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Pan S, Cheah L, Bushra R, Ribbits A, Grimes S, O'Neill JR. Impact of early enteral feed composition on the rate of chyle leak post-esophagectomy. Dis Esophagus 2024; 37:doae008. [PMID: 38366666 DOI: 10.1093/dote/doae008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 01/12/2024] [Indexed: 02/18/2024]
Abstract
Patients undergoing esophagectomy are at risk of malnutrition and benefit from perioperative enteral feeding. Esophagectomy carries a risk of chyle leak, and this risk may be influenced by early enteral feed composition. We evaluated the impact of early enteral medium-chain triglyceride-rich feed on the prevalence and severity of chyle leak post-esophagectomy, length of stay, and postoperative weight change. This retrospective study included consecutive patients undergoing esophagectomy at a single center between January 2015 and December 2022. Patients received enteral feed on postoperative days 1-5 with Nutrison Energy or Protein Plus Energy ('standard') (January 2015- June 2021) or Nutrison Peptisorb Plus High Energy High Protein ('HEHP') enteral feed (June 2021 to December 2022). All patients transitioned to 'standard' supplemental jejunal feeding on postoperative day 6 onwards and were discharged on oral IDDSI level 4 diet. Patients who did not commence early enteral feeding were excluded from analysis. A total of 329 patients were included. Patients who received early HEHP feed had fewer chyle leaks (5/52; 9.6%) compared with patients who received standard feed (68/277; 24.5%, P = 0.017). The HEHP group had a shorter total length of hospital stay (P = 0.011). Weight change from preoperative baseline was equivalent in both groups at 6 weeks (P = 0.066) and 3 months (P = 0.400). In the context of routine jejunostomy use and early enteral feeding post-esophagectomy, HEHP feed on postoperative days 1-5 was associated with significantly fewer chyle leaks and shorter length of stay compared with standard feed. No difference was noted in postoperative weight change between groups.
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Affiliation(s)
- Sally Pan
- Cambridge Oesophagogastric Centre, Division of Digestive Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Lilyanne Cheah
- Cambridge Oesophagogastric Centre, Division of Digestive Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Raisa Bushra
- Cambridge Oesophagogastric Centre, Division of Digestive Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Alexander Ribbits
- Cambridge Oesophagogastric Centre, Division of Digestive Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Samantha Grimes
- Cambridge Oesophagogastric Centre, Division of Digestive Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - J Robert O'Neill
- Cambridge Oesophagogastric Centre, Division of Digestive Diseases, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Edinburgh Cancer Research, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
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Xiao Y, Chen Y, Huang R, Jiang F, Su C, Zhou J. Incidence, risk factors, and outcomes of chylothorax after cardiac procedure in the United States. Heliyon 2024; 10:e29054. [PMID: 38638975 PMCID: PMC11024541 DOI: 10.1016/j.heliyon.2024.e29054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 03/04/2024] [Accepted: 03/28/2024] [Indexed: 04/20/2024] Open
Abstract
Background To examine the epidemiology and risk factors of chylothorax after cardiac procedure in the United States using a contemporary nationally representative database. Methods We identified postoperative chylothorax events through National Inpatient Sample database (2016-2019) and compared baseline demographics, comorbidities, and in-hospital outcomes between hospitalizations with and without postoperative chylothorax. The Cochrane-Armitage test was used to analyze trends in incidence rates. Multivariable Poisson regression models were used to identify potential risk factors for postoperative chylothorax after cardiac procedure. Results A total of 819 (0.24%) admissions were associated with postoperative chylothorax. The crude and standardized incidence rates of chylothorax were 23.7 (95%CI, 22.1-25.4) and 61.5 per 10,000 cardiac procedure-related admissions, respectively, with no significant temporal change in incidence rate over the study period (Ptrend = 0.5249). Infants [adjusted rate ratio (aRR), 117.3, 95% confidence interval (CI), 94.5-145.5] and children (aRR, 60.2, 95%CI, 48.0-75.5) were more likely to develop chylothorax compared to adults. Heart and great vessel procedures (aRR, 4.36, 95%CI, 3.61-5.26), septal repair (aRR, 1.91, 95%CI, 1.58-2.29), heart transplant (aRR, 5.68, 95%CI, 4.55-7.10) and pericardial procedures (aRR, 4.04, 95%CI, 3.32-4.91) were associated with elevated risk for chylothorax. Admissions with chylothorax were associated with higher inpatient mortality (4.9% vs. 3.0%, p<0.0001), longer inpatient stay, higher costs and greater perioperative complication burden. Conclusions Following cardiac procedures, chylothorax is an uncommon but serious complication that affects the prognosis. The analysis reveals varying incidence rates across age groups and specific surgical procedures, with infants at elevated risk.
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Affiliation(s)
- Yue Xiao
- School of International Business, China Pharmaceutical University, Jiangsu, China
| | - Yanfei Chen
- School of International Business, China Pharmaceutical University, Jiangsu, China
| | - Ruijian Huang
- School of International Business, China Pharmaceutical University, Jiangsu, China
| | - Feng Jiang
- School of International Business, China Pharmaceutical University, Jiangsu, China
| | - Cunhua Su
- Cardiothoracic and Vascular Surgery, Nanjing First Hospital, Jiangsu, China
| | - Jifang Zhou
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, Jiangsu, China
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3
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Berger Y, Bard V, Abbas M, Solomon D, Menasherov N, Kashtan H. Thoracic Duct Visualization in Esophageal Resection: A Pilot Trial. Eur Surg Res 2024; 65:60-68. [PMID: 38636484 DOI: 10.1159/000538691] [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: 12/26/2023] [Accepted: 03/20/2024] [Indexed: 04/20/2024]
Abstract
INTRODUCTION Inadvertent thoracic duct injury is common during esophagectomy and may result in postoperative chylothorax. This study's objective was to investigate utility of patent blue injection as a modality for intraoperative thoracic duct visualization. METHODS A prospective, single-arm, interventional study of patients undergoing minimally invasive esophagectomy was performed. Patients were injected with patent blue dye into both groins prior to thoracic stage of surgery and assessed for duct visualization. Control group was formed by propensity score matching using retrospectively collected data regarding patients who underwent esophagectomy. RESULTS A total of 25 patients were included in analysis, compared to a control of 50 patients after matching. Thoracic duct was visualized in 60% of patients in the study group (15/25 patients). Significant differences were found between study and control groups (p < 0.05) with regards to median operative time (422 vs. 285 min, respectively), overall complications (16 vs. 34%, respectively), and median postoperative length of stay (13.5 vs. 10 days, respectively). There was a difference in rate of chyle leak between study and control groups; however, this was not significant (0 vs. 12%, respectively, p = 0.17). CONCLUSION Patent blue injection represents a simple method for thoracic duct visualization during minimally invasive esophagectomy which may improve surgical outcomes.
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Affiliation(s)
- Yael Berger
- Department of Surgery, Rabin Medical Center, Petach-Tiqva, Israel
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Vyacheslav Bard
- Department of Surgery, Rabin Medical Center, Petach-Tiqva, Israel
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Muhammad Abbas
- Department of Surgery, Rabin Medical Center, Petach-Tiqva, Israel
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daniel Solomon
- Department of Surgery, Rabin Medical Center, Petach-Tiqva, Israel
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nikolai Menasherov
- Department of Surgery, Rabin Medical Center, Petach-Tiqva, Israel
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hanoch Kashtan
- Department of Surgery, Rabin Medical Center, Petach-Tiqva, Israel
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Bhatnagar M, Fisher A, Ramsaroop S, Carter A, Pippard B. Chylothorax: pathophysiology, diagnosis, and management-a comprehensive review. J Thorac Dis 2024; 16:1645-1661. [PMID: 38505027 PMCID: PMC10944732 DOI: 10.21037/jtd-23-1636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 01/22/2024] [Indexed: 03/21/2024]
Abstract
Chylothorax is a rare condition characterized by the accumulation of chyle in the pleural space. While it accounts for a small percentage of pleural effusions, chylothorax can lead to significant morbidity and mortality. This article provides a comprehensive overview of chylothorax, covering its relevant anatomy, aetiology, pathophysiology, clinical features, diagnosis, and management. Injury or disruption to the thoracic duct (which is responsible for chyle transport) leads to the development of chylothorax. This may result from trauma, such as iatrogenic injury during surgery, or non-traumatic causes, including malignancy, lymphatic disorders, and heart failure. Recognition of the underlying cause is essential to tailor management. Clinical presentation varies, with symptoms linked to rate of chyle accumulation and the causative condition. Diagnosis relies on pleural fluid analysis, with demonstration of elevated triglyceride levels (>110 mg/dL) and reduced cholesterol levels (<200 mg/dL) being the key diagnostic criteria employed in clinical practice. Various imaging modalities, including computed tomography (CT) scans and lymphatic-specific investigations, may be utilised to aid identification of the site of chyle leak, as well as determine the likely underlying cause. Chylothorax management is multifaceted, with conservative approaches such as dietary modification and pharmacological interventions often initiated as first-line treatment. Drainage of chylous effusion may be necessary for symptom relief. When conservative methods fail, interventional procedures like thoracic duct ligation or embolization can be considered. Due to the diverse aetiological factors and patient characteristics associated with chylothorax, individualized management strategies are recommended. Nonetheless, management of chylothorax is an evolving field with a paucity of high-quality evidence or standardized guidelines, highlighting the importance of ongoing research and a multidisciplinary approach to optimize individual patient care.
