Incidence and management of chylothorax after esophagectomy

Sex differences in survival following surgery for esophageal cancer: A systematic review and meta-analysis

The impact of sex on the prognosis of patients with esophageal cancer remains unclear. Evidence supports that sex- based disparities in esophageal cancer survival could be attributed to sex- specific risk exposures, such as age at diagnosis, race, socioeconomic status, smoking, drinking, and histological type. The aim of our study is to investigate the role of sex disparities in survival of patients who underwent surgery for esophageal cancer. A systematic review and meta-analysis of the existing literature in PubMed, EMBASE, and CENTRAL from December 1966 to February 2023, was held. Studies that reported sex-related differences in survival outcomes of patients who underwent esophagectomy for esophageal cancer were identified. A total of 314 studies were included in the quantitative analysis. Statistically significant results derived from 1-year and 2-year overall survival pooled analysis with Relative Risk (RR) 0.93 (95% Confidence Interval (CI): 0.90-0.97, I2 = 52.00) and 0.90 (95% CI: 0.85-0.95, I2 = 0.00), respectively (RR < 1 = favorable for men). In the postoperative complications analysis, statistically significant results concerned anastomotic leak and heart complications, RR: 1.08 (95% CI: 1.01-1.16) and 0.62 (95% CI: 0.52-0.75), respectively. Subgroup analysis was performed among studies with <200 and > 200 patients, histology types, study continent and publication year. Overall, sex tends to be an independent prognostic factor for esophageal carcinoma. However, unanimous results seem rather obscure when multivariable analysis and subgroup analysis occurred. More prospective studies and gender-specific protocols should be conducted to better understand the modifying role of sex in esophageal cancer prognosis.

Indocyanine green fluorescence imaging technology for the treatment of chylothorax after oesophageal cancer: A case report

Chylothorax is a serious postoperative complication of oesophageal cancer, and to date, there is no standardized and effective intraoperative diagnostic tool that can be used to identify the thoracic duct and determine the location of lymphatic fistulas. A 50-year-old patient with oesophageal squamous cell carcinoma developed chylothorax after thoracolaparoscopy combined with radical resection of oesophageal cancer. Twelve hours after surgery, 1200 mL of clear fluid was drained from the thoracic drainage tube, and a chyle test was sent. A thoracothoracic duct ligation procedure was performed on the first day after surgery. Although fluid accumulating in the posterior mediastinum was observed, the location of the lymphatic fistula could not be determined. During the surgery, indocyanine green (ICG) was injected into the bilateral inguinal lymph nodes, and a fluorescent lens was used to determine the location of the lymphatic fistula so the surgeon could ligate the thoracic duct. ICG fluorescence imaging technology can help surgeons effectively manage chylothorax after oesophageal cancer surgery. To our knowledge, this is the first report to describe the use of ICG fluorescence imaging technology to treat postoperative chylothorax in patients with oesophageal cancer in China.

VATS thoracic duct clipping in post-CABG with chylothorax

Post-coronary artery bypass graft (CABG) surgery, chylothorax is a rare, but a serious, complication. We report a case of 49-year-old female who underwent CABG, and developed pleural effusion on post-operative day 2 which was milky in nature. Chylothorax was confirmed based on the biochemical analysis of the pleural fluid. As the medical line of management failed, video-assisted thoracoscopic surgery (VATS) was done and thoracic duct clipped on the right side. Close to the proximal portion of the left internal thoracic artery, disrupted tributaries of thoracic duct were noted and clipped. Rarity of the case and management is highlighted.

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

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

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.

Does Thoracic Duct Ligation at the Time of Esophagectomy Impact Long-Term Survival? An Individual Patient Data Meta-Analysis

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.

Efficacy of nil per oral, total parenteral nutrition, milrinone and non-suction chest tube drainage-based management for chylothorax following pediatric cardiac surgery

OBJECTIVE

A single centre experience with chylothorax in post cardiac surgical patients.

METHODS

Retrospective review.

