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Muacevic A, Adler JR, Jordan KG, Waters JK, Reznik SI. "Mega" Cisterna Chyli: A Case Report and Review of the Literature. Cureus 2023; 15:e34111. [PMID: 36843809 PMCID: PMC9946758 DOI: 10.7759/cureus.34111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2023] [Indexed: 01/25/2023] Open
Abstract
Enlarged cisterna chyli is an infrequently encountered entity and is most often an asymptomatic, incidental finding on imaging for other reasons. The pathogenesis of cisterna chyli enlargement is not well elucidated and includes infectious, inflammatory, and idiopathic causes. In this report, we present the rare case of an asymptomatic, markedly dilated "mega" cisterna chyli in a 60-year-old female.
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2
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Komatsuzaki S, Hisakura K, Ogawa K, Akashi Y, Kim J, Moue S, Miyazaki Y, Furuya K, Doi M, Owada Y, Shimomura O, Ohara Y, Takahashi K, Hashimoto S, Enomoto T, Koike N, Oda T. Transhiatal bilateral thoracic duct ligation for duplicated thoracic duct injury after esophagectomy: a case report. Surg Case Rep 2022; 8:213. [DOI: 10.1186/s40792-022-01567-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 11/15/2022] [Indexed: 12/03/2022] Open
Abstract
Abstract
Background
The treatment of duplicated thoracic ducts (TDs) injury after esophagectomy generally requires a bilateral transthoracic approach. We present the cases of two patients with postoperative chylothorax who underwent transhiatal bilateral TD ligation for duplicated TDs.
Case presentation
Two patients diagnosed with chylothorax after esophagectomy performed for thoracic esophageal cancer underwent transhiatal TD ligation. Although supradiaphragmatic mass ligation was performed on the fat tissue of the right side of the aorta containing the TD, chyle leakage persisted. To tackle this, the fat tissue of the left side of the aorta was ligated, after which the chyle leakage stopped.
Conclusion
Compared to the conventional transthoracic approach, the transhiatal approach enables the ligation of both left- and right-sided TD in a single surgical operation, without the need to change the patient’s posture. This approach may be appropriate for the treatment of chylothorax after esophagectomy, considering the possibility of duplicated TDs.
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3
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Risk Factors, Diagnosis and Management of Chyle Leak Following Esophagectomy for Cancers. ANNALS OF SURGERY OPEN 2022; 3:e192. [PMID: 36199483 PMCID: PMC9508983 DOI: 10.1097/as9.0000000000000192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 06/28/2022] [Indexed: 11/26/2022] Open
Abstract
This Delphi exercise aimed to gather consensus surrounding risk factors, diagnosis, and management of chyle leaks after esophagectomy and to develop recommendations for clinical practice.
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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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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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Chevallay M, Jung M, Chon SH, Takeda FR, Akiyama J, Mönig S. Esophageal cancer surgery: review of complications and their management. Ann N Y Acad Sci 2020; 1482:146-162. [PMID: 32935342 DOI: 10.1111/nyas.14492] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/14/2020] [Accepted: 08/20/2020] [Indexed: 02/06/2023]
Abstract
Esophagectomy, even with the progress in surgical technique and perioperative management, is a highly specialized surgery, associated with a high rate of complications. Early recognition and adequate treatment should be a standard of care for the most common postoperative complications: anastomotic leakage, pneumonia, atrial fibrillation, chylothorax, and recurrent laryngeal nerve palsy. Recent progress in endoscopy with vacuum and stent placement, or in radiology with embolization, has changed the management of these complications. The success of nonoperative treatments should be frequently reassessed and reoperation must be proposed in case of failure. We have summarized the clinical signs, diagnostic process, and management of the frequent complications after esophagectomy for esophageal cancer.
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Affiliation(s)
- Mickael Chevallay
- Division of Visceral Surgery, Department of Surgery, Geneva University Hospital, Geneva, Switzerland
| | - Minoa Jung
- Division of Visceral Surgery, Department of Surgery, Geneva University Hospital, Geneva, Switzerland
| | - Seung-Hun Chon
- Department of General, Visceral, Cancer and Transplantation Surgery, University Hospital of Cologne, Cologne, Germany
| | | | - Junichi Akiyama
- Division of Gastroenterology and Hepatology, National Center for Global Health and Medicine (NCGM), Tokyo, Japan
| | - Stefan Mönig
- Division of Visceral Surgery, Department of Surgery, Geneva University Hospital, Geneva, Switzerland
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7
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Posterior retroperitoneoscopic thoracic duct ligation: a novel surgical approach. Surg Endosc 2018; 32:3732-3737. [PMID: 29855711 DOI: 10.1007/s00464-018-6262-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 05/29/2018] [Indexed: 10/14/2022]
Abstract
BACKGROUND Treatment of postoperative chylothorax can be challenging. Conservative treatment and/or surgical management by means of open or minimally invasive thoracic duct ligation for persistent chylothorax are accepted therapeutic options. We present a new retroperitoneoscopic approach for thoracic duct ligation. METHODS Between January 2006 and May 2017, posterior retroperitoneoscopic thoracic duct ligation was performed in four patients. The thoracic duct was identified transdiaphragmatically and ligated cranially to the cisterna chyli using absorbable clips. RESULTS Retroperitoneoscopic ligation resulted in a complete and lasting chylothorax resolution in three patients and marked improvement in a fourth one. Mean operative time was 86 min (range 40-135). There were no perioperative or postoperative complications. CONCLUSIONS Retroperitoneoscopic thoracic duct ligation is feasible and safe. It allows for a precise anatomical exploration of the thoracic duct caudally to the chyle leak, avoiding the previous operative field and resulting in minimal morbidity. In patients with persistent chylothorax, our approach provides an additional therapeutic option.