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Affiliation(s)
- Malvika Bhatnagar
- Department of Respiratory Medicine, South Tyneside and Sunderland NHS Foundation Trust, South Tyneside, UK
| | - Annette Fisher
- Department of Respiratory Medicine, Northumbria Healthcare NHS Foundation Trust, Cramlington, UK
| | - Sudarshan Ramsaroop
- Department of Respiratory Medicine, South Tyneside and Sunderland NHS Foundation Trust, Sunderland, UK
| | - Alison Carter
- Department of Respiratory Medicine, County Durham and Darlington NHS Foundation Trust, Durham, UK
| | - Benjamin Pippard
- Department of Respiratory Medicine, South Tyneside and Sunderland NHS Foundation Trust, South Tyneside, UK
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Hong Z, Lu Y, Li H, Cheng T, Sheng Y, Cui B, Wu X, Jin D, Gou Y. Effect of Early Versus Late Oral Feeding on Postoperative Complications and Recovery Outcomes for Patients with Esophageal Cancer: A Systematic Evaluation and Meta-Analysis. Ann Surg Oncol 2023; 30:8251-8260. [PMID: 37610489 DOI: 10.1245/s10434-023-14139-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 06/27/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND This study aimed to systematically evaluate the effect of early oral feeding (EOF) versus late oral feeding (LOF) on postoperative complications and rehabilitation outcomes for patients with esophageal cancer. METHODS This study searched relevant literature published up to March 2023 by computer retrieval of PubMed, Embase, The Cochrane Library, and Web of Science. A meta-analysis was performed using Review Manager 5.4 software to compare the effects of EOF and LOF on postoperative complications and recovery outcomes of patients with esophageal cancer. RESULTS The study included 14 articles, including 9 retrospective studies, 4 randomized controlled trials (RCTs), and 1 prospective study. The 2555 patients included in the study comprised 1321 patients who received EOF and 1234 patients who received LOF. The results of the meta-analysis showed that compared with the LOF group, the EOF group has a shorter time to the first flatus postoperatively (mean difference [MD], - 1.12; 95% confidence interval [CI], (- 1.25 to - 1.00; P < 0.00001), a shorter time to the first defecation postoperatively (MD, - 1.31; 95% CI, - 1.67 to - 0.95;, P < 0.00001], and a shorter hospital stay postoperatively (MD, - 2.87; 95% CI, - 3.84 to - 1.90; P < 0.00001). The two groups did not differ significantly statistically in terms of postoperative anastomotic leakage rate (P = 0.10), postoperative chyle leakage rate (P = 0.10), or postoperative pneumonia rate (P = 0.15). CONCLUSION Early oral feeding after esophageal cancer surgery can shorten the time to the first flatus and the first defecation postoperatively, shorten the hospital stay, and promote the recovery of patients. Moreover, it has no significant effect on the incidence of postoperative complications.
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Affiliation(s)
- Ziqiang Hong
- Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Yingjie Lu
- Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Hongchao Li
- Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Tao Cheng
- Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, China
| | | | - Baiqiang Cui
- Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Xusheng Wu
- Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Dacheng Jin
- Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, China
| | - Yunjiu Gou
- Department of Thoracic Surgery, Gansu Provincial Hospital, Lanzhou, China.
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dos Santos LL, dos Santos CL, Hu NKT, Datrino LN, Tavares G, Tristão LS, Orlandini MF, Serafim MCA, Tustumi F. Outcomes of Chylothorax Nonoperative Management After Cardiothoracic Surgery: A Systematic Review and Meta-Analysis. Braz J Cardiovasc Surg 2023; 38:e20220326. [PMID: 37801640 PMCID: PMC10552558 DOI: 10.21470/1678-9741-2022-0326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 03/16/2023] [Indexed: 10/08/2023] Open
Abstract
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.
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Affiliation(s)
- Laura Lucato dos Santos
- Departament of Gastroenterology, Faculdade de Medicina,
Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Clara Lucato dos Santos
- Departament of Evidence-Based Medicine, Faculdade de Medicina,
Centro Universitário Lusíada, Santos, São Paulo, Brazil
| | - Natasha Kasakevic Tsan Hu
- Departament of Evidence-Based Medicine, Faculdade de Medicina,
Centro Universitário Lusíada, Santos, São Paulo, Brazil
| | - Leticia Nogueira Datrino
- Departament of Evidence-Based Medicine, Faculdade de Medicina,
Centro Universitário Lusíada, Santos, São Paulo, Brazil
| | - Guilherme Tavares
- Departament of Evidence-Based Medicine, Faculdade de Medicina,
Centro Universitário Lusíada, Santos, São Paulo, Brazil
| | - Luca Schiliró Tristão
- Departament of Evidence-Based Medicine, Faculdade de Medicina,
Centro Universitário Lusíada, Santos, São Paulo, Brazil
| | - Marina Feliciano Orlandini
- Departament of Evidence-Based Medicine, Faculdade de Medicina,
Centro Universitário Lusíada, Santos, São Paulo, Brazil
- Departament of Evidence-Based Medicine, Oya Care, São Paulo,
São Paulo, Brazil
| | | | - Francisco Tustumi
- Departament of Gastroenterology, Faculdade de Medicina,
Universidade de São Paulo, São Paulo, São Paulo, Brazil
- Departament of Health Sciences, Faculdade de Medicina, Hospital
Israelita Albert Einstein, São Paulo, São Paulo, Brazil
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Kim J, Bang DH, Choi TW, Won JH, Kwon Y. Lymphangiography and lymphatic embolisation for the treatment of chyle leaks after neck surgery: assessment of lymphangiography findings and embolisation techniques. Br J Radiol 2023; 96:20220831. [PMID: 37393535 PMCID: PMC10461271 DOI: 10.1259/bjr.20220831] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 05/21/2023] [Accepted: 06/09/2023] [Indexed: 07/03/2023] Open
Abstract
OBJECTIVE To assess lymphangiography findings and outcome of lymphatic embolisation to manage chyle leak after neck surgery. METHODS Consecutive cases of lymphangiography performed between April 2018 and May 2022 for management of chyle leaks related to neck surgery were retrospectively reviewed. Lymphangiography findings, techniques, and outcomes were analysed. RESULTS Eight patients (mean age: 46.5 years) were included. Six patients had undergone radical neck dissection for thyroid cancer, and two had undergone lymph node excision. Clinical presentations were: chyle drainage through Jackson Pratt catheters in five patients, lymphorrhea through surgical wounds in two, and enlarging lymphocele in one. Lymphangiography techniques included: inguinal lymphangiography in four patients, retrograde lymphangiography in three, and transcervical lymphangiography in one. Lymphangiography revealed leaks in the terminal thoracic duct in two patients, bronchomediastinal trunk in two, jugular trunk in three, and superficial neck channels in one. Embolisation techniques included: non-selective embolisation of terminal thoracic duct (n = 2), selective embolisation of the jugular trunk (n = 3), selective embolisation of the bronchomediastinal trunk (n = 2), and intranodal glue embolisation of superficial neck channels (n = 1). One patient underwent a repeat procedure. Chyle leak resolved in all patients over a mean of 4.6 days. No complication was encountered. CONCLUSION Lymphatic embolisation seems to be effective and safe in managing chyle leaks after neck surgery. Lymphangiography allowed for the categorisation of chyle leaks according to their location. Post-embolisation patency of the thoracic duct may be preserved in chyle leaks that do not directly involve the thoracic duct. ADVANCES IN KNOWLEDGE Lymphatic embolisation is safe and effective in managing chyle leaks after neck surgery. On lymphangiography, the location of contrast media extravasation may not be consistent. The technique for embolisation should be based on the location of the leak. Post-embolisation patency of the thoracic duct may be preserved in chyle leaks that do not directly involve the thoracic duct.
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Affiliation(s)
- Jinoo Kim
- Department of Radiology, Ajou University Hospital, Suwon, Gyeonggi-do, Republic of Korea
| | - Dong Ho Bang
- Department of Radiology, Ajou University Hospital, Suwon, Gyeonggi-do, Republic of Korea
| | - Tae Won Choi
- Department of Radiology, Ajou University Hospital, Suwon, Gyeonggi-do, Republic of Korea
| | - Je Hwan Won
- Department of Radiology, Ajou University Hospital, Suwon, Gyeonggi-do, Republic of Korea
| | - Yohan Kwon
- Department of Radiology, Ajou University Hospital, Suwon, Gyeonggi-do, Republic of Korea
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8
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Wang K, Xiao J, Li L, Li X, Yang Y, Liu Z, Jiang J. The application of a medium-chain fatty diet and enteral nutrition in post-operative chylous leakage: analysis of 63 patients. Front Nutr 2023; 10:1128864. [PMID: 37545584 PMCID: PMC10399236 DOI: 10.3389/fnut.2023.1128864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 06/30/2023] [Indexed: 08/08/2023] Open
Abstract
Background Post-operative chylous leakage (CL) is the pathologic leakage of chylomicron fluid after surgery. This retrospective study was performed to evaluate a uniform oral nutrition management strategy on the post-operative CL. Methods We retrospectively reviewed patients who developed post-operative CL and received consultation from a clinical nutritionist in seven departments of the Second Affiliated Hospital of Dalian Medical University from May 2020 to April 2022. We designed the oral nutrition intervention program which mainly standardized the type and amount of foods contained in the medium-chain triglyceride (MCT) diet. The influencing factors of curative efficacy were analyzed. Finally, binary logistic regression analysis was conducted to observe the relationship between curative efficacy and potentially predictive variables, including post-operative albumin, post-operative hemoglobin, surgical procedure, and drainage volume at consultation. Results Sixty-three patients with post-operative CL were included in this analysis. Of this number, 58 patients were cured successfully without other treatments. Three patients had a significantly prolonged recovery period, and the remaining two cases were treated by reoperation therapy. The leakage volume at the initiation of enteral intervention had no statistically significant difference in seven surgical departments and surgical sites (left, right, median, and bilateral). The length of stay (LOS) of patients with CL after the intervention was not significantly increased in cardiac, hepatobiliary, gastrointestinal, and urological surgeries. Patients with CL had longer LOS than those without CL in gynecology (P=0.044) and thyroid surgery departments (P=0.008). Each unit increase in post-operative hemoglobin would increase the probability of an effective outcome by 8%, which was statistically significant (P = 0.037). Conclusion In treating patients with post-operative CL, we recommend the MCT diet and EN as the first option, rather than fasting, parenteral nutrition (PN), or octreotide.
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Affiliation(s)
- Ke Wang
- Department of Clinical Nutrition, Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Jiaming Xiao
- Department of Nutrition and Food Hygiene, School of Public Health, Dalian Medical University, Dalian, Liaoning, China
| | - Li Li
- Department of Clinical Nutrition, Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Xu Li
- Department of Clinical Nutrition, Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Yilun Yang
- Department of Clinical Nutrition, Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Zhiyu Liu
- Department of Urological Surgery, Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Jing Jiang
- Department of Nursing, Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
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9
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Yang YB, Dai L, Wu YY, Yan WP, Liang Z, Lin Y, Chen KN. Pre-operative oil ingestion reduces the probability of thoracic duct trunk ligation during esophagectomy. Dis Esophagus 2023; 36:6931732. [PMID: 36533426 DOI: 10.1093/dote/doac093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 08/14/2022] [Accepted: 11/22/2022] [Indexed: 05/30/2023]
Abstract
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.
