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Aiolfi A, Bona D, Calì M, Manara M, Rausa E, Bonitta G, Elshafei M, Markar SR, Bonavina L. Does Thoracic Duct Ligation at the Time of Esophagectomy Impact Long-Term Survival? An Individual Patient Data Meta-Analysis. J Clin Med 2024; 13:2849. [PMID: 38792391 PMCID: PMC11122204 DOI: 10.3390/jcm13102849] [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: 04/09/2024] [Revised: 05/01/2024] [Accepted: 05/08/2024] [Indexed: 05/26/2024] Open
Abstract
Background: Thoracic duct ligation (TDL) during esophagectomy has been proposed to reduce the risk of postoperative chylothorax. Because of its role in immunoregulation, some authors argued that it had an unfavorable TDL effect on survival. The aim of this study was to analyze the effect of TDL on overall survival (OS). Methods: PubMed, MEDLINE, Scopus, and Web of Science were searched through December 2023. The primary outcome was 5-year OS. The restricted mean survival time difference (RMSTD), hazard ratios (HRs), and 95% confidence intervals (CI) were used as pooled effect size measures. The GRADE methodology was used to summarize the certainty of the evidence. Results: Five studies (3291 patients) were included. TDL was reported in 54% patients. The patients' age ranged from 49 to 69, 76% were males, and BMI ranged from 18 to 26. At the 5-year follow-up, the combined effect from the multivariate meta-analysis is -3.5 months (95% CI -6.1, -0.8) indicating that patients undergoing TDL lived 3.5 months less compared to those without TDL. TDL was associated with a significantly higher hazard for mortality at 12 months (HR 1.54, 95% CI 1.38-1.73), 24 months (HR 1.21, 95% CI 1.12-1.35), and 28 months (HR 1.14, 95% CI 1.02-1.28). TDL and noTDL seem comparable in terms of the postoperative risk for chylothorax (RR = 0.66; p = 0.35). Conclusions: In this study, concurrent TDL was associated with reduced 5-year OS after esophagectomy. This may suggest the need of a rigorous follow-up within the first two years of follow-up.
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Affiliation(s)
- Alberto Aiolfi
- IRCCS Ospedale Galeazzi—Sant’Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, 20157 Milan, Italy; (D.B.)
| | - Davide Bona
- IRCCS Ospedale Galeazzi—Sant’Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, 20157 Milan, Italy; (D.B.)
| | - Matteo Calì
- IRCCS Ospedale Galeazzi—Sant’Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, 20157 Milan, Italy; (D.B.)
| | - Michele Manara
- IRCCS Ospedale Galeazzi—Sant’Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, 20157 Milan, Italy; (D.B.)
| | - Emanuele Rausa
- IRCCS Ospedale Galeazzi—Sant’Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, 20157 Milan, Italy; (D.B.)
| | - Gianluca Bonitta
- IRCCS Ospedale Galeazzi—Sant’Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, 20157 Milan, Italy; (D.B.)
| | - Moustafa Elshafei
- Department of Bariatric and Metabolic Medicine, Clinic Northwest, 60488 Frankfurt, Germany;
| | - Sheraz R. Markar
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford OX1 2JD, UK;
| | - Luigi Bonavina
- IRCCS Policlinico San Donato, Division of General and Foregut Surgery, Department of Biomedical Sciences for Health, University of Milan, 20097 Milan, Italy;
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2
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Donohoe CL. Editorial: Role of thoracic duct ligation in esophagectomy. Dis Esophagus 2023; 36:doad047. [PMID: 37465850 DOI: 10.1093/dote/doad047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 06/23/2023] [Indexed: 07/20/2023]
Affiliation(s)
- C L Donohoe
- Department of Surgery, Trinity St James Cancer Institute, St James' Hospital, Dublin, Ireland
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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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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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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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dos Santos CL, dos Santos LL, Tavares G, Tristão LS, Orlandini MF, Serafim MCA, Datrino LN, Bernardo WM, Tustumi F. Prophylactic thoracic duct obliteration and resection during esophagectomy: What is the impact on perioperative risks and long‐term survival? A systematic review and meta‐analysis. J Surg Oncol 2022; 126:90-98. [DOI: 10.1002/jso.26827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 02/06/2022] [Accepted: 02/08/2022] [Indexed: 01/27/2023]
Affiliation(s)
- Clara L. dos Santos
- Department of Evidence‐based Medicine Centro Universitário Lusíada Santos SP Brazil
| | - Laura L. dos Santos
- Department of Gastroenterology Universidade de São Paulo Sao Paulo SP Brazil
| | - Guilherme Tavares
- Department of Evidence‐based Medicine Centro Universitário Lusíada Santos SP Brazil
| | - Luca S. Tristão
- Department of Evidence‐based Medicine Centro Universitário Lusíada Santos SP Brazil
| | - Marina F. Orlandini
- Department of Evidence‐based Medicine Centro Universitário Lusíada Santos SP Brazil
| | - Maria C. A. Serafim
- Department of Evidence‐based Medicine Centro Universitário Lusíada Santos SP Brazil
| | - Letícia N. Datrino
- Department of Evidence‐based Medicine Centro Universitário Lusíada Santos SP Brazil
| | - Wanderley M. Bernardo
- Department of Evidence‐based Medicine Centro Universitário Lusíada Santos SP Brazil
- Department of Gastroenterology Universidade de São Paulo Sao Paulo SP Brazil
| | - Francisco Tustumi
- Department of Evidence‐based Medicine Centro Universitário Lusíada Santos SP Brazil
- Department of Gastroenterology Universidade de São Paulo Sao Paulo SP Brazil
- Department of Surgery Hospital Israelita Albert Einstein Sao Paulo SP Brazil
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7