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8
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Defize IL, Schurink B, Weijs TJ, Roeling TAP, Ruurda JP, van Hillegersberg R, Bleys RLAW. The anatomy of the thoracic duct at the level of the diaphragm: A cadaver study. Ann Anat 2018; 217:47-53. [PMID: 29510243 DOI: 10.1016/j.aanat.2018.02.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 01/11/2018] [Accepted: 02/01/2018] [Indexed: 01/30/2023]
Abstract
BACKGROUND Injury and subsequent leakage of unrecognized thoracic duct tributaries during transthoracic esophagectomy may lead to chylothorax. Therefore, we hypothesized that thoracic duct anatomy at the diaphragm is more complex than currently recognized and aimed to provide a detailed description of the anatomy of the thoracic duct at the diaphragm. BASIC PROCEDURES The thoracic duct and its tributaries were dissected in 7 (2 male and 5 female) embalmed human cadavers. The level of origin of the thoracic duct and the points where tributaries entered the thoracic duct were measured using landmarks easily identified during surgery: the aortic and esophageal hiatus and the arch of the azygos vein. MAIN FINDINGS The thoracic duct was formed in the thoracic cavity by the union of multiple abdominal tributaries in 6 cadavers. In 3 cadavers partially duplicated systems were present that communicated with interductal branches. The thoracic duct was formed by a median of 3 (IQR: 3-5) abdominal tributaries merging 8.3cm (IQR: 7.3-9.3cm) above the aortic hiatus, 1.8cm (IQR: -0.4 to 2.4cm) above the esophageal hiatus, and 12.3cm (IQR: 14.0 to -11.0cm) below the arch of the azygos vein. CONCLUSION This study challenges the paradigm that abdominal lymphatics join in the abdomen to pass the diaphragm as a single thoracic duct. In this study, this occurred in 1/7 cadavers. Although small, the results of this series suggest that the formation of the thoracic duct above the diaphragm is more common than previously thought. This knowledge may be vital to prevent and treat post-operative chyle leakage.
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Affiliation(s)
- Ingmar L Defize
- Department of Anatomy, University Medical Center Utrecht, Universiteitsweg 100, P.O. Box 85060, 3508 AB Utrecht, The Netherlands; Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
| | - Bernadette Schurink
- Department of Anatomy, University Medical Center Utrecht, Universiteitsweg 100, P.O. Box 85060, 3508 AB Utrecht, The Netherlands; Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, P.O. Box 85500, 3508 GA Utrecht, The Netherlands.
| | - Teus J Weijs
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
| | - Tom A P Roeling
- Department of Anatomy, University Medical Center Utrecht, Universiteitsweg 100, P.O. Box 85060, 3508 AB Utrecht, The Netherlands
| | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
| | - Richard van Hillegersberg
- Department of Surgery, University Medical Center Utrecht, Heidelberglaan 100, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
| | - Ronald L A W Bleys
- Department of Anatomy, University Medical Center Utrecht, Universiteitsweg 100, P.O. Box 85060, 3508 AB Utrecht, The Netherlands.
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Shimakawa T, Naritaka Y, Miyazawa M, Asaka S, Shimazaki A, Yamaguchi K, Yokomizo H, Yoshimatsu K, Shiozawa S, Katsube T. Lymphangiography Was Useful in Postoperative Intractable Chylothorax after Surgery for Esophageal Cancer: A Case Report. J NIPPON MED SCH 2017; 84:268-273. [PMID: 29279556 DOI: 10.1272/jnms.84.268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Postoperative chylothorax after surgery for esophageal cancer is a rare but serious complication. Treatment initially consists of conservative therapy and, if it fails to provide improvement, it is important to perform surgical treatment without delay. We report on a recent case of intractable chylothorax. This report describes a 72-year-old man with Stage III esophageal squamous cell carcinoma. Subtotal esophagectomy, through a right thoracoabdominal approach with two-field lymphadenectomy, and cervical esophagogastric anastomosis via the retrosternal route, were performed. On the 12th postoperative day, a diagnosis of chylothorax was made. Conservative treatment was initiated, but it proved to be ineffective. Therefore, ligation of the thoracic duct via a thoracotomy was performed, but this was not effective, either. Lymphangiography undertaken to identify the site of the leak in the thoracic duct enabled a diagnosis of an extremely rare double thoracic duct and identification of the site of the leak in the thoracic duct, thereby allowing curative direct ligation of the site. This case underscores the remarkable usefulness of lymphangiography in dealing with intractable postoperative chylothorax.