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Affiliation(s)
- Yong-Bo Yang
- First Department of Thoracic Surgery, Peking University Cancer Hospital and Institute, 100143 Beijing
- Key Laboratory of Carcinogenesis and Translational Research, Ministry of Education, Peking University Cancer Hospital and Institute, 100143 Beijing, China
| | - Liang Dai
- First Department of Thoracic Surgery, Peking University Cancer Hospital and Institute, 100143 Beijing
- Key Laboratory of Carcinogenesis and Translational Research, Ministry of Education, Peking University Cancer Hospital and Institute, 100143 Beijing, China
| | - Ya-Ya Wu
- First Department of Thoracic Surgery, Peking University Cancer Hospital and Institute, 100143 Beijing
- Key Laboratory of Carcinogenesis and Translational Research, Ministry of Education, Peking University Cancer Hospital and Institute, 100143 Beijing, China
| | - Wan-Pu Yan
- First Department of Thoracic Surgery, Peking University Cancer Hospital and Institute, 100143 Beijing
- Key Laboratory of Carcinogenesis and Translational Research, Ministry of Education, Peking University Cancer Hospital and Institute, 100143 Beijing, China
| | - Zhen Liang
- First Department of Thoracic Surgery, Peking University Cancer Hospital and Institute, 100143 Beijing
- Key Laboratory of Carcinogenesis and Translational Research, Ministry of Education, Peking University Cancer Hospital and Institute, 100143 Beijing, China
| | - Yao Lin
- First Department of Thoracic Surgery, Peking University Cancer Hospital and Institute, 100143 Beijing
- Key Laboratory of Carcinogenesis and Translational Research, Ministry of Education, Peking University Cancer Hospital and Institute, 100143 Beijing, China
| | - Ke-Neng Chen
- First Department of Thoracic Surgery, Peking University Cancer Hospital and Institute, 100143 Beijing
- Key Laboratory of Carcinogenesis and Translational Research, Ministry of Education, Peking University Cancer Hospital and Institute, 100143 Beijing, China
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Martinovic D, Tokic D, Puizina Mladinic E, Usljebrka M, Kadic S, Lesin A, Vilovic M, Lupi-Ferandin S, Ercegovic S, Kumric M, Bukic J, Bozic J. Nutritional Management of Patients with Head and Neck Cancer-A Comprehensive Review. Nutrients 2023; 15:nu15081864. [PMID: 37111081 PMCID: PMC10144914 DOI: 10.3390/nu15081864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/07/2023] [Accepted: 04/11/2023] [Indexed: 04/29/2023] Open
Abstract
While surgical therapy for head and neck cancer (HNC) is showing improvement with the advancement of reconstruction techniques, the focus in these patients should also be shifting to supportive pre and aftercare. Due to the highly sensitive and anatomically complex region, these patients tend to exhibit malnutrition, which has a substantial impact on their recovery and quality of life. The complications and symptoms of both the disease and the therapy usually make these patients unable to orally intake food, hence, a strategy should be prepared for their nutritional management. Even though there are several possible nutritional modalities that can be administrated, these patients commonly have a functional gastrointestinal tract, and enteral nutrition is indicated over the parenteral option. However, after extensive research of the available literature, it seems that there is a limited number of studies that focus on this important issue. Furthermore, there are no recommendations or guidelines regarding the nutritional management of HNC patients, pre- or post-operatively. Henceforth, this narrative review summarizes the nutritional challenges and management modalities in this particular group of patients. Nonetheless, this issue should be addressed in future studies and an algorithm should be established for better nutritional care of these patients.
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Affiliation(s)
- Dinko Martinovic
- Department of Maxillofacial Surgery, University Hospital of Split, 21000 Split, Croatia
| | - Daria Tokic
- Department of Anesthesiology and Intensive Care, University Hospital of Split, 21000 Split, Croatia
| | - Ema Puizina Mladinic
- Department of Maxillofacial Surgery, University Hospital of Split, 21000 Split, Croatia
| | - Mislav Usljebrka
- Department of Maxillofacial Surgery, University Hospital of Split, 21000 Split, Croatia
| | - Sanja Kadic
- Department of Maxillofacial Surgery, University Hospital of Split, 21000 Split, Croatia
| | - Antonella Lesin
- Department of Maxillofacial Surgery, University Hospital of Split, 21000 Split, Croatia
| | - Marino Vilovic
- Department of Pathophysiology, University of Split School of Medicine, 21000 Split, Croatia
| | - Slaven Lupi-Ferandin
- Department of Maxillofacial Surgery, University Hospital of Split, 21000 Split, Croatia
| | - Sasa Ercegovic
- Department of Maxillofacial Surgery, University Hospital of Split, 21000 Split, Croatia
| | - Marko Kumric
- Department of Pathophysiology, University of Split School of Medicine, 21000 Split, Croatia
| | - Josipa Bukic
- Department of Pharmacy, University of Split School of Medicine, 21000 Split, Croatia
| | - Josko Bozic
- Department of Pathophysiology, University of Split School of Medicine, 21000 Split, Croatia
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11
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Balasubramaniam R, Mossad M. Feasibility study of percutaneous thoracic duct embolization with lower-limb intermittent pneumatic compression devices. Diagn Interv Radiol 2023; 29:326-330. [PMID: 36987984 PMCID: PMC10679707 DOI: 10.5152/dir.2022.21975] [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: 10/14/2021] [Accepted: 01/19/2022] [Indexed: 01/13/2023]
Abstract
PURPOSE To demonstrate intranodal thoracic duct embolization (TDE) for treating chyle leaks following thoracic surgery and the feasibility of applying lower-limb intermittent pneumatic compression devices during TDE. METHODS Between December 2017 and October 2020, 12 consecutive TDEs for post-operative chyle leaks were performed in 11 patients using intranodal lymphangiogram (IL) with an intermittent pneumatic compressive device applied to the lower limb. The procedure's duration, technical/clinical success, and complications were retrospectively evaluated. RESULTS IL was successful at imaging the thoracic duct in all procedures (100%), and TDE had an intention- to-treat success rate of 92% (11/12). No related complications were observed during follow-up, which took place at a mean of 27 days. The time from the commencement of lymphangiogram until visualization of the thoracic duct was a mean of 21.6 min, and the mean overall procedure time was 87.3 min. CONCLUSION This study supports IL-guided TDE as a safe and effective option to treat post-thoracic surgery chyle leaks. We revealed shorter lymphangiogram times compared with previously published studies, and we postulate that the application of intermittent lower-limb pneumatic compressive devices contributed toward this study's results by expediting the return of lymph from the lower limb. This study is the first to illustrate this approach in TDE and advocates for randomized controlled studies to further evaluate the influence of intermittent pneumatic compressive devices on the procedure.
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Affiliation(s)
| | - Mona Mossad
- Department of Radiology, Royal Stoke University Hospital, Staffordshire, England
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12
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Duletzke NT, Kiraly LN, Martindale RG. Chylothorax and chylous ascites: Overview, management, and nutrition. Nutr Clin Pract 2023; 38:557-563. [PMID: 36938719 DOI: 10.1002/ncp.10973] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 03/21/2023] Open
Abstract
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.
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Affiliation(s)
- Nicholas T Duletzke
- Department of Surgery, Oregon Health and Science University, Oregon, Portland, USA
| | - Laszlo N Kiraly
- Department of Surgery, Oregon Health and Science University, Oregon, Portland, USA
| | - Robert G Martindale
- Department of Surgery, Oregon Health and Science University, Oregon, Portland, USA
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13
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Fumagalli Romario U, de Pascale S, Colombo S, Attanasio A, Sabbatini A, Sandrin F. Esophagectomy-prevention of complications-tips and tricks for the preoperative, intraoperative and postoperative stage. Updates Surg 2023; 75:343-355. [PMID: 35851675 DOI: 10.1007/s13304-022-01332-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 07/06/2022] [Indexed: 01/24/2023]
Abstract
Esophagectomy still remains the mainstay of treatment for localized esophageal cancer. Many progresses have been made in the technique of esophagectomy in the last decades but the overall morbidity for this operation remains formidable. Postoperative complication and mortality rate after esophagectomy are significant; anastomotic leak has an incidence of 11,4%. The occurrence of a complication is a significant negative prognostic factor for long term survival and is also linked to longer postoperative stay, a lower quality of life, increased hospital costs. Preventing the occurrence of postoperative morbidity and reducing associated postoperative mortality rate is a major goal for surgeons experienced in resective esophageal surgery. Many details of pre, intra and postoperative care for patients undergoing esophagectomy need to be shared among the professionals taking care of these patients (oncologists, dieticians, physiotherapists, surgeons, nurses, anesthesiologists, gastroenterologists) in order to improve the short and long term clinical results.
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14
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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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15
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Yang F, Gao J, Cheng S, Li H, He K, Zhou J, Chen K, Wang Z, Yang F, Zhang Z, Li J, Zhou Z, Chi C, Li Y, Wang J. Near-infrared fluorescence imaging of thoracic duct in minimally invasive esophagectomy. Dis Esophagus 2023; 36:6645483. [PMID: 35849094 DOI: 10.1093/dote/doac049] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 06/23/2022] [Accepted: 06/24/2022] [Indexed: 02/03/2023]
Abstract
Chylothorax is a serious complication after esophagectomy and there are unmet needs for new intraoperative navigation tools to reduce its incidence. The aim of this study is to explore the feasibility and effectiveness of near-infrared fluorescence imaging (NIR-FI) with indocyanine green (ICG) to identify thoracic ducts (TDs) and chyle leakage during video-assisted thoracoscopic esophagectomy. We recruited 41 patients who underwent thoraco-laparoscopic minimally invasive esophagectomy (MIE) for esophageal cancer in this prospective, open-label, single-arm clinical trial. ICG was injected into the right inguinal region before operations, after which TD anatomy and potential chyle leakage were checked under the near-infrared fluorescence intraoperatively. In 38 of 41 patients (92.7%) using NIR-FI, TDs were visible in high contrast. The mean signal-to-background ratio (SBR) value of all fluorescent TDs was 3.05 ± 1.56. Fluorescence imaging of TDs could be detected 0.5 hours after ICG injection and last up to 3 hours with an acceptable SBR value. The optimal observation time window is from about 1 to 2 hours after ICG injection. Under the guidance of real-time NIR-FI, three patients were found to have chylous leakage and the selective TD ligations were performed intraoperatively. No patient had postoperative chylothorax. NIR-FI with ICG can provide highly sensitive and real-time assessment of TDs as well as determine the source of chyle leakage, which might help reduce TD injury and direct selective TD ligation. It could be a promising navigation tool to reduce the incidence of chylothorax after minimally invasive esophagectomy.