RESULTS

Chylothorax developed in 55 out of 873 operated patients (6.3%). Median age of the chylothorax cohort was 95 days (range 1-995). Neonates constituted 36% and 49% were infants. Group-1(35 patients-treated during the years 2011-2015) included those who were managed with low fat diet initially with other standard measures including steroid, octreotide, pleurodesis, lymphangiogram or thoracic duct ligation whenever required.Group-2 (20 patients, treated between year 2016-2018) were managed with nil per oral, total parenteral nutrition, extended use of milrinone and no use of chest tube suction with other above standard measures when required.Group-1 and group-2 were comparable in terms of their age and weight (p > 0.05).We observed lower volume of chest drainage, shorter intubation time, length of intensive care stay and hospital stay in group-2 compared to group-1 though they were statistically not significant (p > 0.05). Occurrence of massive chylothorax (>20 ml/kg/day) in group-1 was significantly higher [18 patients (51%) in group-1 vs 4 patients in group-2 (20%) (Chi-square 5.25, p = 0.02)]. In hospital mortality in group-1 was higher compared to group-2 (5/35 = 14.5% vs 1/20 = 5%), however, it was statistically not significant [risk ratio 2.86; 95% CI 0.36, 22.77; p = 0.59)]. Acute kidney injury was observed in about 25% of patients who had chylothorax. A higher mortality was observed in patients with chylothorax who had acute kidney injury [5/14 (35%)] compared to those who did not have acute kidney injury [1/41 (2.4%)] (Chi-square 11.89, p = 0.001)].

SUMMARY

In a heterogenous cohort of post-cardiac surgical patients who developed chylothorax, our suggested new regime (nil per oral, parenteral nutrition, extended use of milrinone and no suction applied to the chest drains) contributed to reduce the frequency of massive chylothorax occurrence significantly.

Thoracic Duct Visualization in Esophageal Resection: A Pilot Trial

INTRODUCTION

Inadvertent thoracic duct injury is common during esophagectomy and may result in postoperative chylothorax. This study's objective was to investigate utility of patent blue injection as a modality for intraoperative thoracic duct visualization.

METHODS

A prospective, single-arm, interventional study of patients undergoing minimally invasive esophagectomy was performed. Patients were injected with patent blue dye into both groins prior to thoracic stage of surgery and assessed for duct visualization. Control group was formed by propensity score matching using retrospectively collected data regarding patients who underwent esophagectomy.

RESULTS

A total of 25 patients were included in analysis, compared to a control of 50 patients after matching. Thoracic duct was visualized in 60% of patients in the study group (15/25 patients). Significant differences were found between study and control groups (p < 0.05) with regards to median operative time (422 vs. 285 min, respectively), overall complications (16 vs. 34%, respectively), and median postoperative length of stay (13.5 vs. 10 days, respectively). There was a difference in rate of chyle leak between study and control groups; however, this was not significant (0 vs. 12%, respectively, p = 0.17).

CONCLUSION

Patent blue injection represents a simple method for thoracic duct visualization during minimally invasive esophagectomy which may improve surgical outcomes.

Association between underweight status and chylothorax after esophagectomy for esophageal cancer: A propensity score-matched analysis

Objective

To use a nationwide database of hospitalizations to investigate underweight status as a risk factor for postesophagectomy complications.

Methods

We identified all patients who underwent esophagectomy with a diagnosis of esophageal cancer and known body mass index in the 2018-2020 Nationwide Readmissions Database. All hospital visits for esophagectomy and within 30 days of initial discharge were analyzed for postoperative complications, including chylothorax. Patients who were underweight were propensity score matched with patients who were not. Multivariable logistic regression was performed to identify complications that were significantly associated with underweight status.

Results

There were 1877 patients with esophageal cancer meeting inclusion criteria. Following propensity score matching, 433 patients who were underweight were matched to 433 patients who were not. In the multivariable model of the matched sample, which adjusted for age, sex, Charlson Comorbidity Index, history of chemotherapy or radiation therapy, and preoperative surgical feeding access, patients who were underweight were estimated to have 2.06 times the odds for chylothorax (95% confidence interval [CI], 1.07-4.25, P = .035). Underweight status was also significantly associated with acute bleed (odds ratio [OR], 1.52; 95% CI, 1.12-2.05, P = .007), pneumothorax (OR, 2.33; 95% CI, 1.19-4.85; P = .017), pneumonia (OR, 2.30; 95% CI, 1.53-3.50, P < .001), and in-hospital mortality (OR, 2.42; 95% CI, 1.31-4.69, P = .006).

