morbidity event was 0.40 (95% CI 0.23 - 0.59), and reoperation rate was 0.37 (95% CI 0.27 - 0.49). Mortality rate was 0.10 (95% CI 0.06 - 0.02).

CONCLUSION

Nonoperative treatment for chylothorax after cardiothoracic procedures has significant hospital stay, morbidity, mortality, and reoperation rates.

Pre-operative oil ingestion reduces the probability of thoracic duct trunk ligation during esophagectomy

Chylothorax is an important complication after esophagectomy. Ligation of the injured thoracic duct is the main method to prevent chylothorax after esophagectomy, but may be associated with adverse effects. Whether ligation of the injured tributary alone, keeping the main trunk intact, may suffice to prevent post-operative chylothorax is not well known. Since March 2017, 40 mL of olive oil was administered to patients posted for esophagectomy. We compared patients admitted between March 2017 and December 2019 with patients admitted between July 2014 and February 2017, who had not received pre-operative oil. The outcome measures were the need for thoracic duct main trunk or tributary ligation, development of chylothorax and missed ligation. There were 371 patients in the oil ingestion group and 308 patients in the standard control group. Chylothorax in the oil ingestion group was significantly lower than that in the standard control group (1.3% vs. 4.5%, P = 0.012). Chyle leak from thoracic duct tributaries was diagnosed in a significantly higher percentage (5.7% vs. 0.0%, P < 0.001) and missed ligation of the injured thoracic duct was significantly lower (0.3% vs. 3.9%, P = 0.002) in the oil ingestion group compared with the standard control group. The incidence of post-operative chylothorax was not statistically different (6.3% vs. 10.0%, P = 1.000) between the tributary and the trunk ligation group. Pre-operative oil ingestion can help visualize the thoracic duct trunk and its tributaries during esophagectomy. Thus, non-selected thoracic duct trunk ligation and missed ligation during esophagectomy can be reduced. Precise ligation of the injured tributary while the main trunk is intact can also prevent post-operative chylothorax.

Chylothorax and chylous ascites: Overview, management, and nutrition

Chyle leaks of any source or type can cause significant morbidity and mortality. Attention to the anatomy and physiology of the leak, followed by stepwise dietary and pharmacologic management, obviates the need for surgical intervention in a majority of patients. In this article, we review the importance, etiology, anatomy, diagnosis, nutrition and immunologic effects, and options for treatment of chylothorax and chylous ascites based on experience and prior literature. We propose a multidisciplinary approach to optimize these treatments including the primary surgical teams, pharmacists, and dietitians, with reoperation as a last resort to minimize the morbidity of this challenging complication.

Clinical implications of chyle leakage following esophagectomy

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.

Transhiatal bilateral thoracic duct ligation for duplicated thoracic duct injury after esophagectomy: a case report

Background

The treatment of duplicated thoracic ducts (TDs) injury after esophagectomy generally requires a bilateral transthoracic approach. We present the cases of two patients with postoperative chylothorax who underwent transhiatal bilateral TD ligation for duplicated TDs.

Case presentation

Two patients diagnosed with chylothorax after esophagectomy performed for thoracic esophageal cancer underwent transhiatal TD ligation. Although supradiaphragmatic mass ligation was performed on the fat tissue of the right side of the aorta containing the TD, chyle leakage persisted. To tackle this, the fat tissue of the left side of the aorta was ligated, after which the chyle leakage stopped.

Conclusion

Compared to the conventional transthoracic approach, the transhiatal approach enables the ligation of both left- and right-sided TD in a single surgical operation, without the need to change the patient’s posture. This approach may be appropriate for the treatment of chylothorax after esophagectomy, considering the possibility of duplicated TDs.

Risk Factors, Diagnosis and Management of Chyle Leak Following Esophagectomy for Cancers

This Delphi exercise aimed to gather consensus surrounding risk factors, diagnosis, and management of chyle leaks after esophagectomy and to develop recommendations for clinical practice.

Treatment of Refractory Chylous Ascites with an Innovative Peritoneovenous Shunt: Temporary Usage of a Continuous Renal Replacement System: A Case Report

Esophagectomy and esophageal reconstruction are commonly chosen as surgical options for esophageal cancer. However, prolonged untreated chyle leakage is associated with a poor prognosis. We report the case of a patient with refractory chylous ascites. To limit the ongoing fluid loss, we utilized the chylous ascites as an additional fluid source in a renal replacement therapy system. A continuous renal replacement therapy (CRRT) drainage system was modified to drain both the chylous ascites and venous blood. The ascites drainage rate was determined empirically and regulated by a dial-flow extension set. The CRRT mode was set to continuous venovenous hemodiafiltration and maintained for 7 days. After the patient was weaned from CRRT, ascites did not reaccumulate, and the patient's general condition improved dramatically. No infections related to the system occurred. This procedure temporarily alleviates symptoms and provides more time for alternative treatment strategies.