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Affiliation(s)
- Feng Yang
- Department of Thoracic Surgery, Center of Thoracic Mini-invasive Surgery, Peking University People's Hospital, Beijing, China
| | - Jian Gao
- Department of Thoracic Surgery, Center of Thoracic Mini-invasive Surgery, Peking University People's Hospital, Beijing, China
| | - Sida Cheng
- Department of Thoracic Surgery, Center of Thoracic Mini-invasive Surgery, Peking University People's Hospital, Beijing, China
| | - Hao Li
- Department of Thoracic Surgery, Center of Thoracic Mini-invasive Surgery, Peking University People's Hospital, Beijing, China
| | - Kunshan He
- CAS Key Laboratory of Molecular Imaging, the State Key Laboratory of Management and Control for Complex Systems, Institute of Automation, Chinese Academy of Sciences, Beijing, China.,State Key Laboratory of Computer Science and Beijing Key Lab of Human-Computer Interaction, Institute of Software, Chinese Academy of Sciences, Beijing, China
| | - Jian Zhou
- Department of Thoracic Surgery, Center of Thoracic Mini-invasive Surgery, Peking University People's Hospital, Beijing, China
| | - Kezhong Chen
- Department of Thoracic Surgery, Center of Thoracic Mini-invasive Surgery, Peking University People's Hospital, Beijing, China
| | - Zhenfan Wang
- Department of Thoracic Surgery, Center of Thoracic Mini-invasive Surgery, Peking University People's Hospital, Beijing, China
| | - Fan Yang
- Department of Thoracic Surgery, Center of Thoracic Mini-invasive Surgery, Peking University People's Hospital, Beijing, China
| | - Zeyu Zhang
- Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, School of Medicine and Engineering, Beihang University, Beijing, China
| | - Jianfeng Li
- Department of Thoracic Surgery, Center of Thoracic Mini-invasive Surgery, Peking University People's Hospital, Beijing, China
| | - Zuli Zhou
- Department of Thoracic Surgery, Center of Thoracic Mini-invasive Surgery, Peking University People's Hospital, Beijing, China
| | - Chongwei Chi
- CAS Key Laboratory of Molecular Imaging, the State Key Laboratory of Management and Control for Complex Systems, Institute of Automation, Chinese Academy of Sciences, Beijing, China
| | - Yun Li
- Department of Thoracic Surgery, Center of Thoracic Mini-invasive Surgery, Peking University People's Hospital, Beijing, China
| | - Jun Wang
- Department of Thoracic Surgery, Center of Thoracic Mini-invasive Surgery, Peking University People's Hospital, Beijing, China
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16
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Akbar A, Hendrickson T, Vangara A, Marlowe S, Hussain A, Ganti SS. Hepatic Chylothorax: An Uncommon Pleural Effusion. J Investig Med High Impact Case Rep 2023; 11:23247096221150634. [PMID: 36644885 PMCID: PMC9846292 DOI: 10.1177/23247096221150634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
An 83-year-old male with chronic obstructive pulmonary disease and liver cirrhosis presented with confusion and dyspnea. On chest X-ray, he had the right mid to lower lung zone white out. Ultrasound-guided thoracentesis drained 1.5 L of milky white pleural fluid which was transudative according to chemical analysis. Transudative chylothorax in liver cirrhosis without ascites is rare, but can happen. When the flow of ascitic chylous fluid into the pleural space equals the rate of ascites production, clinical absence of detectable ascites will occur. Hepatic chylothorax is important and should be kept in differentials when evaluating patients with liver cirrhosis.
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Affiliation(s)
- Aelia Akbar
- Appalachian Regional Healthcare, Harlan, KY, USA
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17
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Komatsuzaki S, Hisakura K, Ogawa K, Akashi Y, Kim J, Moue S, Miyazaki Y, Furuya K, Doi M, Owada Y, Shimomura O, Ohara Y, Takahashi K, Hashimoto S, Enomoto T, Koike N, Oda T. Transhiatal bilateral thoracic duct ligation for duplicated thoracic duct injury after esophagectomy: a case report. Surg Case Rep 2022; 8:213. [DOI: 10.1186/s40792-022-01567-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 11/15/2022] [Indexed: 12/03/2022] Open
Abstract
Abstract
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.
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18
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Agrawal A, Chaddha U, Kaul V, Desai A, Gillaspie E, Maldonado F. Multidisciplinary Management of Chylothorax. Chest 2022; 162:1402-1412. [PMID: 35738344 DOI: 10.1016/j.chest.2022.06.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 05/04/2022] [Accepted: 06/10/2022] [Indexed: 12/14/2022] Open
Abstract
Chylothorax, the accumulation of chyle in the pleural space, is usually caused by the disruption of the thoracic duct or its tributaries. Etiologies are broadly divided into traumatic, including postsurgical, and nontraumatic, most commonly in the setting of malignancy. The management of chylothorax largely depends on the cause and includes dietary modification and drainage of the pleural space. A definitive intervention, whether surgical or a percutaneous lymphatic intervention, should be considered in patients with a persistently high volume of chylous output and in those with a prolonged leak, before complications such as malnutrition ensue. No methodologically robust clinical trials guiding management are currently available. In this article, we review the current literature and propose a stepwise, evidence-based multidisciplinary approach to the management of patients with both traumatic and nontraumatic chylothorax.
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Affiliation(s)
- Abhinav Agrawal
- Interventional Pulmonology, Division of Pulmonary, Critical Care & Sleep Medicine, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY.
| | - Udit Chaddha
- Interventional Pulmonology, Division of Pulmonary, Critical Care & Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Viren Kaul
- Division of Pulmonary and Critical Care Medicine, Crouse Health/SUNY Upstate Medical University, Syracuse, NY
| | - Ajinkya Desai
- Interventional Radiology, Department of Radiology, University of Mississippi Medical Center, Jackson, MS
| | - Erin Gillaspie
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Fabien Maldonado
- Interventional Pulmonology, Department of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
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19
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Mahmodlou R, Yousefiazar A. Incidence of chylothorax over nineteen years of transhiatal esophagectomy: A case series and review study. Turk J Surg 2022; 38:401-408. [PMID: 36875269 PMCID: PMC9979556 DOI: 10.47717/turkjsurg.2022.5821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 09/12/2022] [Indexed: 01/12/2023]
Abstract
Objectives Chylothorax (CTx) is the leak and accumulation of lymphatic fluid within the pleural cavity. The incidence of CTx has the highest rate after esophagectomy. This study aimed to present three cases of post-esophagectomy chylothorax among 612 esophagectomies that were performed over 19 years, in which post-esophagectomy chylothorax was reviewed in terms of risk factors, diagnosis, and management. Material and Methods Six hundred and twelve patients were included in the study. Transhiatal esophagectomy was used for all patients. In three cases, chylothorax was detected. In all of the three cases, secondary surgery was performed for the management of chylothorax. Mass ligation was performed for the first and third cases having leak from the right side. In the second case, the leak was from the left side without prominent duct; and despite mass ligation that was done several times, no significant reduction in chyle was observed. Results In the first case, in spite of reduced output, the patient gradually progressed to respiratory distress. His condition deteriorated over time and he died after three days. In the second case that needed third surgery, the patient's condition deteriorated and she died after two days due to respiratory failure. The third patient had postoperative recovery. The patient was discharged on fifth day after the second operation. Conclusion In post-esophagectomy chylothorax, the key to preventing high mortality rates can be the identification of risk factors as well as timely detection of symptoms and proper management. Besides, early surgical intervention should be considered to prevent early complications of chylothorax.
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Affiliation(s)
- Rahim Mahmodlou
- Department of General Surgery, Urmia University of Medical Sciences, Urmia, Iran
| | - Awat Yousefiazar
- Department Anesthesia and Surgical Technology, Urmia University of Medical Sciences School of Allied Medical Sciences, Urmia, Iran
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20
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Adequate Management of Postoperative Complications after Esophagectomy: A Cornerstone for a Positive Outcome. Cancers (Basel) 2022; 14:cancers14225556. [PMID: 36428649 PMCID: PMC9688292 DOI: 10.3390/cancers14225556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 11/09/2022] [Accepted: 11/10/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Esophagectomy for cancer is one of the most complex procedures in visceral surgery. Postoperative complications negatively affect the patient's overall survival. They are not influenced by the histology type (adenocarcinoma (AC)/squamous cell carcinoma (SCC)), or the surgical approach (open, laparoscopic, or robotic-assisted). Among those dreadful complications are anastomotic leak (AL), esophago-respiratory fistula (ERF), and chylothorax (CT). METHODS In this review, we summarize the methods to avoid these complications, the diagnostic approach, and new therapeutic strategies. RESULTS In the last 20 years, both centralization of the medical care, and the development of endoscopy and radiology have positively influenced the management of postoperative complications. For the purpose of their prevention, perioperative measures have been applied. The treatment includes conservative, endoscopic, and surgical approaches. CONCLUSIONS Post-esophagectomy complications are common. Prevention measures should be known. Early recognition and adequate treatment of these complications save lives and lead to better outcomes.
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21
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Ongoing Controversies in Esophageal Cancer I. Thorac Surg Clin 2022; 32:541-551. [DOI: 10.1016/j.thorsurg.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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22
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Wang S, Jiang W. Post-esophagectomy chylothorax refractory to mass ligation of thoracic duct above diaphragm: a case report. J Cardiothorac Surg 2022; 17:259. [PMID: 36203167 PMCID: PMC9540730 DOI: 10.1186/s13019-022-02001-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 09/18/2022] [Indexed: 11/10/2022] Open
Abstract
Background Post-esophagectomy chylothorax is a relatively rare but potentially lethal complication. The treatment strategy of post-esophagectomy chylothorax remains a subject of debate which mainly focuses on the indication and timing of surgical intervention. For cases in which the leakage site is not localized, a mass ligation of the thoracic duct above diaphragm is advocated as the surgical procedure is believed to ensure sealing all the accessory ducts that could be the source of the chylothorax. But in this paper, we report a case of post-esophagectomy chylothorax which was refractory to mass ligation of thoracic duct above diaphragm. Case presentation A 59-year old man suffered from high output chylothorax (> 1000 ml/24 h for more than 30 days) after esophagectomy through left thoracotomy. Considering the failure of lymphangiography, we performed mass ligation of thoracic duct above diaphragm. However, we failed to close the chylous leakage. Finally, we found that a rare variated tributary of thoracic duct was the resource of the chylous output. Both the variation of lymphatic system and the coincidence of injured site lead to the invalidness of reoperation. After definitely ligating the variated tributary, chylothorax was cured. Conclusion This case supplies a direct evidence that mass ligation of thoracic duct is of no avail in some refractory chylothorax, which indicates the importance of chylous leakage localization.
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Affiliation(s)
- Shengxi Wang
- Department of Oncology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324 Jingwu Road, Huaiyin District, Jinan, 250000, Shandong, China
| | - Wenpeng Jiang
- Department of Thoracic Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 324 Jingwu Road, Huaiyin District, Jinan, 250000, Shandong, China.
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23
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Abstract
Esophageal squamous cell carcinoma (ESCC) is common in the developing world with decreasing incidence in developed countries and carries significant morbidity and mortality. Major risk factors for ESCC development include significant use of alcohol and tobacco. Screening for ESCC can be recommended in high-risk populations living in highly endemic regions. The treatment of ESCC ranges from endoscopic resection therapy or surgery in localized disease to chemoradiotherapy in metastatic disease, and prognosis is directly related to the stage at diagnosis. New immunotherapies and molecular targeted therapies may improve the dismal survival outcomes in patients with metastatic ESCC.