Conclusions

Underweight status was found to be a risk factor for chylothorax after esophagectomy, which may have implications for perioperative care of esophageal cancer patients. Future studies should assess whether using feeding tubes or total parenteral nutrition preoperatively or thoracic duct ligation intraoperatively decreases risk of chylothorax among patients who were underweight.

Use of Total Parenteral Nutrition (TPN) as a Vehicle for Drug Delivery

Total Parenteral Nutrition (TPN) is a method of providing nutrients directly into the bloodstream for individuals who are unable to meet their nutritional needs through the normal digestive process or gastrointestinal system. It provides macronutrients and micronutrients in a single container, reducing handling and contamination risks and making it more cost-effective. TPN has the potential to be used as a drug delivery system, with applications in combination therapies, personalized medicine, and integrating advanced technologies. It can enhance drug dosage precision and provide nutritional assistance, potentially reducing hospitalization and improving patient outcomes. However, implementing new applications requires thorough testing and regulatory approval. TPN could be particularly useful in pediatric and geriatric care and could also contribute to global health by combating malnutrition in areas with limited medical resources. Healthcare professionals prepare a sterile solution tailored to each patient's nutritional needs, and administration involves a central venous catheter. However, the simultaneous administration of medications with PN admixtures can result in pharmacological incompatibility, which can impact the stability of the oil-in-water system. The European Society for Clinical Nutrition and Metabolism and the American Society for Parenteral and Enteral Nutrition recommendations advise against including non-nutrient drugs in PN admixtures due to safety concerns. This review focuses on the utilization of Total Parenteral Nutrition (TPN) as a method for delivering drugs. It discusses the benefits and difficulties associated with its commercial application and offers suggestions for future research endeavors.

Effect of Early Versus Late Oral Feeding on Postoperative Complications and Recovery Outcomes for Patients with Esophageal Cancer: A Systematic Evaluation and Meta-Analysis

BACKGROUND

This study aimed to systematically evaluate the effect of early oral feeding (EOF) versus late oral feeding (LOF) on postoperative complications and rehabilitation outcomes for patients with esophageal cancer.

METHODS

This study searched relevant literature published up to March 2023 by computer retrieval of PubMed, Embase, The Cochrane Library, and Web of Science. A meta-analysis was performed using Review Manager 5.4 software to compare the effects of EOF and LOF on postoperative complications and recovery outcomes of patients with esophageal cancer.

RESULTS

The study included 14 articles, including 9 retrospective studies, 4 randomized controlled trials (RCTs), and 1 prospective study. The 2555 patients included in the study comprised 1321 patients who received EOF and 1234 patients who received LOF. The results of the meta-analysis showed that compared with the LOF group, the EOF group has a shorter time to the first flatus postoperatively (mean difference [MD],  -  1.12; 95% confidence interval [CI], (-  1.25 to -  1.00; P < 0.00001), a shorter time to the first defecation postoperatively (MD, -  1.31; 95% CI, -  1.67 to -   0.95;, P < 0.00001], and a shorter hospital stay postoperatively (MD, -  2.87; 95% CI, -  3.84 to -  1.90; P < 0.00001). The two groups did not differ significantly statistically in terms of postoperative anastomotic leakage rate (P = 0.10), postoperative chyle leakage rate (P = 0.10), or postoperative pneumonia rate (P = 0.15).

CONCLUSION

Early oral feeding after esophageal cancer surgery can shorten the time to the first flatus and the first defecation postoperatively, shorten the hospital stay, and promote the recovery of patients. Moreover, it has no significant effect on the incidence of postoperative complications.

Intractable chylous leak after radical esophagectomy treated with radiotherapy

Postoperative chylous leak after esophagectomy is a rare but potentially life-threatening complication that results in hypovolemia, electrolyte imbalance, malnutrition, and immunologic deficiency. However, the management of postoperative chylous leak remains controversial. Following a diagnosis of esophageal cancer, a 64-year-old man was treated by video-assisted thoracoscopic esophagectomy, laparoscopic gastric tube formation, prophylactically thoracic duct ligation, and reconstruction with esophagogastrostomy at the neck level. Massive postoperative drainage from the thorax and abdomen did not initially meet the diagnostic criteria for chylothorax, which was ultimately diagnosed 3 weeks after the operation. Despite various treatments including total parenteral nutrition, octreotide and midodrine, reoperation (thoracic duct ligation and mechanical pleurodesis), and thoracic duct embolization, the chylous leak persisted. Finally, low-dose radiation therapy was administered with a daily dose of 2 Gy and completed at a total dose of 14 Gy. After this, the amount of pleural effusion gradually decreased over 2 weeks, and the last drainage tube was removed. The patient was alive and well at 60 months postoperatively. Herein, we describe a patient with intractable chylous leak after esophagectomy, which persisted despite conservative treatment, thoracic duct ligation, and embolization, but was finally successfully treated with radiotherapy.