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Adjuvant chemotherapy for node-positive esophageal squamous cell carcinoma improves survival. Ann Thorac Surg 2021; 114:1205-1213. [PMID: 34626616 DOI: 10.1016/j.athoracsur.2021.08.068] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 07/16/2021] [Accepted: 08/30/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the survival benefits of adjuvant chemotherapy in patients with positive lymph nodes after esophagectomy for esophageal squamous cell carcinoma. METHODS Patients who underwent esophagectomy for esophageal cancer in the Affiliated Cancer Hospital of Zhengzhou University (Henan Cancer Hospital) from 2013 to 2017 were selected for this retrospective cohort study. Patients with positive lymph nodes were grouped into the surgery alone group and adjuvant chemotherapy group. Propensity score matching (1:1) was used to minimize baseline differences. RESULTS Among the 5118 patients who underwent esophagectomy, 792 patients were enrolled in the study. After matching, 253 (of 476) patients (adjuvant chemotherapy group) and 253 (of 316) patients (surgery alone group) were included. The median overall survival was significantly prolonged in the adjuvant chemotherapy group (54.0 months, 95% CI, 41.1-66.9 months) compared with the surgery alone group (28.0 months, 95% CI, 22.4-33.6 months) (P <0.001). A significant difference was also observed in median disease-free survival between the two groups (adjuvant chemotherapy group, 33.0 months, 95% CI, 20.8-45.2 months compared with the surgery alone group, 22.0 months, 95% CI, 17.0-27.0 months; P = 0.007). In a multivariable analysis, receiving adjuvant chemotherapy (P <0.001) was significantly associated with a reduced risk of death and dissection of more than six lymph node stations (P = 0.05) was marginally associated with a reduced risk of death. CONCLUSIONS Postoperative adjuvant chemotherapy improves the overall survival and disease-free survival of patients with resected esophageal squamous cell carcinoma with positive lymph nodes.
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Bazancir LA, Jensen RJ, Frevert SC, Ryom P, Achiam MP. Embolization of the thoracic duct in patients with iatrogenic chylothorax. Dis Esophagus 2021; 34:6129921. [PMID: 33550366 DOI: 10.1093/dote/doab001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 10/14/2020] [Accepted: 12/29/2020] [Indexed: 12/11/2022]
Abstract
Chylothorax is leakage of lymphatic fluid accumulating in the pleural cavity due to the thoracic duct's (TD) trauma or obstructions. It generally occurs as a traumatic complication after general thoracic surgery procedures (0.4%), especially after esophagectomy (4.7-8.6%). Traditionally, surgical intervention is performed if conservative management fails, but reports of high mortality (2.1%) and morbidity (38%) have led to the development of a minimally invasive percutaneous treatment method; TD embolization (TDE). The records of all patients treated for chylothorax with TDE from April 2015 to June 2019 were reviewed. Only patients with iatrogenic chylothorax were included. The outcomes measures are defined as a technical and a clinical success. A technical success, is defined as the ability to perform the embolization procedure, thereby injecting embolizing material Histoacryl with or without coils. A clinical success is defined as a complete cessation of lymphatic leakage into the pleural cavity without surgical intervention and, therefore, a cured patient. Lymphography was performed in all patients, and visualization of cisterna chyli was achieved in 14/17 patients (82.4%). Of the 17 patients included, 15 patients were successfully embolized and cured of chylothorax (88.2%). Successfully embolized patients had a median discharge time of 7 days. Most patients reported postprocedural pain, which was dealt with using conventional pain medication. TDE seems like a safe percutaneous treatment technique with a high clinical success rate in iatrogenic chylothorax patients which can be readily implemented if the clinical experience is available..
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Affiliation(s)
- Laser Arif Bazancir
- Department of Surgical Gastroenterology, Copenhagen University, Copenhagen, Denmark
| | - Ruben Juhl Jensen
- Department of Diagnostic Radiology, Copenhagen University, Copenhagen, Denmark
| | | | - Philip Ryom
- Department of Cardiothoracic Surgery, Copenhagen University, Copenhagen, Denmark
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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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Tanaka K, Yamasaki M, Sugimura K, Shiraishi O, Motoori M, Hamakawa T, Takeno A, Yamashita K, Makino T, Kimura Y, Miyata H, Hirao M, Eguchi H, Yasuda T, Yano M, Doki Y. Thoracic Duct Resection Has a Favorable Impact on Prognosis by Preventing Hematogenous Spread of Esophageal Cancer Cells: A Multi-institutional Analysis of 2269 Patients. Ann Surg Oncol 2021; 28:4402-4410. [PMID: 33861403 DOI: 10.1245/s10434-021-09962-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 02/19/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND The impact of thoracic duct (TD) resection on prognosis is controversial. This study aimed to examine the impact of TD resection. METHODS In this six-institution, matched-cohort study, 2269 consecutive patients with esophageal squamous cell carcinoma who underwent esophagectomy between 2000 and 2017 were enrolled for analysis of long-term outcomes, including overall survival (OS), disease-free survival (DFS), cause-specific survival (CSS), and recurrence patterns. RESULTS Based on a propensity score, 642 TD-resected and 642 TD-preserved patients with all stages of disease were selected. At 5 years, the TD-resected group had an OS of 57.7%, a DFS of 50.9%, and a CSS of 62.2%. These rates were significantly higher than the corresponding rates of 48.7% (p = 0.0078), 41.0% (p = 0.0297), and 55.3% (p = 0.0473) in the TD-preserved group. The OS in the TD-preserved and TD-resected groups was similar for the patients with cStage 1 or 2 (p = 0.6265), but it was significantly higher in the TD-resected group for the patients with cStage 3 or 4 (p = 0.0052). The incidence of total recurrence did not differ between the two groups. However, the incidence of hematogenous recurrence in the TD-resected group (19.0%) was significantly lower than in the TD-preserved group (26.2%) (p = 0.0021). For cT4a tumors, the incidence of local recurrence in the TD-resected group (2.4%) was significantly lower than in the TD-preserved group (18.4%) (p = 0.0183). CONCLUSIONS Performance of TD resection may help to improve prognosis, especially for patients with advanced esophageal squamous cell carcinoma, by reducing hematogenous and local recurrence. Prospective trials are needed to determine whether prophylactic TD resection has a positive impact on the prognosis of patients with esophageal cancer.