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Affiliation(s)
- D Chamil Codipilly
- Division of Gastroenterology and Hepatology, Mayo Clinic, SMH Campus, 6 Alfred GI Unit, 200 1st Street South West, Rochester MN 55905, USA
| | - Kenneth K Wang
- Division of Gastroenterology and Hepatology, Mayo Clinic, SMH Campus, 6 Alfred GI Unit, 200 1st Street South West, Rochester MN 55905, USA.
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Risk Factors, Diagnosis and Management of Chyle Leak Following Esophagectomy for Cancers. ANNALS OF SURGERY OPEN 2022; 3:e192. [PMID: 36199483 PMCID: PMC9508983 DOI: 10.1097/as9.0000000000000192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 06/28/2022] [Indexed: 11/26/2022] Open
Abstract
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.
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Intra-Nodal Indocyanine Green Injection to Delineate Thoracic Duct During Minimally Invasive Esophagectomy. J Gastrointest Surg 2022; 26:1559-1565. [PMID: 35501550 DOI: 10.1007/s11605-022-05341-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 04/16/2022] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Post-operative chylothorax is a dreaded complication after esophagectomy; hence real-time identification of the thoracic duct (TD) may aid in avoiding its injury or promptly tackling injury when it occurs. We utilized intra-nodal injection of Indocyanine green (ICG) dye to delineate TD anatomy while performing esophagectomy for esophageal carcinoma. METHOD Two ml of 1 mg/ml solution of ICG was injected into the inguinal lymph nodes under ultrasound guidance. TD was checked with the laparoscopic Karl Storz IMAGE1 STM or Robotic da Vinci Xi system. The thoracic esophagus, periesophageal tissue, and lymph nodes were dissected. The TD was visualized throughout the dissection using OverlayTM technology & Firefly mode™ and checked at the end to rule out any dye leak. TD was clipped if any dye leakage or TD injury (TDI) was noted using Near Infra-Red Spectroscopy. RESULTS Twenty one patients with M:F 13:8 underwent minimally invasive esophagectomy (MIE) [thoracoscopic assisted (n = 15) and robotic-assisted (n = 6)]. TD was visualized in all the cases after a median (IQR) time of 35 (30, 35) min. The median (IQR) duration of the thoracic phase was 150 (120,165) min. TDI occurred in 1 case, identified intra-operatively, and TD was successfully clipped. There were no post-operative chylothorax or adverse reactions from the ICG injection. CONCLUSION Intra-nodal ICG injection before MIE helps to identify the TD in real-time and is a valuable intra-operative aid to prevent or successfully manage a TD injury. It may help to prevent the dreaded complication of post-operative chylothorax after esophagectomy.
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Robinson AV, Kennedy L, Roper T, Khan M, Jaunoo S. The management of chyle leak post-oesophagectomy for oesophageal carcinoma: a systematic review. Ann R Coll Surg Engl 2022; 104:480-489. [PMID: 34860128 PMCID: PMC9246555 DOI: 10.1308/rcsann.2021.0199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Chyle leak is an uncommon yet potentially fatal complication of oesophagectomy for oesophageal cancer. The management of chyle leak is a debated, controversial topic and to date there is no standardised approach or validated algorithm for its management. This review aims to summarise current treatment algorithms for chyle leak post-oesophagectomy and their outcomes. METHODS A systematic search of Embase, MEDLINE, UpToDate and Cochrane was conducted to identify studies reporting on the management of chyle leak following oesophagectomy for oesophageal cancer. Data on interventional success rate and mortality are reported. FINDINGS Twenty-one studies met the inclusion criteria including over 23,254 oesophagectomies and identifying 838 chyle leaks (incidence <3.6%). The majority of cases were initially managed conservatively (95.3%), with a failure rate of 50.4%. Immediate surgical or radiological management resolved chylothorax in the majority of cases (97.3%), however the numbers were small. Death occurred in 54 cases (6.6%), all of whom underwent conservative management initially. CONCLUSIONS Owing to the heterogeneity of treatment algorithms, timings and indications for interventions, the optimal strategy for managing chyle leak remains unclear. This review has identified an unmet need for prospective multicentre studies assessing the efficacy of predefined algorithms.
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Affiliation(s)
- AV Robinson
- University Hospitals Sussex NHS Foundation Trust, UK
| | - L Kennedy
- University Hospitals Sussex NHS Foundation Trust, UK
| | - T Roper
- University Hospitals Sussex NHS Foundation Trust, UK
| | - M Khan
- University Hospitals Sussex NHS Foundation Trust, UK
| | - S Jaunoo
- University Hospitals Sussex NHS Foundation Trust, UK
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Barbato G, Cammelli F, Braccini G, Staderini F, Cianchi F, Coratti F. Fluorescent lymphography for thoracic duct identification: Initial experience of a simplified and feasible ICG administration. Int J Med Robot 2022; 18:e2380. [PMID: 35120398 DOI: 10.1002/rcs.2380] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 12/30/2021] [Accepted: 02/01/2022] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Indocyanine green (ICG) lymphography can be performed to obtain realtime fluorescent images of the thoracic duct (TD). The injection of ICG into the inguinal nodes usually is ultrasound-guided. Our hypothesis was to simplify the ICG administration until making it executable by unqualified personnel without ultrasound guidance. MATERIAL AND METHODS From October 2019 to October 2021 we enroled 18 patients. ICG was injected with a 25 Gauge needle in the subcutaneous tissue of the inguinal region bilaterally 14-16 h before surgery. RESULTS The TD was visualised in every case considered. The easy switching between fluorescence and white light visualization facilitated the identification and dissection of the TD avoiding involuntary injuries. CONCLUSIONS The simplified ICG administration to identify TD during oesophagectomy is easy to perform, does not require specifically trained staff, is not time demanding and has comparable results to the procedure performed under ultrasound guide.
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Affiliation(s)
- Giuseppe Barbato
- Digestive Surgery Unit, Department of Clinical and Experimental Medicine, Careggi University Hospital, Florence, Italy
| | - Francesca Cammelli
- Digestive Surgery Unit, Department of Clinical and Experimental Medicine, Careggi University Hospital, Florence, Italy
| | - Giovanni Braccini
- Digestive Surgery Unit, Department of Clinical and Experimental Medicine, Careggi University Hospital, Florence, Italy
| | - Fabio Staderini
- Digestive Surgery Unit, Department of Clinical and Experimental Medicine, Careggi University Hospital, Florence, Italy
| | - Fabio Cianchi
- Digestive Surgery Unit, Department of Clinical and Experimental Medicine, Careggi University Hospital, Florence, Italy
| | - Francesco Coratti
- Digestive Surgery Unit, Department of Clinical and Experimental Medicine, Careggi University Hospital, Florence, Italy
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Lymphatic Interventions in the Cancer Patient. Curr Oncol Rep 2022; 24:1351-1361. [PMID: 35639331 DOI: 10.1007/s11912-022-01293-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW The incidence of lymphatic leakage (iatrogenic and non-iatrogenic) is growing in cancer population due to the increased complexity of the surgical procedures and improved overall survival in cancer patients. The purpose of this article is to review the contemporary approach in the field of percutaneous lymphatic embolization in cancer patients with lymphatic leaks. RECENT FINDINGS Since the advent of intranodal lymphangiography in 2011 alongside with the MR and CT lymphangiography, the accuracy of diagnosis of the lymphatic diseases has significantly improved significantly. These advancements have triggered a revival of minimally invasive lymphatic interventions. Lymphatic embolization is expanding from the classic indication, thoracic duct embolization, to other lymphatic disorders (chylous ascites, lymphoceles, liver lymphorrhea, protein-losing enteropathy). The growth of lymphatic research and the standardization of the lymphatic interventions require a multidisciplinary and collaborative approach between physicians and researchers.
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Bak SH, Kim C, Kim CH, Ohno Y, Lee HY. Magnetic resonance imaging for lung cancer: a state-of-the-art review. PRECISION AND FUTURE MEDICINE 2022. [DOI: 10.23838/pfm.2021.00170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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30
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Lin H, Liang G, Chai H, Liao Y, Zhang C, Cheng Y. Comparison of Two Circular-Stapled Techniques for Esophageal Cancer: A Propensity-Matched Analysis. Front Oncol 2022; 11:759599. [PMID: 34976807 PMCID: PMC8716395 DOI: 10.3389/fonc.2021.759599] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 11/25/2021] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVE The optimal technique for the thoracoscopic construction of an intrathoracic esophagogastric anastomosis continues to be a subject of controversy. The aim of this study was to compare the perioperative outcomes of circular-stapled anastomosis using a transorally inserted anvil (Orvil™) with those of circular-stapled anastomosis using a transthoracically placed anvil (non-Orvil™) in totally minimally invasive Ivor Lewis esophagectomy (Ivor Lewis TMIE). METHODS The data of 272 patients who underwent Ivor Lewis TMIE for esophageal cancer at multiple centers were collected from January 1, 2014 to December 31, 2017. After propensity score matching (1:1) for patient baseline characteristics, 65 paired cases were selected for statistical analysis. Logistic regression analysis was performed to investigate the significant factors of anastomotic leakage. RESULTS In the propensity score-matched analysis, compared with the non-Orvil™ group, the Orvil™ group was associated with a significantly shorter operation time (p=0.031), less intraoperative hemorrhage (p<0.001), lower need for intraoperative transfusions (p=0.009), earlier postoperative oral feeding time (p=0.010), longer chest tube duration (p<0.001), shorter postoperative hospital stays (p=0.001), lower total hospitalization costs (p<0.001) and a lower postoperative anastomotic leakage rate (p=0.033). Multivariate logistic regression analysis showed that anastomotic technique and pulmonary infection were independent factors for the development of postoperative anastomotic leakage (p< 0.05). CONCLUSIONS Orvil™ anastomosis exhibited better perioperative effects than non-Orvil™ anastomosis after the propensity score-matched analysis. Remarkably, the Orvil™ technique contributed to a lower postoperative anastomotic leakage rate than the non-Orvil™ technique.