Clinical implications of chyle leakage following esophagectomy

The clinical consequences of chyle leakage following esophagectomy are underexposed. The aim of this study was to investigate the clinical implications of chyle leakage following esophagectomy. This retrospective study of prospectively collected data included patients who underwent transthoracic esophagectomy in 2017-2020. Routinely, the thoracic duct was resected en bloc as part of the mediastinal lymphadenectomy. Chyle leakage was defined as milky drain fluid for which specific treatment was initiated and/or a triglyceride level in drain fluid of ≥1.13 mmol/L, according to the Esophagectomy Complications Consensus Group (ECCG) classification. Primary endpoints were the clinical characteristics of chyle leakage (type, severity and treatment). Secondary endpoints were the impact of chyle leakage on duration of thoracic drainage and hospital stay. Chyle leakage was present in 43/314 patients (14%), of whom 24 (56%) were classified as severity A and 19 (44%) as severity B. All patients were successfully treated with either medium chain triglyceride diet (98%) or total parental nutrition (2%). There were no re-interventions for chyle leakage during initial admission, although one patient needed additional pleural drainage during readmission. Patients with chyle leakage had 3 days longer duration of thoracic drainage (bias corrected accelerated (BCa) 95%CI:0.46-0.76) and 3 days longer hospital stay (BCa 95%CI:0.07-0.36), independently of the presence of other complications. Chyle leakage is a relatively frequent complication following esophagectomy. Postoperative chyle leakage was associated with a significant longer duration of thoracic drainage and hospital admission. Nonsurgical treatment was successful in all patients with chyle leakage.

Recurrent chylothorax as a consequence of esophageal stent

Incidence of chylothorax post-esophageal stenting has not been reported. We present a 40-year-old female with metastatic breast cancer who presented with dyspnea. She was recently hospitalized for dysphagia secondary to a mediastinal mass requiring an esophageal stent. CT chest now reported large bilateral pleural effusions. A benign chylothorax was drained from the right side. After persistent high-output drainage, a review of her CT chest revealed thoracic duct impingement by the esophageal stent. The stent was retracted proximally, and pleural fluid output subsequently decreased. Repeat fluid analysis revealed a transudative effusion. This is the first reported case of esophageal stenting causing reversible chylothorax.

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

Background

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

Case presentation

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

Conclusion

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

Multidisciplinary Management of Chylothorax

Chylothorax, the accumulation of chyle in the pleural space, is usually caused by the disruption of the thoracic duct or its tributaries. Etiologies are broadly divided into traumatic, including postsurgical, and nontraumatic, most commonly in the setting of malignancy. The management of chylothorax largely depends on the cause and includes dietary modification and drainage of the pleural space. A definitive intervention, whether surgical or a percutaneous lymphatic intervention, should be considered in patients with a persistently high volume of chylous output and in those with a prolonged leak, before complications such as malnutrition ensue. No methodologically robust clinical trials guiding management are currently available. In this article, we review the current literature and propose a stepwise, evidence-based multidisciplinary approach to the management of patients with both traumatic and nontraumatic chylothorax.

Incidence of chylothorax over nineteen years of transhiatal esophagectomy: A case series and review study

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.

Adequate Management of Postoperative Complications after Esophagectomy: A Cornerstone for a Positive Outcome

BACKGROUND

Esophagectomy for cancer is one of the most complex procedures in visceral surgery. Postoperative complications negatively affect the patient's overall survival. They are not influenced by the histology type (adenocarcinoma (AC)/squamous cell carcinoma (SCC)), or the surgical approach (open, laparoscopic, or robotic-assisted). Among those dreadful complications are anastomotic leak (AL), esophago-respiratory fistula (ERF), and chylothorax (CT).