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Affiliation(s)
- Koji Tanaka
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita City, Osaka, Japan.
| | - Makoto Yamasaki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita City, Osaka, Japan
| | - Keijiro Sugimura
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Osamu Shiraishi
- Department of Surgery, Kindai University Faculty of Medicine, Osaka, Japan
| | - Masaaki Motoori
- Department of Surgery, Osaka General Medical Center, Osaka, Japan
| | - Takuya Hamakawa
- Department of Surgery, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Atsushi Takeno
- Department of Surgery, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | - Kotaro Yamashita
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita City, Osaka, Japan
| | - Tomoki Makino
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita City, Osaka, Japan
| | - Yutaka Kimura
- Department of Surgery, Kindai University Faculty of Medicine, Osaka, Japan
| | - Hiroshi Miyata
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Motohiro Hirao
- Department of Surgery, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Hidetoshi Eguchi
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita City, Osaka, Japan
| | - Takushi Yasuda
- Department of Surgery, Kindai University Faculty of Medicine, Osaka, Japan
| | - Masahiko Yano
- Department of Digestive Surgery, Osaka International Cancer Institute, Osaka, Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery, Graduate School of Medicine, Osaka University, Suita City, Osaka, Japan
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11
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Hu H, Chen H. Unlocking Better Survival for Esophageal Cancer Patients: Is Thoracic Duct Resection the Key? Ann Surg Oncol 2021; 28:4086-4087. [PMID: 33821342 DOI: 10.1245/s10434-021-09968-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 03/25/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Haichuan Hu
- Department of Medicine Harvard Medical School, Massachusetts General Hospital Cancer Center, Boston, MA, USA.
| | - Haiquan Chen
- Departments of Thoracic Surgery and State Key Laboratory of Genetic Engineering, Fudan University Shanghai Cancer Center, Shanghai, People's Republic of China.
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12
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Zhang C, Gong L, Wu W, Zhang M, Zhang H, Zhao C. Association between low-fat enteral nutrition after esophagectomy and a lower incidence of chyle leakage: A call for more and better evidence. J Int Med Res 2021; 48:300060520926370. [PMID: 32468882 PMCID: PMC7263155 DOI: 10.1177/0300060520926370] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Objective Reliable methods to prevent chyle leakage after esophagectomy are needed. This retrospective study was performed to evaluate the correlation between low-fat nutrition and the incidence of chyle leakage after esophagectomy. Methods This multicenter retrospective case–control study involved patients who underwent Ivor Lewis esophagectomy from December 2012 to August 2017. Tube feeding was started on postoperative day 1 with a normal fat-containing formula (control group, 203 patients) or low fat-containing formula (241 patients). Results The patients in the control group and low-fat group had a similar incidence of chyle leakage (7 [3.4%] vs. 19 [9.4%], respectively) and anastomotic leakage (4 [2.0%] vs. 11 [5.4%], respectively). The multivariate logistic regression indicated that high-volume surgeon experience (performance of ≥100 esophagectomies per year) was correlated with a lower incidence of chyle leakage (odds ratio, 0.280; 95% confidence interval, 0.110–0.712), whereas low-fat nutrition was correlated with an increased risk of anastomotic leakage (odds ratio, 5.995; 95% confidence interval, 1.201–29.925). Conclusion Prophylactic low-fat enteral nutrition following esophagectomy might not decrease the risk of chyle leakage. More and better evidence is needed.