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Affiliation(s)
- Hang Lin
- Department of Thoracic Surgery, Xiangya Hospital, Central South University, Changsha, China.,Department of Oncology, National Health Commission (NHC) Key Laboratory of Cancer Proteomics, Xiangya Hospital, Central South University, Changsha, China
| | - Ge'ao Liang
- Department of Burns and Plastic Surgery, Third Xiangya Hospital, Central South University, Changsha, China
| | - Huiping Chai
- Department of Thoracic Surgery, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yongde Liao
- Department of Thoracic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chunfang Zhang
- Department of Thoracic Surgery, Xiangya Hospital, Central South University, Changsha, China.,Human Engineering Research Center for Pulmonary Nodules Precise Diagnosis and Treatment, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Yuanda Cheng
- Department of Thoracic Surgery, Xiangya Hospital, Central South University, Changsha, China.,Human Engineering Research Center for Pulmonary Nodules Precise Diagnosis and Treatment, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
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Power R, Smyth P, Donlon NE, Nugent T, Donohoe CL, Reynolds JV. Management of chyle leaks following esophageal resection: a systematic review. Dis Esophagus 2021; 34:doab012. [PMID: 33723611 PMCID: PMC8597908 DOI: 10.1093/dote/doab012] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 01/28/2021] [Accepted: 02/01/2021] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Robert Power
- National Oesophageal and Gastric Centre, St James's Hospital, Dublin, Ireland
| | - Philip Smyth
- National Oesophageal and Gastric Centre, St James's Hospital, Dublin, Ireland
| | - Noel E Donlon
- National Oesophageal and Gastric Centre, St James's Hospital, Dublin, Ireland
| | - Timothy Nugent
- National Oesophageal and Gastric Centre, St James's Hospital, Dublin, Ireland
| | - Claire L Donohoe
- National Oesophageal and Gastric Centre, St James's Hospital, Dublin, Ireland
| | - John V Reynolds
- National Oesophageal and Gastric Centre, St James's Hospital, Dublin, Ireland
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Higuchi T, Ozawa S, Koyanagi K, Oguma J, Ninomiya Y, Yatabe K, Yamamoto M, Nomura T, Niwa T. Clinical impacts of magnetic resonance thoracic ductography on preventing postoperative chylothorax after thoracoscopic esophagectomy for esophageal cancer. Esophagus 2021; 18:753-763. [PMID: 33770289 DOI: 10.1007/s10388-021-00832-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 03/20/2021] [Indexed: 02/03/2023]
Abstract
PURPOSE The study aimed to determine whether magnetic resonance thoracic ductography (MRTD) is useful for preventing injury to the thoracic duct (TD) during thoracoscopic esophagectomy and for reducing the incidence of postoperative chylothorax. MATERIALS AND METHOD A total of 389 patients underwent thoracoscopic esophagectomy between September 2009 and February 2019 in Tokai University Hospital. Of them, we evaluated 228 patients who underwent preoperative MRTD (MRTD group) using Adachi's classification and our novel classification (Tokai classification). Then, the clinicopathological factors of the MRTD group (n = 228) were compared with those of the non-MRTD group (n = 161), and comparative analyses were conducted after propensity score matching (PSM). RESULTS The TD could be visualized by MRTD in 228 patients. The MRTD findings were divided into 9 classifications including normal findings and abnormal TD findings (Adachi classification vs Tokai classification; 5.3% vs 16.2%). After PSM, both groups consisted of 128 patients. The rate of postoperative chylothorax after thoracoscopic esophagectomy was significantly lower in the MRTD group (0.8%) than in the non-MRTD group (6.3%) (p = 0.036). In the multivariate analysis for risk factors for chylothorax, the independent prognostic factors were preoperative therapy and the presence of MRTD. CONCLUSIONS This study revealed that MRTD was useful for preventing of chylothorax after thoracoscopic esophagectomy for esophageal cancer.
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Affiliation(s)
- Tadashi Higuchi
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Soji Ozawa
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan.
| | - Kazuo Koyanagi
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Junya Oguma
- Division of Esophageal Surgery, National Cancer Center Hospital, Tokyo, Japan
| | - Yamato Ninomiya
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Kentaro Yatabe
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Miho Yamamoto
- Department of Gastroenterological Surgery, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
| | - Takakiyo Nomura
- Department of Radiology, Tokai University School of Medicine, Kanagawa, Japan
| | - Tetsu Niwa
- Department of Radiology, Tokai University School of Medicine, Kanagawa, Japan
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Fluorescence Guided Thoracic Duct Dissection in Robotic En-bloc Esophagectomy. Ann Thorac Surg 2021; 113:e465-e467. [PMID: 34560041 DOI: 10.1016/j.athoracsur.2021.08.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 08/11/2021] [Indexed: 11/24/2022]
Abstract
En-bloc resection of the thoracic duct compartment enhances adequate lymph node removal and may improve oncological outcomes in esophagectomy for esophageal malignancies. However, it also increases the risk of postoperative chylothorax with a reported incidence of 5-20%. We describe a technique that facilitates intraoperative identification of the thoracic duct as well as proximal and distal ligation during robot-assisted esophagectomy by lymphangiography guided injection of indocyanine green in de right groin in left lateral positioning. This approach can be swiftly applied at any time during any thoracoscopic procedure in lateral position when visualization of the thoracic duct anatomy is needed.
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Takhellambam L, Yadav TD, Kumar H, Gupta V, Tandup C, Gorsi U, Sharma V, Mandhavdhare H, Samra T, Singh H. Prophylactic ligation of the opacified thoracic duct in minimally invasive esophagectomy - feasibility and safety. Langenbecks Arch Surg 2021; 406:2515-2520. [PMID: 34410481 DOI: 10.1007/s00423-021-02300-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 08/09/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Chyle leak is a rare but morbid complication of esophagectomy. We assessed the feasibility of visualization and prophylactic ligation of the opacified thoracic duct (TD) after administration of 50 ml of olive oil. METHODS This prospective single center study considered all patients with carcinoma of the middle and lower thirds of the thoracic esophagus including the gastroesophageal junction (GEJ), managed from January 2018 to December 2019, for inclusion. All patients underwent McKeown minimally invasive esophagectomy. After anesthesia and endotracheal intubation, 50 ml of olive oil was administered through a nasogastric (NG) tube. During thoracoscopic esophageal mobilization, the opacified thoracic duct was identified and ligated using Weck Hem-o-lok clips immediately above the diaphragmatic hiatus. Postoperatively, the nature, volume, and triglyceride levels of the fluid from the chest drain were recorded. RESULTS Forty-three patients with carcinoma of the esophagus were assessed for inclusion and eventually, 33 were enrolled. The median age of the study population was 55 years, and there were 20 males. The tumor site was the lower esophagus in 24 (72.7%) patients. The most common histolopathological finding was squamous cell carcinoma (97%). The opacified thoracic duct could be identified and ligated in 31 (93.9%) patients. The median duration from the administration of olive oil to the ligation of the thoracic duct was 100 min. The median chest drain output and triglyceride levels on postoperative day (POD) one were 250 ml and 48 mg% respectively. No patient developed postoperative chylothorax. CONCLUSION Opacification and visualization of the thoracic duct during thoracoscopy can be aided by administering olive oil. Ligation of this opacified duct is feasible and safe.
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Affiliation(s)
- Lunkhomba Takhellambam
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Thakur Deen Yadav
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Hemanth Kumar
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vikas Gupta
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Cherring Tandup
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ujjwal Gorsi
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Vishal Sharma
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Harshal Mandhavdhare
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Tanvir Samra
- Department of Anaesthesiology and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Harjeet Singh
- Department of Surgical Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
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Syal R, Kumar R, Varshney VK, Garg P. Post-oesophagectomy chylothorax: An unusual cause of postoperative stridor. Indian J Anaesth 2021; 65:345-347. [PMID: 34103756 PMCID: PMC8174585 DOI: 10.4103/ija.ija_1130_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 10/18/2020] [Accepted: 02/09/2021] [Indexed: 12/03/2022] Open
Affiliation(s)
- Rashmi Syal
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Rakesh Kumar
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Vaibhav K Varshney
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Pawan Garg
- Department of Interventional Radiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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Leray H, Brouchet L, Tanguy Le Gac Y, Bouharaoua S, Otal P, Ferron G, Gabiache E, Angeles MA, Martínez-Gómez C, Martinez A. Postoperative chest liver herniation after cardiophrenic lymph node resection by a transdiaphragmatic approach following primary cytoreductive surgery for advanced endometrioid ovarian cancer: A case report. Gynecol Oncol Rep 2021; 36:100727. [PMID: 33728369 PMCID: PMC7935709 DOI: 10.1016/j.gore.2021.100727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 02/04/2021] [Accepted: 02/07/2021] [Indexed: 10/31/2022] Open
Abstract
Resection of enlarged cardiophrenic lymph nodes (CPLN) is a procedure required to obtain complete cytoreduction in selected patients affected by advanced ovarian cancer. Their resection by transdiaphragmatic approach has been demonstrated to be feasible with low rates of morbidity. The main complications associated with this procedure are pleural effusion, pneumothorax, and rarely, chylothorax. This case describes a postoperative chylothorax and chest liver herniation in a patient who underwent a cytoreductive surgery for advanced endometrioid ovarian cancer, which included a right transdiaphragmatic CPLN resection. Surgical management by thoracotomy was required to repair the right diaphragmatic defect combined with conservative management of the chylothorax. The diaphragmatic closure was achieved employing interrupted stitches with a non-absorbable suture. No prosthetic material was required.
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Affiliation(s)
- Hélène Leray
- Department of Surgical Oncology, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse (IUCT) - Oncopole, Toulouse, France
| | - Laurent Brouchet
- Department of Thoracic Surgery, Hospital Larrey, Toulouse University Hospital, Toulouse, France
| | - Yann Tanguy Le Gac
- Department of Surgical Oncology, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse (IUCT) - Oncopole, Toulouse, France
| | - Sihem Bouharaoua
- Intensive Care Unit, Toulouse University Hospital, Institut Universitaire du Cancer de Toulouse (IUCT) - Oncopole, Toulouse, France
| | - Philippe Otal
- Radiology Department, Hospital Rangueil, Toulouse University Hospital, Toulouse, France
| | - Gwenaël Ferron
- Department of Surgical Oncology, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse (IUCT) - Oncopole, Toulouse, France.,INSERM CRCT Team 19, ONCOSARC - Oncogenesis of sarcomas, Toulouse, France
| | - Erwan Gabiache
- Department of Nuclear Medicine, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse (IUCT) - Oncopole, Toulouse, France
| | - Martina Aida Angeles
- Department of Surgical Oncology, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse (IUCT) - Oncopole, Toulouse, France
| | - Carlos Martínez-Gómez
- Department of Surgical Oncology, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse (IUCT) - Oncopole, Toulouse, France.,INSERM CRCT Team 1, Tumor Immunology and Immunotherapy, Toulouse, France
| | - Alejandra Martinez
- Department of Surgical Oncology, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse (IUCT) - Oncopole, Toulouse, France.,INSERM CRCT Team 1, Tumor Immunology and Immunotherapy, Toulouse, France
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Ding PX, Liu C, Lu HB, Wang L, Li ZM, Lee EW. Giant mediastinal lymphocele after esophagectomy successfully treated with thoracic duct embolization. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2021; 7:215-218. [PMID: 33997556 PMCID: PMC8093313 DOI: 10.1016/j.jvscit.2020.12.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 12/23/2020] [Indexed: 11/30/2022]
Abstract
A 64-year old man had developed a giant mediastinal lymphocele after undergoing esophagectomy for the treatment of esophageal squamous cell carcinoma. The thoracic duct was embolized with six micro-coils, followed by embolization using a 1:3 mixture of N-butyl-2-cyanoacrylate (Histoacryl; B. Braun, Melsungen, Germany) and ethiodized oil. Resolution of the lymphocele was achieved within 5 days after embolization. To the best of our knowledge, ours is the first reported case of thoracic duct embolization for the treatment of mediastinal lymphocele.