METHODS

In this review, we summarize the methods to avoid these complications, the diagnostic approach, and new therapeutic strategies.

RESULTS

In the last 20 years, both centralization of the medical care, and the development of endoscopy and radiology have positively influenced the management of postoperative complications. For the purpose of their prevention, perioperative measures have been applied. The treatment includes conservative, endoscopic, and surgical approaches.

CONCLUSIONS

Post-esophagectomy complications are common. Prevention measures should be known. Early recognition and adequate treatment of these complications save lives and lead to better outcomes.

Post-esophagectomy chylothorax refractory to mass ligation of thoracic duct above diaphragm: a case report

Background

Post-esophagectomy chylothorax is a relatively rare but potentially lethal complication. The treatment strategy of post-esophagectomy chylothorax remains a subject of debate which mainly focuses on the indication and timing of surgical intervention. For cases in which the leakage site is not localized, a mass ligation of the thoracic duct above diaphragm is advocated as the surgical procedure is believed to ensure sealing all the accessory ducts that could be the source of the chylothorax. But in this paper, we report a case of post-esophagectomy chylothorax which was refractory to mass ligation of thoracic duct above diaphragm.

Case presentation

A 59-year old man suffered from high output chylothorax (> 1000 ml/24 h for more than 30 days) after esophagectomy through left thoracotomy. Considering the failure of lymphangiography, we performed mass ligation of thoracic duct above diaphragm. However, we failed to close the chylous leakage. Finally, we found that a rare variated tributary of thoracic duct was the resource of the chylous output. Both the variation of lymphatic system and the coincidence of injured site lead to the invalidness of reoperation. After definitely ligating the variated tributary, chylothorax was cured.

Conclusion

This case supplies a direct evidence that mass ligation of thoracic duct is of no avail in some refractory chylothorax, which indicates the importance of chylous leakage localization.

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

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

The management of chyle leak post-oesophagectomy for oesophageal carcinoma: a systematic review

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.

Fluorescent lymphography for thoracic duct identification: Initial experience of a simplified and feasible ICG administration

INTRODUCTION

Indocyanine green (ICG) lymphography can be performed to obtain realtime fluorescent images of the thoracic duct (TD). The injection of ICG into the inguinal nodes usually is ultrasound-guided. Our hypothesis was to simplify the ICG administration until making it executable by unqualified personnel without ultrasound guidance.

MATERIAL AND METHODS

From October 2019 to October 2021 we enroled 18 patients. ICG was injected with a 25 Gauge needle in the subcutaneous tissue of the inguinal region bilaterally 14-16 h before surgery.

RESULTS

The TD was visualised in every case considered. The easy switching between fluorescence and white light visualization facilitated the identification and dissection of the TD avoiding involuntary injuries.

CONCLUSIONS

The simplified ICG administration to identify TD during oesophagectomy is easy to perform, does not require specifically trained staff, is not time demanding and has comparable results to the procedure performed under ultrasound guide.

Lymphatic leakage after pelvic lymphadenectomy for cervical cancer: a retrospective case-control study

BACKGROUND

The study aims to evaluate the clinical features and management of postoperative lymphatic leakage (PLL) in patients with cervical cancer who received pelvic lymphadenectomy.

METHODS

This retrospective study screened consecutive patients with cervical cancer (stage Ia2-IIb).

RESULTS

Among 3427 cases screened, 63 patients (1.8%) were diagnosed with PLL, which manifested as persistent abdominal drainage (42/63, 66.7%), chylous ascites (12/63, 19.0%) or vaginal drainage (9/63, 14.3%). Median time from surgery to onset of PLL was 6 days (range, 4-21 days). All cases resolved in a median 10 days (range, 3-56 days) after conservative treatment; although one case experienced recurrence of vaginal drainage after 26 days, this also resolved after conservative therapy. Multivariate analysis showed that two cycles of neoadjuvant chemotherapy (odds ratio [OR], 3.283; 95% confidence interval [95%CI], 1.289-8.360; P = 0.013), a decrease in hemoglobin level of ≥20 and < 30 g/L (OR, 6.175; 95%CI, 1.033-10.919; P = 0.046) or ≥ 30 g/L (OR, 8.467; 95%CI, 1.248-17.426; P = 0.029), and postoperative albumin level ≥ 30 and < 35 g/L (OR, 2.552; 95%CI, 1.112-5.857; P = 0.027) or < 30 g/L (OR, 5.517; 95%CI, 2.047-18.148; P = 0.012) were associated with PLL.