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Affiliation(s)
- Chu Zhang
- Department of Thoracic Surgery, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, Zhejiang, P.R. China
| | - Longbo Gong
- Department of Thoracic Surgery, Xuzhou Central Hospital, Medical School of Southeast University, Xuzhou, Jiangsu, P.R. China
| | - Wenbin Wu
- Department of Thoracic Surgery, Xuzhou Central Hospital, Medical School of Southeast University, Xuzhou, Jiangsu, P.R. China
| | - Miao Zhang
- Department of Thoracic Surgery, Xuzhou Central Hospital, Medical School of Southeast University, Xuzhou, Jiangsu, P.R. China
| | - Hui Zhang
- Department of Thoracic Surgery, Xuzhou Central Hospital, Medical School of Southeast University, Xuzhou, Jiangsu, P.R. China
| | - Chen Zhao
- Department of Thoracic Surgery, Xuzhou Central Hospital, Medical School of Southeast University, Xuzhou, Jiangsu, P.R. China
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Li B, Yang Y, Toker A, Yu B, Kang CH, Abbas G, Soukiasian HJ, Li H, Daiko H, Jiang H, Fu J, Yi J, Kernstine K, Migliore M, Bouvet M, Ricciardi S, Chao YK, Kim YH, Wang Y, Yu Z, Abbas AE, Sarkaria IS, Li Z. International consensus statement on robot-assisted minimally invasive esophagectomy (RAMIE). J Thorac Dis 2020; 12:7387-7401. [PMID: 33447428 PMCID: PMC7797844 DOI: 10.21037/jtd-20-1945] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Bin Li
- Department of Thoracic Surgery, Section of Esophageal Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yang Yang
- Department of Thoracic Surgery, Section of Esophageal Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Alper Toker
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, School of Medicine, Morgantown, WV, USA
| | - Bentong Yu
- Department of Thoracic Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Chang Hyun Kang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ghulam Abbas
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, School of Medicine, Morgantown, WV, USA
| | - Harmik J Soukiasian
- Division of Thoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Hecheng Li
- Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hiroyuki Daiko
- Department of Esophageal Surgery, National Cancer Center Hospital East, Chiba, Japan
| | - Hongjing Jiang
- Department of Esophageal Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Jianhua Fu
- Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Jun Yi
- Department of Cardiothoracic Surgery, Jinling Hospital, Medical Scholl of Nanjing University, Nanjing, China
| | - Kemp Kernstine
- Department of Cardiothoracic Surgery, UT Southwestern, Dallas, TX, USA
| | - Marcello Migliore
- Section of Thoracic Surgery, Department of Surgery and Medical Specialties, Policlinico University Hospital, University of Catania, Catania, Italy
| | - Michael Bouvet
- Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Sara Ricciardi
- Division of Thoracic Surgery, Department of Surgical, Medical, Molecular, Pathology and Critical Care, University Hospital of Pisa, Pisa, Italy
| | - Yin-Kai Chao
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linkou, Chang Gung University, Taoyuan
| | - Yong-Hee Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yun Wang
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Zhentao Yu
- Department of Esophageal Cancer, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
| | - Abbas E Abbas
- Division of Thoracic Surgery, Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Inderpal S Sarkaria
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Zhigang Li
- Department of Thoracic Surgery, Section of Esophageal Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
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14
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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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15
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Liu L, Gong L, Zhang M, Wu W. The effect of prophylactic thoracic duct ligation during esophagectomy on the incidence of chylothorax and survival of the patients: an updated review. Postgrad Med 2020; 133:265-271. [PMID: 32729759 DOI: 10.1080/00325481.2020.1803666] [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] [Indexed: 10/23/2022]
Abstract
BACKGROUND The role of thoracic duct ligation (TDL) during esophagectomy remains controversial. This review aimed to elucidate the effect of TDL on chylothorax and survival of the patients after esophagectomy for cancer. METHODS We searched articles from PubMed, Web of Science, Scopus, Cochrane, and Google Scholar till May 2020 according to the PRISMA guidelines using the terms of [Oesophagectomy OR esophagectomy] AND [chylothorax] AND [thoracic duct ligation]. Only those compared the incidence of chylothorax in patients who ligated or resected the thoracic duct (ligation group) or preserved the thoracic duct (preservation group) were selected. RESULTS First, 15 studies including one randomized controlled trial were collected for meta-analysis regarding post-esophagectomy chylothorax. Of these, 3658 patients underwent TDL and 4638 cases preserved the thoracic duct. Both groups showed similar chylothorax rate (odd ratios 0.73 in favor of ligation group; 95% confidence interval [CI] 0.50-1.07, p = 0.11). Second, four studies providing survival information were included for another meta-analysis, and the patients in preservation group demonstrated better 5-year overall survival compared to those in ligation group (odds ratio 1.25; 95% CI 1.08-1.44, p = 0.002). CONCLUSIONS The present review provided updated evidence opposing prophylactic TDL during esophagectomy for lowering chylothorax. Considering the harmful effect of TDL on survival of the patients, further well-designed trials should be considered in selected cases under strict supervision.
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Affiliation(s)
- Lei Liu
- Department of Gastroenterology of Yichang Central People's Hospital, Institute of Digestive Disease, China Three Gorges University, Yichang, People's Republic of China
| | - Longbo Gong
- Department of Surgery, Xuzhou Central Hospital, Southeast University School of Medicine, Xuzhou, People's Republic of China
| | - Miao Zhang
- Department of Surgery, Xuzhou Central Hospital, Southeast University School of Medicine, Xuzhou, People's Republic of China
| | - Wenbin Wu
- Department of Surgery, Xuzhou Central Hospital, Southeast University School of Medicine, Xuzhou, People's Republic of China
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16
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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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Ashok A, Niyogi D, Ranganathan P, Tandon S, Bhaskar M, Karimundackal G, Jiwnani S, Shetmahajan M, Pramesh CS. The enhanced recovery after surgery (ERAS) protocol to promote recovery following esophageal cancer resection. Surg Today 2020; 50:323-334. [PMID: 32048046 PMCID: PMC7098920 DOI: 10.1007/s00595-020-01956-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 11/29/2019] [Indexed: 02/07/2023]
Abstract
Esophageal cancer surgery, comprising esophagectomy with radical lymphadenectomy, is a complex procedure associated with considerable morbidity and
mortality. The enhanced recovery after surgery (ERAS) protocol which aims to improve perioperative care, minimize complications, and accelerate recovery is showing promise for achieving better perioperative outcomes. ERAS is a multimodal approach that has been reported to shorten the length of hospital stay, reduce surgical stress response, decrease morbidity, and expedite recovery. While ERAS components straddle preoperative, intraoperative, and postoperative periods, they need to be seen in continuum and not as isolated elements. In this review, we elaborate on the components of an ERAS protocol after esophagectomy including preoperative nutrition, prehabilitation, counselling, smoking and alcohol cessation, cardiopulmonary evaluation, surgical technique, anaesthetic management, intra- and postoperative fluid management and pain relief, mobilization and physiotherapy, enteral and oral feeding, removal of drains, and several other components. We also share our own institutional protocol for ERAS following esophageal resections.