Surgical outcomes after totally minimally invasive Ivor Lewis esophagectomy. A systematic review and meta-analysis

BACKGROUND

A transthoracic esophagectomy is associated with high rates of morbidity. Minimally invasive esophagectomy has emerged to decrease such morbidity. The aim of this study was to accurately determine surgical outcomes after totally minimally invasive Ivor-Lewis Esophagectomy (TMIE).

METHODS

A systematic literature search was performed to identify original articles analyzing patients who underwent TMIE. Main outcomes included overall morbidity, major morbidity, pneumonia, arrhythmia, anastomotic leak, chyle leak, and mortality. A meta-analysis was conducted to estimate the overall weighted proportion and its 95% confidence interval (CI) for each analyzed outcome.

RESULTS

A total of 5619 patients were included for analysis; 4781 (85.1%) underwent a laparoscopic/thoracoscopic esophagectomy and 838 (14.9%) a robotic-assisted esophagectomy. Mean age of patients was 63.5 (55-67) years and 75.8% were male. Overall morbidity and major morbidity rates were 39% (95% CI, 33%-45%) and 20% (95% CI, 13%-28%), respectively. Postoperative pneumonia and arrhythmia rates were 10% (95% CI, 8%-13%) and 12% (95% CI, 8%-17%), respectively. Anastomotic leak rate across studies was 8% (95% CI, 6%-10%). Chyle leak rate was 3% (95% CI, 2%-5%). Mortality rate was 2% (95% CI, 2%-2%). Median ICU stay and length of hospital stay were 2 (1-4) and 11.2 (7-20) days, respectively.

CONCLUSIONS

Totally minimally invasive Ivor-Lewis esophagectomy is a challenging procedure with high morbidity rates. Strategies to enhance postoperative outcomes after this operation are still needed.

Management of chyle leaks following esophageal resection: a systematic review

BACKGROUND

Chyle leakage is an uncommon but potentially life-threatening complication following esophageal resections. The optimal management strategy is not clear, with a limited evidence base.

METHODS

Searches were conducted up to 31 December 2020 on MEDLINE, Embase, and Web of Science for randomized trials or retrospective studies that evaluated the management of chyle leakage following esophageal resection. Two authors independently screened studies, extracted data, and assessed for bias. The protocol was prospectively registered on PROSPERO (CRD: 42021224895) and reported in accordance with preferred reporting items for systematic reviews and meta-analyses guidelines.

RESULTS

A total of 530 citations were reviewed. Twenty-five studies, totaling 1016 patients met the inclusion criteria, including two low-quality clinical trials and 23 retrospective case series. Heterogeneity of study design and outcomes prevented meta-analysis. The overall incidence of chyle leak/fistula was 3.2%. Eighteen studies describe management of chyle leaks conservatively, 17 by surgical ligation of the thoracic duct, 5 by pleurodesis, and 6 described percutaneous lymphangiography with thoracic duct embolization or disruption.

CONCLUSIONS

The evidence base for optimal management of chyle leakage postesophagectomy is lacking, which may be related to its low incidence. There is a paucity of high-quality prospective studies directly comparing treatment modalities, but there is some low-certainty evidence that percutaneous approaches have reduced morbidity but lower efficacy compared with surgery. Further high-quality, prospective studies that compare interventions at different levels of severity are needed to determine the optimal approach to treatment.

Management of chyle leakage after general thoracic surgery: Impact of thoracic duct embolization

Background

The aim of this study was to investigate the impact of thoracic duct embolization (TDE) on the management of postoperative chyle leakage.

Methods

We retrospectively reviewed the electronic medical record database of 4171 patients who underwent curative resection for lung or esophageal cancer between January 2015 and June 2017. We classified the period before the introduction of TDE as the first period and the period after the introduction of TDE as the second period.

Results

A total of 105 patients who developed chyle leakage after surgery were included. In the first period, 49 patients who underwent lung surgery developed chylothorax. Of those, two patients (4.1%) underwent surgical ligation of the thoracic duct (TD). Of eight patients with chyle leakage after esophagectomy, four patients (50%) underwent TD ligation. In the second period, 30 patients developed postoperative chyle leakage after pulmonary resection. Only one (3.3%) of them required surgical ligation. Of eight patients with chyle leakage after esophagectomy, only two (11.1%) patients underwent TD ligation. Five patients (16.7%) received TDE after lung surgery and five patients (27.7%) after esophageal surgery. Also, in the second period, the hospital stay of patients who underwent lung cancer surgery was shorter than the first period (12.6 ± 4.6 days vs. 16.3 ± 9.7 days; p = 0.026).