CONCLUSION

Neoadjuvant chemotherapy, postoperative anemia and postoperative hypoproteinemia are risk factors for PLL.

Management of chyle leaks following esophageal resection: a systematic review

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Postoperative pneumonia in the acute phase is an important prognostic factor in patients with esophageal cancer

BACKGROUND

The impact of pneumonia on prognosis is controversial, and no report has focused on its onset. This study aimed to examine the impact of pneumonia according to its onset on prognosis and its associated risk factors after esophagectomy.

METHODS

In total, 484 patients who underwent curative resection for esophageal squamous cell carcinoma were retrospectively reviewed. Patients with pneumonia were divided into two groups by the date of onset: pneumonia in the acute phase within 7 days after surgery (n = 59) and pneumonia in the subacute phase 8 days after surgery (n = 49).

RESULTS

The disease-free survival of patients with acute pneumonia was significantly lower than that of those without pneumonia (P = .0002), whereas the disease-free survival of patients with subacute pneumonia was similar to that of patients without pneumonia (P = .5363). In multivariate analysis for disease-free survival, P-stage III to IV (hazard ratio [HR], 3.344; P < .0001), transfusion (HR, 1.4078; P = .0291), and acute pneumonia (HR, 1.8463; P = .0009) were independent prognostic factors. Multivariate analysis revealed that age >75 years (odds ratio [OR], 2.1746; P = .0232), respiratory disease comorbidity (OR, 4.3869; P = .0002), cT3-4 (OR, 2.0143; P = .0477), extended surgery duration (OR, 2.3406; P = .0152), and posterior mediastinal reconstruction (OR, 0.1432; P = .0439) were independent risk factors for acute pneumonia.

CONCLUSION

Post-esophagectomy pneumonia in the acute phase was an independent prognostic factor, whereas advanced age, respiratory disease comorbidity, and extended surgery duration were risk factors for acute pneumonia.

Differential diagnosis of chylothorax in therapeutic practice

The article is devoted to the differential diagnosis of chylous pleural effusion. The spectrum of traumatic and non-traumatic causes of chylothorax is discussed in detail. Examples of necessary diagnostic measures are given for the accumulation of milky fluid in the pleural cavity in order to verify chylothorax.

Chylothorax - Modalities of management and outcomes: A case series

Background:

At present, there are no universally accepted protocols for the management of chylothorax. This study aims at reporting the clinical experience and presenting our institutional protocol for managing chylothorax.

Materials and Methods:

This is a retrospective analysis of chylothorax patients managed at a dedicated thoracic surgical unit over 8 years. A detailed analysis of demography and perioperative variables including complications was carried out. Factors influencing failure of conservative and surgical therapy were analyzed.

Results:

A total of 26 patients were included with a mean age of 42.4 years (range, 2–72 years). Postsurgical chylothorax was the most common variant (53.8%). Majority (46.1%) of the patients had >1000 ml/24 h intercostal tube drainage at presentation. All patients were initially subjected to conservative management, of which 11 (42.4%) patients were managed successfully with conservative therapy alone. Rest 15 (57.6%) patients required video-assisted thoracoscopic thoracic duct ligation, which was successful in 10/15 (66.7%) patients, whereas additional intervention was required in 5/15 (33.3%) patients. Drain output of >1000 ml/day was an independent predictor of failure of conservative therapy. Nontraumatic bilateral chylothorax was associated with high probability of failure of surgical therapy in the first attempt and may require additional treatment modality.

Conclusions:

Initial conservative management is recommended for all chylothorax patients, which is unlikely to succeed if daily drainage is >1000 ml/24 h. VATS thoracic duct ligation is recommended in such cases. Nontraumatic bilateral chylothorax has higher surgical failure rates. In such cases, additional procedures in the form of pleurodesis and/or thoracic duct embolization/disruption should be considered.

White lung with milky effusion

Thoracic duct injury is a rare complication of dorsal spine operations. Ultrasound chest plays an important tool for rapid diagnosis of acute dyspnea, drainage of massive effusion, and daily follow-up. Conservative treatment of postoperative chylous with measures to decrease chylous formation can lead to a resolution of chylothorax.