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Affiliation(s)
- Apurva Ashok
- Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Centre, Tata Memorial Hospital, Homi Bhabha National Institute, Parel, Mumbai, 400012, India
| | - Devayani Niyogi
- Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Centre, Tata Memorial Hospital, Homi Bhabha National Institute, Parel, Mumbai, 400012, India
| | - Priya Ranganathan
- Division of Thoracic Surgery, Department of Anesthesiology, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Sandeep Tandon
- Division of Thoracic Surgery, Department of Pulmonary Medicine, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Maheema Bhaskar
- Division of Thoracic Surgery, Department of Pulmonary Medicine, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - George Karimundackal
- Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Centre, Tata Memorial Hospital, Homi Bhabha National Institute, Parel, Mumbai, 400012, India
| | - Sabita Jiwnani
- Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Centre, Tata Memorial Hospital, Homi Bhabha National Institute, Parel, Mumbai, 400012, India
| | - Madhavi Shetmahajan
- Division of Thoracic Surgery, Department of Anesthesiology, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - C S Pramesh
- Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Centre, Tata Memorial Hospital, Homi Bhabha National Institute, Parel, Mumbai, 400012, India.
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18
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Arshava EV, Parekh KR. Thoracoscopic Thoracic Duct Ligation: How I Teach It. Ann Thorac Surg 2020; 109:1330-1334. [PMID: 32035916 DOI: 10.1016/j.athoracsur.2020.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 01/11/2020] [Accepted: 01/14/2020] [Indexed: 12/25/2022]
Affiliation(s)
- Evgeny V Arshava
- Division of Cardiothoracic Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa.
| | - Kalpaj R Parekh
- Division of Cardiothoracic Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
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19
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Prophylactic ligation of the thoracic duct branch prevents chylothorax after pulmonary resection for right lung cancer. Surg Today 2020; 50:881-888. [PMID: 31980933 DOI: 10.1007/s00595-020-01969-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 01/05/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE Chylothorax is a rare and challenging complication of thoracic surgery. Whereas most current studies focus on postoperative treatment and preventative measures for esophageal cancer surgery, the current study investigates the impact of prophylactic ligation of the thoracic duct branch on postoperative chylothorax after pulmonary resection for right lung cancer. METHODS The subjects of this retrospective study were 1165 patients who underwent right pulmonary resection and mediastinal lymph-node dissection in our department between January 2015 and August 2019. Those who underwent prophylactic ligation of the thoracic duct branch after 4R lymph-node dissection were assigned to group A (n = 475), and those who did not were assigned to group B (n = 690). The incidence of postoperative chylothorax, the success rate of conservative treatment, the postoperative hospital stay, and the chest drainage volume were recorded and compared statistically between the two groups. RESULTS The incidence of postoperative chylothorax was significantly lower in group A than in group B (0.84% vs. 2.90%, p = 0.015). Patients who had a chylothorax in group A had a significantly shorter postoperative hospital stay, less mean drainage volume per day, and less total drainage than those in group B (7.25 ± 0.50 days vs. 11.00 ± 2.81 days, p = 0.003; 0.64 ± 0.04 L vs. 0.80 ± 0.09 L, p = 0.003; 4.64 ± 0.40 L vs. 8.82 ± 2.84 L; p = 0.002). The success rate of conservative treatment was higher in group A than in group B, but the difference was not significant (100% vs. 75.0%, p = 0.544). CONCLUSION Performing prophylactic ligation of the thoracic duct branch during right pulmonary resection and mediastinal lymph-node dissection is an effective and safe method of preventing postoperative chylothorax.
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20
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Duong TT, An HH, Quoc LV, Truong NV, Son VN, Hien NV, Tuan NP, Sang NV, Duc NM. Outcomes of Right Thoracoscopic Esophagectomy Combined with Laparotomy: a Preliminary Vietnamese Study. Med Arch 2020; 74:463-469. [PMID: 33603272 PMCID: PMC7879347 DOI: 10.5455/medarh.2020.74.463-469] [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: 12/02/2022] Open
Abstract
Background: Esophageal cancer is the fourth-most-common cancerous disease of the gastrointestinal tract, with increasing incidence rates. Aim: The present study aimed to assess the outcomes of right thoracoscopic esophagectomy combined with laparotomy for esophageal cancer treatment in Vietnamese patients. Methods: A cross-sectional study of 71 patients was conducted at 108 Military Central Hospital, Hanoi, Vietnam, from January 2010 to December 2017. Results: Right thoracoscopic esophagectomy combined with laparotomy was performed in 71 patients with esophageal cancer. The mean patient age was 55.8 years, and 100% were male. Patients were diagnosed with the following cancer stages: Stage 0: 4.2%; Stage I: 14.1%; Stage II: 59.2%; and Stage III: 22.5%. The lymph node metastasis rate was 33.8%. The overall complication rate was 42.3%, which included a pneumonia rate of 12.3%, a respiratory failure rate of 7.0%, an anastomotic leak rate of 11.3%, and a chylothorax rate of 4.2%. The mean postoperative time was 16.4 days. The mean follow-up time was 21.7 months. The median overall survival was 45.7 months. The 1-year, 2-year, 3-year, and 4-year survival rates were 79.7%, 62.3%, 52.3%, and 43.6%, respectively. Conclusions: Thoracoscopic esophagectomy combined with laparotomy for esophageal cancer was a safe, effective, and minimally invasive procedure that should play a continued role in cancer treatment.