Conclusions

TDE is an effective method for the management of chyle leakage and might help to avoid invasive surgery.

Risk of chyle leak after robotic versus video-assisted thoracoscopic esophagectomy

BACKGROUND

We investigate the incidence and risk factors for post-operative outcomes including chyle leak following minimally invasive esophagectomy (MIE).

METHODS

Patients undergoing MIE from May 2016 until August 2020 were prospectively followed. Outcomes of robotic and video-assisted thoracoscopic surgery (VATS) esophagectomy were analyzed.

RESULTS

347 esophagectomies were performed: 70 cases were done robotically by 2 surgeons and 277 by VATS by 14 surgeons. Patients had similar demographics, surgical technique, length of stay (LOS), and re-operation rates. Overall complication rates between robotic and VATS MIE were statistically similar (61% vs. 50%; p = 0.082). The majority of complications for either VATS (41.5%) or robotic-assisted minimally invasive esophagectomy (RAMIE) (51.4%) were grade II. Nineteen patients developed a chyle leak. Patients with a chyle leak were similar in age, gender, and hospital LOS (all p > 0.05), but were more likely to undergo a three-hole or robotic esophagectomy (both p < 0.05) as well as have higher rehabilitation requirements on discharge (26% vs. 10%; p = 0.05). Among the two surgeons who each performed > 20 robotic esophagectomies (n = 70), nine chyle leaks occurred. Rates varied by surgeon (7 vs. 2; p = 0.003). Lower leak rates occurred in the surgeon with more robotic esophagectomy experience (n = 47 vs. 23). Patients were similar in age, and gender (p > 0.05), but those with a chyle leak were more likely to undergo three-hole esophagectomies, prophylactic thoracic duction ligations, undergo the abdominal portion via laparotomy, and not have a prophylactic omental flap (all p < 0.05).

CONCLUSION

Robotic and VATS esophagectomy have similar rates of re-operation, length of stay, discharge needs and complications. Differences in outcomes between VATS and Robotic esophagectomy appears to be related to surgeon experience with the robot but may also be associated with techniques such as anastomotic height, omental flap utilization and performance of laparoscopy.

Prolonged iatrogenic thoracic duct chylous fistula in Neck Surgery: conservative management or surgery? A Literature review

BACKGROUND

Thoracic duct chylous fistula is a rare complication following neck surgery, especially for malignant disease. Despite its low incidence, it can be a life-threatening postoperative complication increasing the risk of infection, bleeding, hypovolemia, electrolyte imbalance, and malnutrition. Currently, the management of thoracic duct fistula is not standardized yet. It can range from conservative to surgical approaches, and even when surgery indication occurs, there is no unanimous agreement on timing and operative steps, so the surgical approach still remains mostly subjective, in accordance with clinical conditions of the patients and with surgeon's experience.

AIMS

The aim of the study was to search into Literature a common accepted behaviour in thoracic duct chylous fistula occurring.

METHODS

A literature review was carried out. Conservative treatments include fasting associated with total parental nutrition or low-fat diet, compressive dressings, and octreotide administration. If conservative treatment fails, in order to avoid dangerous consequences, functional repair of the thoracic duct injury with lymphovenous microanastomosis should be the preferred solution, rather than an approach that obliterates the thoracic duct or lymphatic-chylous pathways, such as thoracic duct embolization, therapeutic lymphangiography, and thoracic duct ligation.

CONCLUSIONS

In our experience, patients undergone thyroidectomy and neck dissection for thyroid-differentiated cancer, who report an unrecognized thoracic duct chylous fistula after surgery, must be treated via integrated conservative and surgical treatment. A literature review about thoracic duct chylous fistula following neck surgery, focusing on the current management and therapeutic approach, was furthermore carried out, in order to delineate the actual therapeutic options in case of thoracic duct chylous fistula occurrence.

Chyle Leak Following Radical En Bloc Esophagectomy with Two-Field Nodal Dissection: Predisposing Factors, Management, and Outcomes

BACKGROUND

Chyle leak is an uncommon complication following esophagectomy, accounting for significant morbidity and mortality; however, the optimal treatment for the chylothorax is still controversial.

OBJECTIVE

The aim of this study was to evaluate the incidence, management, and outcomes of chyle leaks within a specialist esophagogastric cancer center.

METHODS

Consecutive patients undergoing esophagectomy for esophageal cancers (adenocarcinoma or squamous cell carcinoma) between 1997 and 2017 at the Northern Oesophagogastric Unit were included from a contemporaneously maintained database. Primary outcome was overall survival, while secondary outcomes were overall complications, anastomotic leaks, and pulmonary complications.

