Clinical implications of chyle leakage following esophagectomy

Resection vs. Ligation vs. Preservation of the Thoracic Duct During Esophagectomy for Cancer: A Systematic Review and Meta-Analysis

BACKGROUND/OBJECTIVES

The effect of thoracic duct (TD) management-resection, ligation, or preservation-during esophagectomy for cancer remains controversial. This systematic review and meta-analysis aimed to assess the impact of TD management strategies on oncological outcomes and surgical morbidity.

METHODS

A systematic review and meta-analysis were performed following PRISMA reporting guidelines. Searches of OVID, Embase, and Web of Science identified studies comparing thoracic duct resection or TD ligation with TD preservation in esophagectomy for cancer. Outcomes included 5-year overall survival (OS), postoperative morbidity, postoperative chyle leakage, lymph node yield, and length of stay. Random-effects meta-analyses using the Hartung-Knapp-Sidik-Jonkman variance correction were conducted.

RESULTS

A total of 17 studies involving 4200 patients were included. TD resection was associated with a significantly higher lymph node yield (mean difference [MD]: 4, 95% CI: 0 to 8, p = 0.043), but also increased risk of chyle leakage (odds ratio [OR]: 2.41, 95% CI: 1.04-5.61, p = 0.044). There was no significant improvement in 5-year OS with TD resection compared to TD preservation (hazard ratio [HR]: 0.94, 95% CI: 0.76-1.17, p = 0.48). TD ligation showed no significant differences in 5-year OS (HR: 1.15, 95% CI: 0.81-1.63, p = 0.33) or morbidity compared to TD preservation. Certainty of evidence was low across outcomes.

CONCLUSIONS

TD resection increases lymph node yield but is associated with higher rates of chyle leakage, without a significantly improved overall survival. TD ligation does not significantly affect oncological or surgical outcomes compared to TD preservation. A higher grade of evidence is needed to determine the definitive oncological and surgical impact of TD management strategies.

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

OBJECTIVE

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Impact of early enteral feed composition on the rate of chyle leak post-esophagectomy

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.