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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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Casas MA, Angeramo CA, Bras Harriott C, Schlottmann F. Surgical outcomes after totally minimally invasive Ivor Lewis esophagectomy. A systematic review and meta-analysis. Eur J Surg Oncol 2021; 48:473-481. [PMID: 34955315 DOI: 10.1016/j.ejso.2021.11.119] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 09/20/2021] [Accepted: 11/16/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND A transthoracic esophagectomy is associated with high rates of morbidity. Minimally invasive esophagectomy has emerged to decrease such morbidity. The aim of this study was to accurately determine surgical outcomes after totally minimally invasive Ivor-Lewis Esophagectomy (TMIE). METHODS A systematic literature search was performed to identify original articles analyzing patients who underwent TMIE. Main outcomes included overall morbidity, major morbidity, pneumonia, arrhythmia, anastomotic leak, chyle leak, and mortality. A meta-analysis was conducted to estimate the overall weighted proportion and its 95% confidence interval (CI) for each analyzed outcome. RESULTS A total of 5619 patients were included for analysis; 4781 (85.1%) underwent a laparoscopic/thoracoscopic esophagectomy and 838 (14.9%) a robotic-assisted esophagectomy. Mean age of patients was 63.5 (55-67) years and 75.8% were male. Overall morbidity and major morbidity rates were 39% (95% CI, 33%-45%) and 20% (95% CI, 13%-28%), respectively. Postoperative pneumonia and arrhythmia rates were 10% (95% CI, 8%-13%) and 12% (95% CI, 8%-17%), respectively. Anastomotic leak rate across studies was 8% (95% CI, 6%-10%). Chyle leak rate was 3% (95% CI, 2%-5%). Mortality rate was 2% (95% CI, 2%-2%). Median ICU stay and length of hospital stay were 2 (1-4) and 11.2 (7-20) days, respectively. CONCLUSIONS Totally minimally invasive Ivor-Lewis esophagectomy is a challenging procedure with high morbidity rates. Strategies to enhance postoperative outcomes after this operation are still needed.
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Affiliation(s)
- María A Casas
- Department of Surgery, Hospital Alemán of Buenos Aires, Argentina
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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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Jeon YJ, Cho JH, Hyun D, Shin S, Kim HK, Choi YS, Kim J, Zo JI, Shim YM. Management of chyle leakage after general thoracic surgery: Impact of thoracic duct embolization. Thorac Cancer 2021; 12:1382-1386. [PMID: 33783956 PMCID: PMC8088932 DOI: 10.1111/1759-7714.13914] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/15/2021] [Accepted: 02/15/2021] [Indexed: 01/30/2023] Open
Abstract
Background The aim of this study was to investigate the impact of thoracic duct embolization (TDE) on the management of postoperative chyle leakage. Methods We retrospectively reviewed the electronic medical record database of 4171 patients who underwent curative resection for lung or esophageal cancer between January 2015 and June 2017. We classified the period before the introduction of TDE as the first period and the period after the introduction of TDE as the second period. Results A total of 105 patients who developed chyle leakage after surgery were included. In the first period, 49 patients who underwent lung surgery developed chylothorax. Of those, two patients (4.1%) underwent surgical ligation of the thoracic duct (TD). Of eight patients with chyle leakage after esophagectomy, four patients (50%) underwent TD ligation. In the second period, 30 patients developed postoperative chyle leakage after pulmonary resection. Only one (3.3%) of them required surgical ligation. Of eight patients with chyle leakage after esophagectomy, only two (11.1%) patients underwent TD ligation. Five patients (16.7%) received TDE after lung surgery and five patients (27.7%) after esophageal surgery. Also, in the second period, the hospital stay of patients who underwent lung cancer surgery was shorter than the first period (12.6 ± 4.6 days vs. 16.3 ± 9.7 days; p = 0.026). Conclusions TDE is an effective method for the management of chyle leakage and might help to avoid invasive surgery.