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Affiliation(s)
- Peng-Xu Ding
- Department of Intervention, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Chao Liu
- Department of Intervention, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Hui-Bin Lu
- Department of Intervention, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ling Wang
- Department of Intervention, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zong-Ming Li
- Department of Intervention, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Edward Wolfgang Lee
- Division of Interventional Radiology, Department of Radiology, UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, Calif
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Milito P, Chmelo J, Dunn L, Kamarajah SK, Madhavan A, Wahed S, Immanuel A, Griffin SM, Phillips AW. Chyle Leak Following Radical En Bloc Esophagectomy with Two-Field Nodal Dissection: Predisposing Factors, Management, and Outcomes. Ann Surg Oncol 2020; 28:3963-3972. [PMID: 33263829 PMCID: PMC8184542 DOI: 10.1245/s10434-020-09399-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 10/31/2020] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Pamela Milito
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK.,University of Milan, Milan, Italy
| | - Jakub Chmelo
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Lorna Dunn
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK.,Northumbria Healthcare NHS Foundation Trust, Northumbria, UK
| | - Sivesh K Kamarajah
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Anantha Madhavan
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Shajahan Wahed
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Arul Immanuel
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - S Michael Griffin
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Alexander W Phillips
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK. .,School of Medical Education, Newcastle University, Newcastle upon Tyne, UK.
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Abbas AE, Sarkaria IS. Specific complications and limitations of robotic esophagectomy. Dis Esophagus 2020; 33:6006411. [PMID: 33241309 DOI: 10.1093/dote/doaa109] [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: 05/15/2020] [Revised: 08/24/2020] [Accepted: 09/12/2020] [Indexed: 12/11/2022]
Abstract
Regardless of the approach to esophagectomy, it is an operation that may be associated with significant risk to the patient. Robotic-assisted minimally invasive esophagectomy (RAMIE) has the same potential for short- and long-term complications as does open and minimally invasive esophagectomy. These complications include among others, the risk for anastomotic leak, gastric tip necrosis, vocal cord palsy, and chylothorax. Moreover, there are additional risks that are unique to the robotic platform such as hardware or software malfunction. These risks are heavily influenced by numerous factors including the patient's comorbidities, whether neoadjuvant therapy was administered, and the extent of the surgical team's experience. The limitations of RAMIE are therefore based on the careful assessment of the patient for operability, the tumor for resectability and the team for surgical ability. This article will tackle the topic of complications and limitations of RAMIE by examining each of these issues. It will also describe the recommended terminology for reporting post-esophagectomy complications.
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Affiliation(s)
- Abbas E Abbas
- Division of Thoracic Surgery, Department of Thoracic Medicine and Surgery, Temple University Hospital and Fox Chase Cancer Center, Philadelphia, PA, USA, and
| | - Inderpal S Sarkaria
- Division of Thoracic Surgery, Department of Surgery, University of Pittsburg Medical Center, Pittsburgh, PA, USA
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Shang QX, Wang YC, Yang YS, Hu WP, Chen LQ. Pattern of subcarinal lymph node metastasis and dissection strategy for thoracic esophageal cancer. J Thorac Dis 2020; 12:5667-5677. [PMID: 33209399 PMCID: PMC7656376 DOI: 10.21037/jtd-20-1776] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background This study aimed to assess the role of subcarinal lymph nodes in lymph node metastasis in thoracic esophageal squamous cell carcinoma (ESCC) and to investigate the adequate range of lymph node dissection during esophagectomy. Methods This study included 782 thoracic ESCC patients who underwent esophagectomy between July 2008 and December 2010. The metastatic rate of subcarinal lymph nodes and their influencing factors were investigated. The outcome of subcarinal lymph node dissection was assessed using the efficacy index (the incidence of metastasis to a lymph node station (%) multiplied by the 5-year survival rate (%) of patients with metastasis to that lymph node station and divided by 100). Additionally, postoperative complications were compared between the subcarinal lymph node resection and reservation groups. Results The metastatic rates of subcarinal lymph nodes in the upper, middle, and lower thoracic ESCC were 8.3% (4/48), 19.1% (79/414), and 16.2% (23/142), respectively (χ2=3.669, P>0.05) and in T1, T2, T3, and T4 tumors were 0% (0/71), 4% (4/100), 22.2% (85/383), and 34% (17/50), respectively (χ2=42.859, P<0.05). Tumor invasion and size were significantly correlated with metastasis. For upper thoracic ESCC with positive subcarinal lymph nodes, metastasis tendency was mainly to the lower mediastinum. In middle third esophageal cancer, after subcarinal lymph nodes were involved, metastasis to the lower mediastinal lymph nodes increased by nearly 50%, and bidirectional metastasis increased by nearly three times compared with that before involvement. For lower third cancer with positive subcarinal lymph nodes, metastasis tendency was mainly to the upper mediastinum. The postoperative complication rates in the resection and reservation groups were as follows: overall, 19% and 14.6%, respectively (P>0.05), and pulmonary, 10.3% and 7.3%, respectively (P>0.05). The efficacy indexes of lymph node dissection at the upper, middle, and lower third esophagus were 0%, 7.6%, and 27.5%, respectively. Conclusions Dissection of subcarinal lymph nodes, which does not increase postoperative complications, should be performed routinely in lower thoracic ESCC after submucosal invasion of tumor; meanwhile, tumors larger than 3cm should also result in subcarinal lymph node dissection in patients with a tumor located in the upper esophagus and T1-T2 ESCC.
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Affiliation(s)
- Qi-Xin Shang
- Department of Thoracic Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Yun-Cang Wang
- Department of Thoracic Surgery, Hospital of Chengdu Office of People's Government of Tibetan Autonomous Region, Chengdu, China
| | - Yu-Shang Yang
- Department of Thoracic Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Wei-Peng Hu
- Department of Thoracic Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Long-Qi Chen
- Department of Thoracic Surgery, West China Hospital of Sichuan University, Chengdu, China
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Donlon NE, Nugent TS, Power R, Butt W, Kamaludin A, Dolan S, Guiney M, Mc Eniff N, Ravi N, Reynolds JV. 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. Ir J Med Sci 2020; 190:1111-1116. [PMID: 33040261 DOI: 10.1007/s11845-020-02396-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 10/07/2020] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Noel E Donlon
- Department of Surgery, National Oesophageal and Gastric Cancer Center, St. James's Hospital and Trinity College Dublin, Dublin, Ireland.
| | - Tim S Nugent
- Department of Surgery, National Oesophageal and Gastric Cancer Center, St. James's Hospital and Trinity College Dublin, Dublin, Ireland
| | - Robert Power
- Department of Surgery, National Oesophageal and Gastric Cancer Center, St. James's Hospital and Trinity College Dublin, Dublin, Ireland
| | - Waqas Butt
- Department of Surgery, National Oesophageal and Gastric Cancer Center, St. James's Hospital and Trinity College Dublin, Dublin, Ireland
| | - Ahmad Kamaludin
- Department of Surgery, National Oesophageal and Gastric Cancer Center, St. James's Hospital and Trinity College Dublin, Dublin, Ireland
| | - Steven Dolan
- Department of Interventional Radiology, St. James's Hospital and Beacon Hospital, Dublin, Ireland
| | - Michael Guiney
- Department of Interventional Radiology, St. James's Hospital and Beacon Hospital, Dublin, Ireland
| | - Niall Mc Eniff
- Department of Interventional Radiology, St. James's Hospital and Beacon Hospital, Dublin, Ireland
| | - Narayanasamy Ravi
- Department of Surgery, National Oesophageal and Gastric Cancer Center, St. James's Hospital and Trinity College Dublin, Dublin, Ireland
| | - John V Reynolds
- Department of Surgery, National Oesophageal and Gastric Cancer Center, St. James's Hospital and Trinity College Dublin, Dublin, Ireland
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Fei X, Wang X, Lu Q, Lu C, Chen H, Li C. The influence of thoracic duct ligation on long-term survival of patients with esophageal cancer: a propensity score-matched analysis. J Thorac Dis 2020; 12:5532-5541. [PMID: 33209386 PMCID: PMC7656437 DOI: 10.21037/jtd-20-1341] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Background Ligation of the thoracic duct (LTD) is known to be a useful way to prevent postoperative chylothorax, but its impact on long-term survival is rare to be assessed. Methods Data from 609 patients with esophageal cancer who underwent esophagectomy from September, 2012, to January, 2014, were retrospectively collected. The study cohort was classified into two groups: the thoracic duct ligation group (LG) and the non-ligation group (NLG). Propensity score matching (PSM) was performed to control confounding factors between the two groups. Postoperative complications and length of stay were compared between the two groups. Overall survival was estimated using the Kaplan-Meier method, and compared using the log-rank test. Independent prognostic factors were determined using Cox regression analysis. Results After PSM, there were 185 patients in each of the two groups. LTD had no significant impact on chylothorax, anastomotic leak, recurrent nerve palsy, pneumonia and length of stay (P>0.05). The 1-, 3- and 5-year survival rates were 87.0%, 64.1%, and 50.9% in the LG, respectively, compared to 85.4%, 59.9%, and 42.3%, respectively, in the NLG. The differences between the 2 groups were not statistically significant (P=0.156). In the multivariable analysis, LTD was not an independent prognostic factor, neither before nor after PSM. Conclusions Our study demonstrated that LTD had no significant impact on postoperative complications or long-term survival in patients with esophageal cancer.