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Affiliation(s)
- Trieu Trieu Duong
- Department of Colon and Rectal Surgery, 108 Military Central Hospital, Hanoi, Vietnam
| | - Ho Huu An
- Department of Colon and Rectal Surgery, 108 Military Central Hospital, Hanoi, Vietnam
| | - Le Van Quoc
- Department of Colon and Rectal Surgery, 108 Military Central Hospital, Hanoi, Vietnam
| | - Nguyen Van Truong
- Department of Colon and Rectal Surgery, 108 Military Central Hospital, Hanoi, Vietnam
| | - Vu Ngoc Son
- Department of General Surgery, Haiphong University of Medicine and Pharmacy, Haiphong province, Vietnam
| | - Nguyen Van Hien
- Department of Colon and Rectal Surgery, 108 Military Central Hospital, Hanoi, Vietnam
| | - Nguyen Phu Tuan
- Department of General Surgery, Thanh Hoa General Hospital, Thanh Hoa Province, Vietnam
| | - Nguyen Van Sang
- Department of Radiology, Hanoi University of Public Health, Hanoi, Vietnam
| | - Nguyen Minh Duc
- Department of Radiology, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam.,Department of Radiology, Children's Hospital 2, Ho Chi Minh City, Vietnam
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21
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Short- and long-term outcomes of prophylactic thoracic duct ligation during thoracoscopic–laparoscopic McKeown esophagectomy for cancer: a propensity score matching analysis. Surg Endosc 2019; 34:5023-5029. [DOI: 10.1007/s00464-019-07297-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Accepted: 11/28/2019] [Indexed: 01/30/2023]
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22
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Oshikiri T, Takiguchi G, Miura S, Goto H, Otsubo D, Hasegawa H, Yamamoto M, Kanaji S, Yamashita K, Matsuda T, Fujino Y, Tominaga M, Nakamura T, Suzuki S, Kakeji Y. Thoracic Duct Resection During Esophagectomy Does Not Contribute to Improved Prognosis in Esophageal Squamous Cell Carcinoma: A Propensity Score Matched-Cohort Study. Ann Surg Oncol 2019; 26:4053-4061. [PMID: 31313045 DOI: 10.1245/s10434-019-07627-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Indexed: 02/06/2023]
Abstract
PURPOSE Esophagectomy with extended lymphadenectomy remains the mainstay of treatment for localized esophageal squamous cell carcinoma (ESCC). Thoracic duct (TD) resection has been recommended as part of extended lymphadenectomy, although its merits are unclear. The aim of this two-institutional, matched-cohort study is to clarify whether TD resection improves prognosis in esophagectomy for ESCC. PATIENTS AND METHODS In this two-institutional, matched-cohort study of 399 patients with ESCC who underwent McKeown esophagectomy between 2010 and 2014, the primary outcomes were overall survival (OS), disease-free survival (DFS), and cause-specific survival (CSS). Secondary outcomes were perioperative results and recurrence patterns. RESULTS Based on a propensity score, 122 TD-resected or 122 TD-preserved patients in all stages were selected (median follow-up 4.5 years). The 5-year OS, DFS, and CSS rates in the TD-resected versus TD-preserved groups were 49% versus 60%, 53% versus 57%, and 58% versus 70%, respectively, without any significant differences. Operative time for the thoracic procedure was significantly longer and the number of retrieved mediastinal nodes was significantly higher in the TD-resected group (P = 0.009 and 0.005, respectively). The rates of chylothorax and left recurrent laryngeal nerve (RLN) palsy were significantly higher in the TD-resected group (P = 0.041 and 0.018, respectively). There were no significant differences in rates of local or distant metastases between the two groups. CONCLUSIONS TD resection does not contribute to improve OS, DFS, or CSS in ESCC but increases incidence of chylothorax and left RLN palsy. Prophylactic TD resection should be avoided in esophagectomy for ESCC.
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Affiliation(s)
- Taro Oshikiri
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Kobe, Hyogo, Japan.