RESULTS

During the study period, 992 patients underwent esophagectomy for esophageal cancers, and 5% (n = 50) of them developed chyle leaks. There was no significant difference in survival in patients who developed a chyle leak compared with those who did not (median: 40 vs. 45 months; p = 0.60). Patients developing chyle leaks had a significantly longer length of stay in critical care (median: 4 vs. 2 days; p = 0.002), but no difference in total length of hospital stay.

CONCLUSION

Chyle leak remains a complication following esophagectomy, with limited understanding on its pathophysiology in postoperative recovery. However, these data indicate chyle leak does not have a long-term impact on patients and does not affect long-term survival.

Embolization or disruption of thoracic duct and cisterna chyli leaks post oesophageal cancer surgery should be first line management for ECCG-defined type III chyle fistulae

Chyle leakage from the thoracic duct or cisterna chyli is a relatively rare complication of oesophageal cancer surgery. The majority of cases settle with conservative measures, but high volume leaks may be refractory and result in significant morbidity and require intervention with reoperation or embolization. In the experience of this high-volume centre over the last decade, 3 (0.5%) patients required reoperation and ligation of the thoracic duct; for the so-called type III leaks, interventional radiological approaches were not considered. This article is built around two recent cases, where interventional radiology to embolize and disrupt complex fistulae was successfully performed. The lessons from this experience will change practice at this centre to initial lymphangiography with a view to embolization or disruption of thoracic duct and cisterna chyli leaks as first line therapy for type III chyle leaks, with surgery reserved for where this fails.

The treatments and postoperative complications of esophageal cancer: a review

Abstract

Esophageal cancer is still one of the most common cancers in the world. We review the appropriate treatments at different stages of esophageal cancer and also analyze the advantages and disadvantages of these treatments. The prognosis and recovery of different treatment regimens are further discussed. In particular, post-operative complications are the major causes of high mortality derived from the esophageal cancer. Therefore, we particularly discuss the main complications resulting in high mortality after surgery of esophageal cancer, and summarize their risk factors and treatment options.

Background

As the common cancer, the complications of esophageal cancer after surgery have been not obtained systematic treatment strategy, focusing on treatment regimens based on the different stages of esophageal cancers.

Methods and overview

This paper systematically summarizes the appropriate treatment strategies for different stages of esophageal cancers, and their advantages and disadvantages. We particularly focus on the postoperative survival rate of patients and postoperative complications, and discuss the causes of high mortality risk factors after surgery. The risk factors of death and corresponding treatment methods are further summarized in this study.

Conclusion

Postoperative complications is the main cause responsible for the hard cure of esophageal cancers. The existing literatures indicate that postoperative anastomotic fistula is one of the most important complications leading to death, while it has not received much attention yet. We suggest that anastomotic fistula should be detected and dealt with early by summarizing these literatures. It is, therefore, necessary to develop a set of methods to predict or check anastomotic fistula in advance.

Management of Complications After Esophagectomy

Esophagectomy is a complex operation with many potential complications. Early recognition of postoperative complications allows for the best chance for patient survival. Diagnosis and management of conduit complications, including leak, necrosis, and conduit-airway fistulae, are reviewed. Other common complications, such as chylothorax and recurrent laryngeal nerve injury, also are discussed.

Evaluating the Surgeon's Experience as a Risk Factor for Post-Esophagectomy Chylothorax on a Four-Year Cohort

Background: Chylothorax (CHT) is a known post-operative complication after esophageal surgery with vaguely defined risk factors.

Methods: This is a retrospective chart review of 70 consecutive patients with operable cancer over a period of four years (January 2013 to December 2016). Ivor Lewis and McKeown interventions were performed. Thoracic duct is identified and ligated routinely. Factors related to the patient, the tumor, and the operating surgeon were analyzed.

Results: Incidence of CHT was 10%. Surgeons with less than five years of esophageal surgery experience had the most CHT, 71% (p=0.001). No association was found between tumor location, type, body mass index (BMI), neoadjuvant therapy, response to neoadjuvant therapy or male sex, and CHT. The odds of developing CHT were 17 times higher in patients operated by a junior surgeon (odds ratio, OR=17.67, confidence interval, CI 2.68-116.34, p=0.003). Four patients (5.7%) had anastomotic leaks, none of them had CHT. Senior surgeons had less operative time and harvested more lymph nodes (p=0.0002 and p=0.1086 respectively).

Conclusion: Surgeon’s experience might be considered a major risk factor to develop CHT. This finding needs to be confirmed by a larger multicentric series taking into consideration the human factor.