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Affiliation(s)
- Xiang Fei
- Department of Thoracic Surgery, Changhai Hospital affiliated to Second Military Medical University, Shanghai, China
| | - Xinyu Wang
- Department of Thoracic Surgery, Changhai Hospital affiliated to Second Military Medical University, Shanghai, China
| | - Qijue Lu
- Department of Thoracic Surgery, Changhai Hospital affiliated to Second Military Medical University, Shanghai, China
| | - Chaojing Lu
- Department of Thoracic Surgery, Changhai Hospital affiliated to Second Military Medical University, Shanghai, China
| | - Hezhong Chen
- Department of Thoracic Surgery, Changhai Hospital affiliated to Second Military Medical University, Shanghai, China
| | - Chunguang Li
- Department of Thoracic Surgery, Changhai Hospital affiliated to Second Military Medical University, Shanghai, China
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43
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Management options for post-esophagectomy chylothorax. Surg Today 2020; 51:678-685. [PMID: 32944822 DOI: 10.1007/s00595-020-02143-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 08/03/2020] [Indexed: 12/15/2022]
Abstract
Chylothorax, although an uncommon complication of esophagectomy, is associated with high morbidity and mortality if not treated promptly. Consequently, knowledge of the thoracic duct (TD) anatomy is essential to prevent its inadvertent injury during surgery. If the TD is injured, early diagnosis and immediate intervention are of paramount importance; however, there is still no universal consensus about the management of post-operative chylothorax. With increasing advances in the spheres of interventional radiology and minimally invasive surgery, there are now several options for managing TD injury. We review this topic in detail to provide a comprehensive and practical overview to help surgeons manage this challenging complication. In particular, we discuss an appropriate step-up approach to prevent the morbidity associated with open surgery as well as the metabolic, nutritional, and immunological disorders that accompany a prolonged illness.
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44
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Chevallay M, Jung M, Chon SH, Takeda FR, Akiyama J, Mönig S. Esophageal cancer surgery: review of complications and their management. Ann N Y Acad Sci 2020; 1482:146-162. [PMID: 32935342 DOI: 10.1111/nyas.14492] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/14/2020] [Accepted: 08/20/2020] [Indexed: 02/06/2023]
Abstract
Esophagectomy, even with the progress in surgical technique and perioperative management, is a highly specialized surgery, associated with a high rate of complications. Early recognition and adequate treatment should be a standard of care for the most common postoperative complications: anastomotic leakage, pneumonia, atrial fibrillation, chylothorax, and recurrent laryngeal nerve palsy. Recent progress in endoscopy with vacuum and stent placement, or in radiology with embolization, has changed the management of these complications. The success of nonoperative treatments should be frequently reassessed and reoperation must be proposed in case of failure. We have summarized the clinical signs, diagnostic process, and management of the frequent complications after esophagectomy for esophageal cancer.
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Affiliation(s)
- Mickael Chevallay
- Division of Visceral Surgery, Department of Surgery, Geneva University Hospital, Geneva, Switzerland
| | - Minoa Jung
- Division of Visceral Surgery, Department of Surgery, Geneva University Hospital, Geneva, Switzerland
| | - Seung-Hun Chon
- Department of General, Visceral, Cancer and Transplantation Surgery, University Hospital of Cologne, Cologne, Germany
| | | | - Junichi Akiyama
- Division of Gastroenterology and Hepatology, National Center for Global Health and Medicine (NCGM), Tokyo, Japan
| | - Stefan Mönig
- Division of Visceral Surgery, Department of Surgery, Geneva University Hospital, Geneva, Switzerland
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Farran L, Miró M, Alba E, Barrios O, Joudanin J, Estremiana F, Bettónica C, Aranda H. Lymphography and embolization of the thoracic duct as a treatment for chylothorax after esophagectomy for esophageal cancer. Cir Esp 2020; 99:208-214. [PMID: 32600647 DOI: 10.1016/j.ciresp.2020.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 05/04/2020] [Accepted: 05/06/2020] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Chylothorax is a rare complication in esophagectomies that is associated with increased postoperative mortality. Several factors have been described that may favor its appearance. Its treatment is controversial, and lymphography with percutaneous embolization of the thoracic duct is used by several groups. MATERIAL AND METHOD Our retrospective study included patients who underwent esophagectomy for cancer of the esophagus or the esophagogastric junction (Siewert I/II) between January 2010 and April 2019 and developed chylothorax as a complication. Epidemiological data, type of surgery, morbidity and treatment were analyzed. RESULTS 274 cancer-related esophagectomies were performed in the study period. Thirteen patients (4.7%) were diagnosed with chylothorax in the postoperative period; 3 were resolved with conservative treatment. In the remaining 10 patients, lymphography was performed with aspiration of the cisterna chyli and thoracic duct embolization, which resolved the chylothorax in 9. One patient (10%) presented a biliary fístula after the procedure. CONCLUSIONS Lymphography with aspiration of the cisterna chyli and thoracic duct embolization is a technique with low morbidity that provides good results for the resolution of chylothorax after esophagectomy.
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Affiliation(s)
- Leandre Farran
- Unitat de Cirurgia Esofagogàstrica, Servei de Cirurgia General i Aparell Digestiu, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, España.
| | - Mónica Miró
- Unitat de Cirurgia Esofagogàstrica, Servei de Cirurgia General i Aparell Digestiu, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, España
| | - Esther Alba
- Unitat Angiorradiologia, Servei de Radiologia, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, España
| | - Oriana Barrios
- Unitat de Cirurgia Esofagogàstrica, Servei de Cirurgia General i Aparell Digestiu, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, España
| | - Jonathan Joudanin
- Unitat Angiorradiologia, Servei de Radiologia, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, España
| | - Fernando Estremiana
- Unitat de Cirurgia Esofagogàstrica, Servei de Cirurgia General i Aparell Digestiu, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, España
| | - Carla Bettónica
- Unitat de Cirurgia Esofagogàstrica, Servei de Cirurgia General i Aparell Digestiu, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, España
| | - Humberto Aranda
- Unitat de Cirurgia Esofagogàstrica, Servei de Cirurgia General i Aparell Digestiu, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, España
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Malibary N, Manfredelli S, Almuttawa A, Delhorme JB, Romain B, Brigand C, Rohr S. Evaluating the Surgeon's Experience as a Risk Factor for Post-Esophagectomy Chylothorax on a Four-Year Cohort. Cureus 2020; 12:e8696. [PMID: 32699693 PMCID: PMC7370582 DOI: 10.7759/cureus.8696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Nadim Malibary
- Surgery, King Abdulaziz University, Jeddah, SAU.,Visceral and General Surgery, Hautepierre Hospital, Strasbourg, FRA
| | | | | | | | - Benoit Romain
- Visceral and Digestive Surgery, Hautepierre University Hospital, Strasbourg, FRA
| | - Cecile Brigand
- Visceral and Digestive Surgery, Hautepierre University Hospital, Strasbourg, FRA
| | - Serge Rohr
- Visceral and Digestive Surgery, Hautepierre University Hospital, Strasbourg, FRA
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Chen JY, Liu QW, Zhang SS, Li JB, Yang H, Wen J, Fu JH. Prophylactic thoracic duct ligation is associated with poor prognosis and regional lymph node relapse in esophageal squamous cell carcinoma. J Surg Oncol 2020; 122:336-343. [PMID: 32410255 DOI: 10.1002/jso.25948] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 03/28/2020] [Accepted: 04/13/2020] [Indexed: 01/30/2023]
Abstract
OBJECTIVES The ligation of thoracic duct interrupts the normal lymphatic circulation. Whether the ligation of thoracic duct would affect tumor recurrence and patient survival is unclear. METHODS The correlations between prophylactic thoracic duct ligation (PLG) and prognosis were examined in patients with esophageal squamous cell carcinoma. Patients who received Ivor Lewis or McKeown esophagectomy with systemic lymph node dissection and R0 resection between 2003 and 2013 in Sun Yat-sen University Cancer Center were included in the study. RESULTS A total number of 473 and 462 were included in the PLG group and non-prophylactic thoracic duct ligation (NPLG) group, respectively. The PLG group had a lower 5-year survival rate (48.2% vs 61.6%, P < .001). After a 1:1 propensity score matching, 874 cases (437 pairs) were included and the survival analysis showed that PLG was associated with worse 5-year cumulative survival of 48.6% vs 61.6% in those patients without ligation (P < .001). The multivariate analysis revealed that PLG was an independent factor for poor prognosis after esophagectomy (hazard ratio, HR = 1.56; 95% confidence interval, 95% CI, 1.26-1.93, P < .001). Additionally, PLG was associated with regional lymph node relapse (P = .015). CONCLUSIONS PLG should not be performed routinely if no sign of thoracic duct rupture or tumor invasion were identified.
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Affiliation(s)
- Jun-Ying Chen
- Guangdong Esophageal Cancer Institute, Guangzhou, China.,Department of Thoracic Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Qian-Wen Liu
- Guangdong Esophageal Cancer Institute, Guangzhou, China.,Department of Thoracic Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Shui-Shen Zhang
- Department of Thoracic Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jin-Bo Li
- Department of Thoracic Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Hong Yang
- Guangdong Esophageal Cancer Institute, Guangzhou, China.,Department of Thoracic Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Jing Wen
- Guangdong Esophageal Cancer Institute, Guangzhou, China.,Department of Thoracic Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Jian-Hua Fu
- Guangdong Esophageal Cancer Institute, Guangzhou, China.,Department of Thoracic Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China.,State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
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48
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Germ Cell Tumour of the Ovary Presenting with Chylothorax and Central Vein Thrombosis: a Case Report. INDIAN JOURNAL OF GYNECOLOGIC ONCOLOGY 2020. [DOI: 10.1007/s40944-020-0377-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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49
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A Rare Case of Chylothorax after Heart Transplantation. Case Rep Cardiol 2019; 2019:2049704. [PMID: 31772780 PMCID: PMC6854220 DOI: 10.1155/2019/2049704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 09/06/2019] [Indexed: 11/22/2022] Open
Abstract
Chylothorax is an exceedingly rare but serious complication of orthotopic heart transplantation (OHT). Prompt diagnosis and appropriate management are essential for a good outcome. Management is similar to that of nontransplant patients, but special attention must be given to patients' nutritional and immunological status. Relevant literature on this topic is limited. We describe our experience in the management of chylothorax after OHT and provide a summary of reported cases of this complication after isolated heart and combined heart/lung transplant.
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50
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Sesti J, Luker J, Decker J, Paul S. Modified Blood Patch Used to Treat a High Output Chyle Leak After McKeown Esophagectomy. Ann Thorac Surg 2019; 109:e401-e402. [PMID: 31765618 DOI: 10.1016/j.athoracsur.2019.09.090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 09/24/2019] [Indexed: 10/25/2022]
Abstract
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.
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Affiliation(s)
- Joanna Sesti
- Thoracic Surgical Services, RWJ Barnabas Health, West Orange, New Jersey.
| | - Jenna Luker
- Thoracic Surgical Services, RWJ Barnabas Health, West Orange, New Jersey
| | - Jonathan Decker
- Thoracic Surgical Services, RWJ Barnabas Health, West Orange, New Jersey
| | - Subroto Paul
- Thoracic Surgical Services, RWJ Barnabas Health, West Orange, New Jersey
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