Chylothorax after coronary artery bypass surgery. Report of a case and review of the literature

Chylothorax after coronary artery bypass grafting is a rare complication and leads to increased mortality and morbidity. Because of the rarity of this complication, its management is debatable. We present the case of a 41 years old male patient who had a left sided chylothorax after coronary artery bypass grafting. The patient was managed conservatively with low fat diet and drainage of the chylothorax. A thorough search of the literature published on the subject was done and treatment strategies employed by various authors were studied. Various treatment options are conservative management with chest tube drainage, octreotide and low-fat diet or diet containing medium chain triglycerides. Invasive options are video assisted thoracoscopy and thoracotomy with or without ligation of thoracic duct. An account of the management strategies employed by various authors is presented in this report.

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

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

The influence of thoracic duct ligation on long-term survival of patients with esophageal cancer: a propensity score-matched analysis

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.

An Unusual Cause of Chylothorax after Esophagectomy

Chylothorax due to inadvertent thoracic duct injury after esophagectomy is a well-known complication and requires careful postoperative management and timely intervention to prevent potential morbidity and mortality. We present a case of high-output chylothorax after esophagectomy where the source of chyle leak was not in the thorax.

Management options for post-esophagectomy chylothorax

Chylothorax, although an uncommon complication of esophagectomy, is associated with high morbidity and mortality if not treated promptly. Consequently, knowledge of the thoracic duct (TD) anatomy is essential to prevent its inadvertent injury during surgery. If the TD is injured, early diagnosis and immediate intervention are of paramount importance; however, there is still no universal consensus about the management of post-operative chylothorax. With increasing advances in the spheres of interventional radiology and minimally invasive surgery, there are now several options for managing TD injury. We review this topic in detail to provide a comprehensive and practical overview to help surgeons manage this challenging complication. In particular, we discuss an appropriate step-up approach to prevent the morbidity associated with open surgery as well as the metabolic, nutritional, and immunological disorders that accompany a prolonged illness.

Chyle Leakage after Esophageal Cancer Surgery

Surgeons recommend dissecting lymph nodes in the thorax, abdomen, and neck during surgery for esophageal cancer because of the possibility of metastasis to the lymph nodes in those areas through the lymphatic plexus of the esophageal submucosal layer. Extensive lymph node dissection is essential for accurate staging and is thought to improve survival. However, it can result in several complications, including chyle leakage, which refers to continuous lymphatic fluid leakage and can occur in the thorax, abdomen, and neck. Malnutrition, fluid imbalance, and immune compromise may result from chyle leakage, which can be potentially life-threatening if it persists. Therefore, various treatment methods, including conservative treatment, pharmacological treatment such as octreotide infusion, and interventions such as thoracic duct embolization and surgical thoracic duct ligation, have been applied. In this article, the risk factors, diagnosis, and treatment methods of chyle leakage after esophagectomy are reviewed.

Lymphography and embolization of the thoracic duct as a treatment for chylothorax after esophagectomy for esophageal cancer

INTRODUCTION

Chylothorax is a rare complication in esophagectomies that is associated with increased postoperative mortality. Several factors have been described that may favor its appearance. Its treatment is controversial, and lymphography with percutaneous embolization of the thoracic duct is used by several groups.

MATERIAL AND METHOD

Our retrospective study included patients who underwent esophagectomy for cancer of the esophagus or the esophagogastric junction (Siewert I/II) between January 2010 and April 2019 and developed chylothorax as a complication. Epidemiological data, type of surgery, morbidity and treatment were analyzed.

RESULTS

274 cancer-related esophagectomies were performed in the study period. Thirteen patients (4.7%) were diagnosed with chylothorax in the postoperative period; 3 were resolved with conservative treatment. In the remaining 10 patients, lymphography was performed with aspiration of the cisterna chyli and thoracic duct embolization, which resolved the chylothorax in 9. One patient (10%) presented a biliary fístula after the procedure.

CONCLUSIONS

Lymphography with aspiration of the cisterna chyli and thoracic duct embolization is a technique with low morbidity that provides good results for the resolution of chylothorax after esophagectomy.

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

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

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

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

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

Prophylactic thoracic duct ligation is associated with poor prognosis and regional lymph node relapse in esophageal squamous cell carcinoma

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.