Intranodal lymphangiography for chyle leakage after esophagectomy: A case report

Postoperative chylothorax after esophagectomy is a relatively rare complication, but treatment can sometimes be complicated. We report 3 cases of Lipiodol lymphangiography via inguinal lymph node puncture that was effective for chyle leakage occurring after esophagectomy. Case 1: A 67-year-old man with stage IIIA esophageal squamous cell carcinoma underwent radical esophagectomy by video-assisted thoracic surgery (VATS) following neoadjuvant chemotherapy (NAC). After enteral feeding, right pleural effusion drainage increased sharply and changed to white color that was diagnosed as chylothorax. Conservative treatment was started on postoperative day (POD) 15. On POD 50, intranodal Lipiodol lymphangiography and thoracic duct ligation were performed, resulting in complete improvement by the next day. Case 2: A 69-year-old man with stage IIIC esophageal cancer was treated salvage operation following chemoradiation. Postoperative chylothorax was diagnosed on POD 6. Despite conservative treatment, the pleural fluid volume did not decrease. Intranodal Lipiodol lymphangiography performed on POD 13 showed contrast medium draining from the thoracic duct near the tracheal bifurcation. Thoracotomy for thoracic duct ligation was performed on POD 15. Thereafter, drainage from the thoracic drain decreased significantly, and the right thoracic drain was removed 4 days later. Case 3: A 65-year-old man with Stage IVA hypopharyngeal cancer and Stage IIIA esophageal cancer underwent total pharyngopharyngeal esophagectomy by VATS following NAC. Postoperative chylothorax was diagnosed on POD 7. Despite conservative treatment, the pleural fluid volume did not decrease. Intranodal Lipiodol lymphangiography performed on POD 19 completely visualized the thoracic duct and showed no outflow of contrast from the main thoracic duct into the mediastinum. Pleural fluid decreased remarkably after lymphangiography. Intranodal Lipiodol lymphangiography for postoperative chylothorax accurately visualizes flow within the thoracic duct and clearly depicts its positional relationship with other organs. Besides lymphangiography is not only helps to determine the site of chyle leakage but can also be effective for curing chylothorax by less invasive and safer method.

Modified Blood Patch Used to Treat a High Output Chyle Leak After McKeown Esophagectomy

Chyle leaks after esophagectomy are associated with significant morbidity and mortality. High-output fistulas are particularly difficult to manage, as the likelihood of spontaneous closure with conservative management is low. Leaks that fail to resolve with conservative management are referred for thoracic duct ligation or embolization. Some patients, however, are not candidates for these procedures or have persistent output despite intervention. We report a case of a post-McKeown esophagectomy patient with a high-output chyle leak despite intraoperative thoracic duct ligation. Treatment was successful with a modified blood patch through a neck drain.

Clinical approach and review of causes of a chylothorax

A chylothorax, also known as chylous pleural effusion, is an uncommon cause of pleural effusion with a wide differential diagnosis characterized by the accumulation of bacteriostatic chyle in the pleural space. The pleural fluid will have either or both triglycerides >110 mg/dL and the presence of chylomicrons. It may be encountered following a surgical intervention, usually in the chest, or underlying disease process. Management of a chylothorax requires a multidisciplinary approach employing medical therapy and possibly surgical intervention for post-operative patients and patients who have failed medical therapy. In this review, we aim to discuss the anatomy, fluid characteristics, etiology, and approach to the diagnosis of a chylothorax.

Lymphangiography Was Useful in Postoperative Intractable Chylothorax after Surgery for Esophageal Cancer: A Case Report

Postoperative chylothorax after surgery for esophageal cancer is a rare but serious complication. Treatment initially consists of conservative therapy and, if it fails to provide improvement, it is important to perform surgical treatment without delay. We report on a recent case of intractable chylothorax. This report describes a 72-year-old man with Stage III esophageal squamous cell carcinoma. Subtotal esophagectomy, through a right thoracoabdominal approach with two-field lymphadenectomy, and cervical esophagogastric anastomosis via the retrosternal route, were performed. On the 12th postoperative day, a diagnosis of chylothorax was made. Conservative treatment was initiated, but it proved to be ineffective. Therefore, ligation of the thoracic duct via a thoracotomy was performed, but this was not effective, either. Lymphangiography undertaken to identify the site of the leak in the thoracic duct enabled a diagnosis of an extremely rare double thoracic duct and identification of the site of the leak in the thoracic duct, thereby allowing curative direct ligation of the site. This case underscores the remarkable usefulness of lymphangiography in dealing with intractable postoperative chylothorax.

Treatment of Postsurgical Chylothorax

BACKGROUND

Postoperative chylothorax can be managed by any or all of observation, parenteral nutrition, surgical duct ligation, pleurodesis, or thoracic duct embolization. The objective of this study was to determine the efficacy of standard therapies, such as surgical duct ligation and observation, compared with newer treatment methods (thoracic duct embolization).