| | - Gosuke Takiguchi
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Kobe, Hyogo, Japan
| | - Susumu Miura
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Kobe, Hyogo, Japan
| | - Hironobu Goto
- Department of Gastroenterological Surgery, Hyogo Cancer Center, Akashi, Hyogo, Japan
| | - Dai Otsubo
- Department of Gastroenterological Surgery, Hyogo Cancer Center, Akashi, Hyogo, Japan
| | - Hiroshi Hasegawa
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Kobe, Hyogo, Japan
| | - Masashi Yamamoto
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Kobe, Hyogo, Japan
| | - Shingo Kanaji
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Kobe, Hyogo, Japan
| | - Kimihiro Yamashita
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Kobe, Hyogo, Japan
| | - Takeru Matsuda
- Division of Minimally Invasive Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Kobe, Hyogo, Japan
| | - Yasuhiro Fujino
- Department of Gastroenterological Surgery, Hyogo Cancer Center, Akashi, Hyogo, Japan
| | - Masahiro Tominaga
- Department of Gastroenterological Surgery, Hyogo Cancer Center, Akashi, Hyogo, Japan
| | - Tetsu Nakamura
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Kobe, Hyogo, Japan
| | - Satoshi Suzuki
- Division of Community Medicine and Medical Network, Department of Social Community Medicine and Health Science, Graduate School of Medicine, Kobe University, Kobe, Hyogo, Japan
| | - Yoshihiro Kakeji
- Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, Kobe, Hyogo, Japan
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Palanivelu C, Dey S, Sabnis S, Gupta R, Cumar B, Kumar S, Natarajan R, Ramakrishnan P. Robotic-assisted minimally invasive oesophagectomy for cancer: An initial experience. J Minim Access Surg 2019; 15:234-241. [PMID: 29737322 PMCID: PMC6561075 DOI: 10.4103/jmas.jmas_7_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background: The morbidity related to radical oesophagectomy can be reduced by adopting minimally invasive techniques. Over 250 thoraco-laparoscopic oesophagectomy (TLE) was done in our centre over the last 15 years, before adopting robotic surgery as the latest innovation in the field of minimally invasive surgery. Here, we share our initial experience of robotic-assisted minimally invasive oesophagectomy (RAMIE) for carcinoma oesophagus. Methods: A prospective observational study conducted from February to December 2017. A total of 15 patients underwent RAMIE in this period. Data regarding demography, clinical characteristics, investigations, operating techniques, and post-operative outcome were collected in detail. Results: There were 10 (66.7%) male patients and the median age of all patients was 62.9 (range 36–78) years. The median body mass index was 24.4 (range 15–32.8) kg/m2. Twelve (80.0%) patients had squamous cell carcinoma (SCC) of the oesophagus and 3 (20%) patients had adenocarcinoma (AC). Five (33.3%) patients received neoadjuvant therapy. All 15 patients underwent RAMIE. Patients with SCC underwent McKeown's procedure, and those with AC underwent Ivor Lewis procedure. Extended two-field lymphadenectomy (including total mediastinal lymphadenectomy) was done for all the patients. The median operating time was 558 (range 390–690) min and median blood loss was 145 (range 90–230) ml. There were no intra-operative adverse events, and none of them required conversion to open or total thoracolaparoscopic procedure. The most common post-operative complications were recurrent laryngeal nerve paresis (3 patients, 20.0%) and pneumonia (2 patients, 13.3%). The median hospital stay was 9 (range 7–33) days. In total, 9 (60%) patients required adjuvant treatment. Conclusion: Adequate experience in TLE can help minimally invasive surgeons in easy adoption of RAMIE with satisfactory outcome.
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Affiliation(s)
- Chinnusamy Palanivelu
- Department of Gastrointestinal and Minimal Access Surgery, GEM Hospital and Research Centre, Coimbatore, Tamil Nadu, India
| | - Sumanta Dey
- Department of Gastrointestinal and Minimal Access Surgery, GEM Hospital and Research Centre, Coimbatore, Tamil Nadu, India
| | - Sandeep Sabnis
- Department of Gastrointestinal and Minimal Access Surgery, GEM Hospital and Research Centre, Coimbatore, Tamil Nadu, India
| | - Raghavendra Gupta
- Department of Gastrointestinal and Minimal Access Surgery, GEM Hospital and Research Centre, Coimbatore, Tamil Nadu, India
| | - Bharath Cumar
- Department of Gastrointestinal and Minimal Access Surgery, GEM Hospital and Research Centre, Coimbatore, Tamil Nadu, India
| | - Saravana Kumar
- Department of Gastrointestinal and Minimal Access Surgery, GEM Hospital and Research Centre, Coimbatore, Tamil Nadu, India
| | - Ramesh Natarajan
- Department of Gastrointestinal and Minimal Access Surgery, GEM Hospital and Research Centre, Coimbatore, Tamil Nadu, India
| | - Parthasarathi Ramakrishnan
- Department of Gastrointestinal and Minimal Access Surgery, GEM Hospital and Research Centre, Coimbatore, Tamil Nadu, India
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Schurink B, Defize IL, Mazza E, Ruurda JP, Brosens LAA, Roeling TAP, Bleys RLAW, van Hillegersberg R. Two-Field Lymphadenectomy During Esophagectomy: The Presence of Thoracic Duct Lymph Nodes. Ann Thorac Surg 2018; 106:435-439. [PMID: 29580778 DOI: 10.1016/j.athoracsur.2018.02.047] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 01/30/2018] [Accepted: 02/12/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND Resection of the thoracic duct is part of the formal en bloc mediastinal esophagolymphadenectomy for cancer, although with the adaptation of minimally invasive techniques, some centers started to leave the thoracic duct compartment in situ. However, previous studies reported thoracic duct lymph nodes in this compartment that may contain metastasis. The aim of this study was to assess the presence and number of lymph nodes in the fatty tissue surrounding the thoracic duct. METHODS A right-sided thoracoscopic esophagectomy was performed on seven fresh-frozen human cadavers (male, n = 3; female, n = 4). The esophagus and lymph node stations 7, 8, and 9 were resected en bloc, followed by resection of the thoracic duct compartment consisting of the fatty tissue covering the aorta, the thoracic duct and thoracic duct lymph nodes. Lymph nodes were visualized by a hematoxylin and eosin stain and counted macroscopically and microscopically. RESULTS Thoracic duct lymph nodes were found in 6 of 7 cadavers (86%), with a median number of 1 (range, 0 to 6). Nodes were predominantly located in the area of the azygos vein. A median of 4 subcarinal nodes (range, 1 to 8) and 2 periesophageal nodes (range, 1 to 4) were present. CONCLUSIONS This study shows that thoracic duct lymph nodes are located within the fatty tissue surrounding the thoracic duct. Resection of this compartment during an esophagectomy for cancer increases lymph node yield.