Intranodal lymphangiography for chyle leakage after esophagectomy: A case report

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

Risk factors and outcomes associated with anastomotic leaks following esophagectomy: a systematic review and meta-analysis

Anastomotic leaks (AL) are a major complication after esophagectomy. This meta-analysis aimed to determine identify risks factors for AL (preoperative, intra-operative, and post-operative factors) and assess the consequences to outcome on patients who developed an AL. This systematic review was performed according to PRISMA guidelines, and eligible studies were identified through a search of PubMed, Scopus, and Cochrane CENTRAL databases up to 31 December 2018. A meta-analysis was conducted with the use of random-effects modeling and prospectively registered with the PROSPERO database (Registration CRD42018130732). This review identified 174 studies reporting outcomes of 74,226 patients undergoing esophagectomy. The overall pooled AL rates were 11%, ranging from 0 to 49% in individual studies. Majority of studies were from Asia (n = 79). In pooled analyses, 23 factors were associated with AL (17 preoperative and six intraoperative). AL were associated with adverse outcomes including pulmonary (OR: 4.54, CI95%: 2.99-6.89, P < 0.001) and cardiac complications (OR: 2.44, CI95%: 1.77-3.37, P < 0.001), prolonged hospital stay (mean difference: 15 days, CI95%: 10-21 days, P < 0.001), and in-hospital mortality (OR: 5.91, CI95%: 1.41-24.79, P = 0.015). AL are a major complication following esophagectomy accounting for major morbidity and mortality. This meta-analysis identified modifiable risk factors for AL, which can be a target for interventions to reduce AL rates. Furthermore, identification of both modifiable and non-modifiable risk factors will facilitate risk stratification and prediction of AL enabling better perioperative planning, patient counseling, and informed consent.

Prophylactic ligation of the thoracic duct branch prevents chylothorax after pulmonary resection for right lung cancer

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.

Intraoperative Lipid-Rich Nutrition in the Detection of Chylothorax in Minimally Invasive Ivor Lewis Esophagectomy

Background. Chylothorax is a rare but severe complication after esophagectomy with an incidence of 1.9% to 8.9%. The aim of this study was to evaluate the efficacy of intraoperative lipid-rich feeding in reducing the incidence of post-esophagectomy chylothorax. Methods. A retrospective cohort study was performed among patients who underwent totally minimally invasive esophagectomy with intrathoracic anastomosis (tMIE Ivor Lewis) from February 2015 until December 2016. In this group, a lipid-rich solution was administered intraoperatively via a feeding jejunostomy. A historical cohort of identical patients operated in the period December 2012 to February 2015 did not receive intraoperative feeding and was used as a control. Results. In total, 133 patients underwent tMIE Ivor Lewis, of whom 59 patients (44%) received lipid-rich solution intraoperatively. The administered median total volume was 800 mL. During thoracic dissection, the thoracic duct was clearly visible in 37 patients (63%). With the help of lipid-rich feeding, intraoperative unintended duct damage was detected in 3 patients and treated. Postoperatively, 1 out of 59 patients (1.7%) developed chylothorax that was managed nonoperatively. In the control group, chylothorax was seen in 3 out of 74 patients (4.1%), P = .629. Conclusions. Intraoperative lipid-rich solution through a feeding jejunostomy helps identify thoracic duct damage during tMIE and may reduce postoperative chylothorax.

Management of High-Output Chyle Leak after Harvesting of Vascularized Supraclavicular Lymph Nodes

Vascularized lymph node transfer is a physiologic microsurgical technique used for the treatment of lymphedema. As vascularized lymph node transfer is becoming more common, it is essential that one is aware of all potential complications associated with vascularized lymph node transfer and know how to avoid and manage them when they do occur. The authors recently encountered a complication after supraclavicular vascularized lymph node transfer that has not been previously reported. A patient developed a recalcitrant high-output (>500 ml/day) chyle leak in the neck donor site after supraclavicular vascularized lymph node transfer harvest. In this article, the authors share their experience with massive chyle leak and review the management strategies of how to effectively avoid and treat this potentially dangerous complication. This review of a previously unreported complication of supraclavicular vascularized lymph node transfer is timely and important, as this procedure is increasingly being offered to patients, and surgeons performing these procedures should be familiar with effectively managing this potentially dangerous complication. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, V.