METHODS

A prospectively maintained database at a single institution was used to identify and review patients with postoperative chylothorax from 2008 to 2015.

RESULTS

Postoperative chylothorax occurred in 97 patients, including 54 men (56%). The median age was 61 years (range, 24 to 87 years). Thoracic duct leak followed esophagectomy in 46 patients (47%), pulmonary resection in 30 (31%), mediastinal mass resection in 7 (8%), and after other procedures in 15. Of 28 medically observed patients achieving resolution without intervention, the median peak chest tube output in 24 hours was 725 mL compared with 1,910 mL in the group that required intervention (p = 0.0001). Thoracic duct ligation was successful in 44 of 52 patients that proceeded to the operating room (85%). Of the 40 patients undergoing diagnostic lymphangiography, a leak was identified in 34 (85%), but the cisterna chyli could only be cannulated in 19 (48%) and was subsequently successful in 15 (38%).

CONCLUSIONS

Patients with chylous chest tube outputs of 1,100 mL or more in 24 hours postoperatively should be considered for intervention. Intention-to-treat analysis shows surgical duct ligation is more effective than thoracic duct embolization, with the ability to cannulate the cisterna chyli being the limiting factor. Lymphangiography may help determine which patients are better treated with ligation or embolization.

VATS and open chest surgery in diagnosis and treatment of benign pleural diseases

A negative pressure normally exists between the visceral and parietal pleurae in the lungs, which can act as vacuum for fluid, air and small particles from different parts of the body, allowing them to move into the pleural space and be retained in it, thus resulting to different manifestations of pleural disorders. A pleural effusion is the result of fluid collection between the parietal and visceral pleural surfaces. The most common cause in developed countries is congestive heart failure, followed by pneumonia and malignancy. It is highly important that a systematic approach is undertaken during the investigation of pleural effusions. Treatment should be based on the nature of the effusion and underlying condition, while undiagnosed patients should remain under surveillance. Pleural infection is a serious clinical condition which affects approximately 65,000 patients every year in the UK and can result in mortality in rates as high as 20%. The selection of treatment as well as timing of intervention remains a debatable issue among pulmonologists and thoracic surgeons. Surgical intervention aims to control sepsis, by facilitating evacuation of necrotic material from the pleural space, and obliterate the empyema cavity, by allowing the trapped lung to re-expand via peeling of the organised cortex from its visceral pleura. Thoracoscopic surgery offers the advantages of visual assessment of the pleural space and direct tissue sampling and it can be useful for the diagnosis of unknown pleural effusions and in the management of complicated collections. Open thoracotomy remains the gold standard, however with the advancement of thoracoscopic instruments and techniques, minimally invasive approaches provide comparable outcomes and have been taking over the management of benign pleural diseases.

Thoracic Duct Chylous Fistula Following Severe Electric Injury Combined with Sulfuric Acid Burns: A Case Report

Patient: Male, 32

Final Diagnosis: Thoracic duct chylous fistula

Symptoms: Fistula

Medication: —

Clinical Procedure: A boneless muscle flap transplantatio

Specialty: —

[Chylothorax in practice of thoracic and cardiovascular surgeon]

AIM

to improve the results and current pathogenetic treatment of chylorrhea.

MATERIAL AND METHODS

Thirty seven patients with chylothorax have been treated for the period 2004-2014. In 34 cases traumatic chylothorax developed after surgery and in 3 cases - after intensive care for therapeutic diseases and great veins catheterization. Chylothorax was predominantly diagnosed by X-ray method. Herewith, hydrothorax was established and its nature was defined using laboratory survey. Presence of neutral fat in pleural drainage is the sign of chylothorax. Pathogenetic treatment was often delayed (up to 4.5 months) due to poor awareness of physicians about this pathological process. 6 patients underwent thoracic duct ligation above diaphragm due to ineffective therapy.

RESULTS

Medical therapy had good clinical effect in 83.8% of cases. Postoperatively 1 patient died for single lung inflammation on background of postoperative chylothorax after right-sided pneumonectomy. In other cases chylothora was eliminated with no recurrence in remote postoperative period. It is difficult to recognize injury of thoracic duct or its great branches during surgery. In these cases prolonged thoracic duct ligation above diaphragm is indicated.

Trends in Pleural Effusion Research

Background:

Research in pleural diseases has traditionally been neglected but is now growing.

Objectives:

This study aimed to analyze scientific research trends on pleural effusions over the last decades.