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Affiliation(s)
- Bernadette Schurink
- Department of Anatomy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands; Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Ingmar L Defize
- Department of Anatomy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands; Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Elena Mazza
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Lodewijk A A Brosens
- Department of Pathology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Tom A P Roeling
- Department of Anatomy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Ronald L A W Bleys
- Department of Anatomy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Richard van Hillegersberg
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
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Lin Y, Li Z, Li G, Zhang X, Deng H, Yang X, Liu L. Selective En Masse Ligation of the Thoracic Duct to Prevent Chyle Leak After Esophagectomy. Ann Thorac Surg 2017; 103:1802-1807. [PMID: 28385376 DOI: 10.1016/j.athoracsur.2017.01.025] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 12/05/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND Postoperative chylothorax remains an important cause of reoperation and prolonged hospital stay after esophagectomy for the treatment of esophageal carcinoma. Chylothorax is potentially life threatening and difficult to manage. The benefit of routine thoracic duct ligation is controversial. A promising alternative is to identify chyle leaks at the time of esophagectomy and perform the ligation selectively. We developed a novel technique to identify chyle leak at the time of esophagectomy and compared it with routine ligation of thoracic duct. METHODS This cohort study involved all of the qualified patients with resectable esophageal carcinoma treated between March 1, 2011, and December 31, 2015, by a single surgical team at West China Hospital. Patients receiving routine en masse ligation of the thoracic duct were assigned to group A, and patients receiving selective en masse ligation of the thoracic duct were assigned to group B. All patients in the selective ligation group received 120 mL olive oil orally before the operation. The end point included frequencies of chyle leak detected at the time of esophagectomy, postoperative chylothorax, and need for chylothorax-related reoperation. RESULTS The study enrolled 296 patients who fulfilled the study requirement: 55 in group A and 241 in group B. Patients in group A experienced significantly higher incidences of postoperative chylothorax and chylothorax-related reoperation than group B (9.1% vs 0% [p < 0.01] and 3.6% vs 0% [p < 0.01]). Incidence of detection of intraoperative chyle leak (chylothorax plus chylous ascites) was significantly higher in group B than in group A (9.5% vs 0%, p < 0.01). No intraoperative or postoperative complications related to preoperative oral olive oil administration or selective en masse ligation of the thoracic duct were observed. CONCLUSIONS Our method of selective en masse ligation of the thoracic duct during esophagectomy was feasible and safe and was associated with reduced rates of postoperative chylothorax.
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Affiliation(s)
- Yidan Lin
- Thoracic Surgery Department, West China Hospital, Sichuan University, Chengdu, China.
| | - Zhihui Li
- Thyroid and Breast Surgery Department, West China Hospital, Sichuan University, Chengdu, China
| | - Gang Li
- Thoracic Surgery Department, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaolong Zhang
- Thoracic Surgery Department, West China Hospital, Sichuan University, Chengdu, China
| | - Hanyu Deng
- Thoracic Surgery Department, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaoyan Yang
- Information Center, West China Hospital, Sichuan University, Chengdu, China
| | - Lunxu Liu
- Thoracic Surgery Department, West China Hospital, Sichuan University, Chengdu, China
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Crucitti P, Mangiameli G, Petitti T, Condoluci A, Rocco R, Gallo IF, Longo F, Rocco G. Does prophylactic ligation of the thoracic duct reduce chylothorax rates in patients undergoing oesophagectomy? A systematic review and meta-analysis. Eur J Cardiothorac Surg 2016; 50:1019-1024. [DOI: 10.1093/ejcts/ezw125] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Incidence and management of chylothorax after Ivor Lewis esophagectomy for cancer of the esophagus. J Thorac Cardiovasc Surg 2016; 151:1398-404. [DOI: 10.1016/j.jtcvs.2016.01.030] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Revised: 11/29/2015] [Accepted: 01/17/2016] [Indexed: 01/30/2023]
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Preserving the pulmonary vagus nerve branches during thoracoscopic esophagectomy. Surg Endosc 2015; 30:3816-22. [DOI: 10.1007/s00464-015-4683-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2015] [Accepted: 11/14/2015] [Indexed: 02/06/2023]
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Chylothorax after esophagectomy for esophageal cancer: risk factors and management. Indian J Gastroenterol 2015; 34:240-4. [PMID: 26027841 DOI: 10.1007/s12664-015-0571-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Accepted: 05/11/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND Chylothorax is an uncommon complication of esophagectomy. It carries significant morbidity and mortality. The predisposing factors are ill-defined. METHODS We retrospectively evaluated the data of 45 patients of carcinoma esophagus who underwent esophagectomy after neoadjuvant chemoradiotherapy (NACRT) from January 2010 to July 2012 in our tertiary health care center. RESULTS Four patients (8.88 %) had chylothorax. On analysis of perioperative factors, it was found that patients with chylothorax had tumor in middle third of thoracic esophagus (100 %), shown partial response to neoadjuvant chemoradiation (NACRT) (100 %) and were associated with difficult mediastinal dissection (75 %) leading to higher blood loss requiring transfusion unlike those without chylothorax. There was no significant difference in the incidence of chylothorax following transhiatal, 3/35 = 8.57 % or transthoracic esophagectomy 1/10 = 10 % (p = 0.898). Three patients were managed by transabdominal en masse ligation of tissue between aorta and azygos vein while one patient was managed conservatively. Patients were discharged after a mean hospital stay of 15.5 days. The 30-day mortality rates in the two groups were similar (0 % vs. 4.8 %). CONCLUSION Difficult mediastinal dissection during esophagectomy in middle esophageal cancer may lead to thoracic duct injury. Complete response to NACRT may reduce the risk of chylothorax. Early transabdominal en masse ligation carries excellent results. Low output fistula following thoracic duct injury can be managed conservatively.
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