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Affiliation(s)
- Yeong Jeong Jeon
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong Ho Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dongho Hyun
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sumin Shin
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hong Kwan Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong Soo Choi
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jhingook Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Ill Zo
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Mog Shim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Dezube AR, Kucukak S, De León LE, Kostopanagiotou K, Jaklitsch MT, Wee JO. Risk of chyle leak after robotic versus video-assisted thoracoscopic esophagectomy. Surg Endosc 2021; 36:1332-1338. [PMID: 33660122 DOI: 10.1007/s00464-021-08410-4] [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: 09/22/2020] [Accepted: 02/15/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND We investigate the incidence and risk factors for post-operative outcomes including chyle leak following minimally invasive esophagectomy (MIE). METHODS Patients undergoing MIE from May 2016 until August 2020 were prospectively followed. Outcomes of robotic and video-assisted thoracoscopic surgery (VATS) esophagectomy were analyzed. RESULTS 347 esophagectomies were performed: 70 cases were done robotically by 2 surgeons and 277 by VATS by 14 surgeons. Patients had similar demographics, surgical technique, length of stay (LOS), and re-operation rates. Overall complication rates between robotic and VATS MIE were statistically similar (61% vs. 50%; p = 0.082). The majority of complications for either VATS (41.5%) or robotic-assisted minimally invasive esophagectomy (RAMIE) (51.4%) were grade II. Nineteen patients developed a chyle leak. Patients with a chyle leak were similar in age, gender, and hospital LOS (all p > 0.05), but were more likely to undergo a three-hole or robotic esophagectomy (both p < 0.05) as well as have higher rehabilitation requirements on discharge (26% vs. 10%; p = 0.05). Among the two surgeons who each performed > 20 robotic esophagectomies (n = 70), nine chyle leaks occurred. Rates varied by surgeon (7 vs. 2; p = 0.003). Lower leak rates occurred in the surgeon with more robotic esophagectomy experience (n = 47 vs. 23). Patients were similar in age, and gender (p > 0.05), but those with a chyle leak were more likely to undergo three-hole esophagectomies, prophylactic thoracic duction ligations, undergo the abdominal portion via laparotomy, and not have a prophylactic omental flap (all p < 0.05). CONCLUSION Robotic and VATS esophagectomy have similar rates of re-operation, length of stay, discharge needs and complications. Differences in outcomes between VATS and Robotic esophagectomy appears to be related to surgeon experience with the robot but may also be associated with techniques such as anastomotic height, omental flap utilization and performance of laparoscopy.
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Affiliation(s)
- Aaron R Dezube
- Division of Thoracic Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA.
| | - Suden Kucukak
- Division of Thoracic Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA
| | - Luis E De León
- Division of Thoracic Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA
| | | | - Michael T Jaklitsch
- Division of Thoracic Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA
| | - Jon O Wee
- Division of Thoracic Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA, 02115, USA
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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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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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Park I, Her N, Choe JH, Kim JS, Kim JH. Management of chyle leakage after thyroidectomy, cervical lymph node dissection, in patients with thyroid cancer. Head Neck 2017; 40:7-15. [DOI: 10.1002/hed.24852] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 01/30/2017] [Accepted: 04/25/2017] [Indexed: 12/18/2022] Open
Affiliation(s)
- Inhye Park
- Division of Breast and Endocrine Surgery, Department of Surgery, Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
| | - Nayoon Her
- Division of Breast and Endocrine Surgery, Department of Surgery, Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
| | - Jun-Ho Choe
- Division of Breast and Endocrine Surgery, Department of Surgery, Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
| | - Jee Soo Kim
- Division of Breast and Endocrine Surgery, Department of Surgery, Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
| | - Jung-Han Kim
- Division of Breast and Endocrine Surgery, Department of Surgery, Samsung Medical Center; Sungkyunkwan University School of Medicine; Seoul Korea
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Li S, Li F, Niu R, Zhang H, Cui A, An W, Wang X. Mir-192 suppresses apoptosis and promotes proliferation in esophageal aquamous cell caicinoma by targeting Bim. INTERNATIONAL JOURNAL OF CLINICAL AND EXPERIMENTAL PATHOLOGY 2015; 8:8048-8056. [PMID: 26339371 PMCID: PMC4555699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 06/20/2015] [Indexed: 06/05/2023]
Abstract
MicroRNAs (miRNAs) are small, non-coding RNAs of endogenous origin. Accumulating studies have shown aberrant miRNA expression plays an important role in many tumor types. However, the mechanisms by which miRNAs regulate esophageal squamous cell carcinoma (ESCC) development remain poorly understood. In the present study, we assayed expression level of miR-192 in ESCC tissues and cell lines by real-time PCR, and defined the target gene and biological function by luciferase reporter assay, Western blot and apoptosis assay. We first verified that the expression level of miR-192 was significantly increased in ESCC tissues and cancer cells. Moreover, miR-192 over-expression inhibited cells apoptosis and promoted ESCC cells proliferation. We further demonstrated that miR-192 directly targeted 3'-UTR of Bim gene, and inhibited its protein expression. Importantly, Bim could reduce ESCC cells apoptosis ability induced by miR-192. These data suggest an important role of miR-192 in the molecular etiology of ESCC and implicate the potential application of miR-192 in ESCC therapy.
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Affiliation(s)
- Shujun Li
- Department of Thoracic Surgery, Second Hospital of Hebei Medical UniversityShijiazhuang, China
| | - Feng Li
- Department of Cancer Center, Second Hospital of Hebei Medical UniversityShijiazhuang, China
| | - Ren Niu
- Department of Cancer Center, Second Hospital of Hebei Medical UniversityShijiazhuang, China
| | - Helin Zhang
- Department of Thoracic Surgery, Second Hospital of Hebei Medical UniversityShijiazhuang, China
| | - Airong Cui
- Department of Pathology, Second Hospital of Hebei Medical UniversityShijiazhuang, China
| | - Wenting An
- Department of Central Laboratory, Second Hospital of Hebei Medical UniversityShijiazhuang, China
| | - Xiaolu Wang
- Department of Cancer Center, Second Hospital of Hebei Medical UniversityShijiazhuang, China
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