Method:

We conducted a bibliometric analysis of the Scopus database from its inception to March 2016, searching for original articles and reviews on “pleural effusion” (key word). Journal, year of publication, number of citations, authors and their affiliations, and the Hirsch (H)-index for some of these variables were recorded and analyzed.

Results:

A total of 15 982 documents were retrieved, of which half have been published in the last 18 years and a quarter during the last 8 years. Chest ranked first regarding the number of documents on pleural effusions (both absolute number and yearly rate) and their scientific relevance (H-index of 76). The United States had contributed the most to pleural research productivity (23%). American pulmonologists Dr Richard Light and Dr Steven Sahn exhibited the highest number of papers (206 and 156, respectively) and author H-indexes (44 and 38, respectively).

Conclusion:

There is growing research activity in the field of pleural effusions, which has gained relevance and visibility in clinical respiratory journals. The United States is the leader in quantity and quality of research productivity in pleural medicine.

Failure to rescue patients from early critical complications of oesophagogastric cancer surgery

'Failure to rescue' is a significant cause of mortality in gastrointestinal surgery. Differences in mortality between high and low-volume hospitals are not associated with large difference in complication rates but to the ability of the hospital to effectively rescue patients from the complications. We reviewed the critical complications following surgery for oesophageal and gastric cancer, their prevention and reasons for failure to rescue. Strategies focussing on perioperative optimization, the timely recognition and management of complications may be essential to improving outcome in low-volume hospitals.

Low fat-containing elemental formula is effective for postoperative recovery and potentially useful for preventing chyle leak during postoperative early enteral nutrition after esophagectomy

BACKGROUND AND AIMS

Transthoracic esophagectomy using 3-field lymphadenectomy (TTE-3FL) for esophageal cancer is one of the most aggressive gastrointestinal surgeries. Early enteral nutrition (EN) for TTE-3FL patients is useful and valid for early recovery; however, EN using a fat-containing formula risks inducing chyle leak. In the present study, we retrospectively examined esophageal cancer patients treated byTTE-3FL and administered postoperative EN to elucidate the validity of lowering the fat levels in elemental formulas to prevent postoperative chyle leak and improve postoperative recovery.

METHODS

A total of 74 patients who received TTE-3FL for esophageal cancer were retrospectively examined. Patients were classified into two groups according to the type of postoperative EN: Group LF patients received a low-fat elemental formula, and Group F patients received a standard fat-containing polymeric formula. The following clinical factors were compared between the groups: EN start day, maximum EN calories administered, duration of respirator use, length of ICU stay, incidence of postoperative infectious complications, use of parenteral nutrition (PN), and incidence of postoperative chyle leak.

RESULTS

Patients in Group LF were started on EN significantly earlier after surgery and they consumed significantly higher maximum EN calories compared to Group F patients (P < 0.01). Duration of respirator use and length of ICU stay were also significantly shorter, and TPN was used significantly less in Group LF compared to Group F (P < 0.05). Postoperative chyle leak was observed in six patients in total (8.1%); five patients in Group F and one patient in Group LF, although there was no significant difference in frequency of chyle leak per patient between Group LF and Group F.

CONCLUSIONS

Early EN using low-fat elemental formula after esophagectomy with three-field lymphadenectomy was safe and valid for postoperative recovery and potentially useful in preventing chyle leak.

Quality Management and Key Performance Indicators in Oncologic Esophageal Surgery

Ranking systems and comparisons of quality and performance indicators will be of increasing relevance for complex "high-risk" procedures such as esophageal cancer surgery. The identification of evidence-based standards relevant for key performance indicators in esophageal surgery is essential for establishing monitoring systems and furthermore a requirement to enhance treatment quality. In the course of this review, we analyze the key performance indicators case volume, radicality of resection, and postoperative morbidity and mortality, leading to continuous quality improvement. Ranking systems established on this basis will gain increased relevance in highly complex procedures within the national and international comparison and furthermore improve the treatment of patients with esophageal carcinoma.

Incidence and management of chylothorax after esophagectomy

Background

Chylothorax is a rare but serious postoperative complication in esophageal cancer patients. The aim of this study was to identify risk factors associated with chylothorax and the indication for surgical intervention.

Methods

A consecutive series of 1290 patients who underwent esophagectomy for esophageal cancer was included. Peri-operative data, including postoperative morbidity and mortality, were analyzed.

Results

Thirty-four patients (2.6%) developed chylothorax and had significantly higher instances of pneumonia (26.5% vs. 11.1%, P = 0.012) and arrhythmia (17.6% vs. 2.9%, P = 0.001), and a longer hospital stay (22 vs. 18 days, P < 0.001). Reoperation was performed in 11 patients at a rate of 77.8%, 42.9%, 20%, and 0% for chylothorax diagnosed in two, three, four, and >= 5 days, respectively, after esophagectomy (P < 0.001). After three days of conservative therapy, the chest tube output was significantly greater in patients whose medical management had failed than in those successfully treated (P < 0.001). All patients who required reoperation had >= 13.5 ml/kg of drainage (sensitivity 100%); four of 23 patients with successful medical management had a chest tube output >= 13.5 ml/kg (specificity 83%). Logistic regression analysis showed that body mass index (BMI) < 25 was an independent risk factor for chylothorax (hazard ratio = 9.256, P = 0.029).

Conclusions

Patients with a BMI < 25 are more likely to develop chylothorax after esophagectomy. Operative therapy should be seriously considered in patients who develop chylothorax early postoperatively. In addition, a high daily chylous output of >= 13.5 ml/kg after three days of conservative therapy might be a reliable indicator for reoperation.

Pleural Disorders

This chapter provides an overview of both benign and malignant pleural disorders, starting with the relevant anatomy and physiology. The focus is on the management of pneumothoraces and pleural effusions—conditions that are commonly encountered on a general thoracic surgery service. The pleural cavity is lined by parietal and visceral pleura, which are smooth membranes that are continuous with one another at the hilum and pulmonary ligaments. Parietal Pleura: innermost chest wall layer, divided into cervical, costal, mediastinal and diaphragmatic pleura.

Nutritional management in chyle leaks and chylous effusions

Chyle leaks occur when there is interruption to the lymphatic ducts that transport chyle around the body. The loss of this protein-rich, calorie-rich fluid can cause serious complications including dehydration, malnutrition and immunosuppression. Treatment of chyle leaks depends on the underlying cause, which may be surgical, secondary to malignant invasion or the result of a medical condition. Nutritional support is vital and leads to spontaneous leak closure in many cases. Nutritional management options include total bowel rest with parenteral nutrition, enteral feeding with specialized formula, or oral diet with supplementation. At present there is no consensus regarding which approach is superior. In reality, most patients with chyle leaks are managed with a combination or oral and enteral feeding, but further work is needed to clarify the optimum management strategy.

Chyle leakage patterns and management after oncologic esophagectomy: A retrospective cohort study

BACKGROUND

This study aims to evaluate the incidence and characteristics of chyle leakage after curative oncologic esophagectomy, and the effectiveness of thoracic duct ligation.

METHODS

This is a retrospective cohort study using the medical records of 1514 patients who underwent curative esophagectomy for esophageal cancer between September 1994 and December 2010. Patients whose pleural fluid analysis corresponded to chyle were included, and drainage patterns by different management groups were examined with multilevel models. The chyle leakage patterns during the time before and after duct ligation were also evaluated, adjusting for demographics, clinical characteristics, and treatment.

RESULTS

The prevalence of chyle leakage after esophagectomy was 3.8%. The three management groups were as follows: (i) conservative-controlled only with conservative management; (ii) surgical I-duct ligation during the esophagectomy; and (iii) surgical II-duct ligation after the esophagectomy. Pattern analysis determined that drainage of the conservative group was ∼400 mL/day (maximum on postoperative days [POD] = 9.2); drainage of surgical II was ∼1000 mL/day (maximum on POD = 18.1). On average, thoracic duct ligation was performed 18.7 days after the esophagectomy, and drainage significantly decreased after duct ligation (P-value <0.001).

CONCLUSIONS

There was a clear pattern of lower chyle leakage with the patients requiring conservative management compared with those requiring surgical management. Active and prompt surgical management needs to be considered in the early postoperative phase for patients with high-output (over 1000 mL/day) chyle leakage after esophagectomy.

Esophagectomy-related thoracic duct injury detected by lymphoscintigraphy with 99mTc-diethylenetriamine pentaacetic acid-human serum albumin: report of a case

Chylothorax is an uncommon but potentially life-threatening complication of esophagectomy. A 72-year-old man underwent thoracoscopy-assisted subtotal esophagectomy and reconstruction with a gastric tube, through a retrosternal route, after preoperative chemoradiotherapy. Chylothorax was detected after starting enteral feeding on postoperative day (POD) 7. Despite conservative therapy such as fasting, total parenteral nutrition, and octreotide administration, massive fluid drainage continued. On POD 19, lymphoscintigraphy with (99m)Tc-diethylenetriamine pentaacetic acid-human serum albumin (HSA-D) was performed and the site of leakage was detected at the level of the fourth thoracic vertebra. On POD 23, the thoracic duct was ligated, following which the volume of chylothorax decreased. Lymphoscintigraphy 12 days after the reoperation showed no leakage from the thoracic duct. We recommend lymphoscintigraphy with (99m)Tc-HSA-D for locating the chyle leakage site and helping decide about the operative indication.