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Affiliation(s)
- Takeshi Shimakawa
- Department of Surgery, Tokyo Women's Medical University Medical Center East
| | - Yoshihiko Naritaka
- Department of Surgery, Tokyo Women's Medical University Medical Center East
| | - Miki Miyazawa
- Department of Surgery, Tokyo Women's Medical University Medical Center East
| | - Shinichi Asaka
- Department of Surgery, Tokyo Women's Medical University Medical Center East
| | - Asako Shimazaki
- Department of Surgery, Tokyo Women's Medical University Medical Center East
| | - Kentaro Yamaguchi
- Department of Surgery, Tokyo Women's Medical University Medical Center East
| | - Hajime Yokomizo
- Department of Surgery, Tokyo Women's Medical University Medical Center East
| | | | - Shunichi Shiozawa
- Department of Surgery, Tokyo Women's Medical University Medical Center East
| | - Takao Katsube
- Department of Surgery, Tokyo Women's Medical University Medical Center East
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Diaz-Gutierrez I, Rao MV, Andrade RS. Laparoscopic ligation of cisterna chyli for refractory chylothorax: A case series and review of the literature. J Thorac Cardiovasc Surg 2017; 155:815-819. [PMID: 29129424 DOI: 10.1016/j.jtcvs.2017.08.140] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 08/14/2017] [Accepted: 08/31/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVES We describe an alternative surgical technique for the treatment of chylothorax in patients who have had failure of or are not candidates for transthoracic ligation or embolization by interventional radiology. METHODS We describe our experience with laparoscopic ligation of the cisterna chyli in 3 such patients and compare our results with published literature. We used a 5-port approach as for foregut surgery. We retracted the liver, transected the gastrohepatic ligament, and retracted the stomach to the left. We exposed the right lateral aspect of the aorta at the level of the celiac trunk and clipped fatty tissue between the aorta and the right crus. We skeletonized the right crus and dissected from the right crus to the inferior vena cava. We then retracted the inferior vena cava laterally, exposed all soft tissue posteriorly, and identified the cisterna chyli posteromedially to the inferior vena cava. Finally, we ligated and clipped all fatty tissue between the right crus and the inferior vena cava. RESULTS Success rate was 67%; 1 patient with idiopathic chylothorax did not have resolution and eventually died of multisystem organ failure. There were no procedure-related complications. CONCLUSIONS Laparoscopic ligation of cisterna chyli is an available therapeutic option for patients with chylothorax unresponsive to medical management, embolization, and transthoracic ligation of the thoracic duct. Our series is comparable with other reports of transabdominal approach to chylothorax.
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Affiliation(s)
- Ilitch Diaz-Gutierrez
- Division of Thoracic and Foregut Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minn
| | - Madhuri Vasudev Rao
- Division of Thoracic and Foregut Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minn
| | - Rafael Santiago Andrade
- Division of Thoracic and Foregut Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minn.
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Weijs TJ, Ruurda JP, Broekhuizen ME, Bracco Gartner TC, van Hillegersberg R. Outcome of a Step-Up Treatment Strategy for Chyle Leakage After Esophagectomy. Ann Thorac Surg 2017; 104:477-484. [DOI: 10.1016/j.athoracsur.2017.01.117] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 12/30/2016] [Accepted: 01/30/2017] [Indexed: 12/14/2022]
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12
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Comparison of Early and Late Complications in Three Esophagectomy Techniques. INTERNATIONAL JOURNAL OF CANCER MANAGEMENT 2017. [DOI: 10.5812/ijcm.7644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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13
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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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14
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Transabdominal approach for chylorrhea after esophagectomy by using fluorescence navigation with indocyanine green. Case Rep Surg 2014; 2014:464017. [PMID: 25105050 PMCID: PMC4102023 DOI: 10.1155/2014/464017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2014] [Accepted: 06/15/2014] [Indexed: 11/17/2022] Open
Abstract
A 70-year-old man who underwent two sessions of thoracoscopy-assisted ligation of the thoracic duct to treat refractory chylorrhea after radical esophagectomy for advanced esophageal cancer received conservative therapy. However, there was no improvement in chylorrhea. Then, transabdominal ligation of the lymphatic/thoracic duct at the level of the right crus of the diaphragm was performed using fluorescence navigation with indocyanine green (ICG). The procedure successfully reduced chylorrhea. This procedure provides a valid option for persistent chylothorax/chylous ascites accompanied by chylorrhea with no response to conservative treatment, transthoracic ligation, or both.
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15
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Choh CT, Rychlik IJ, McManus K, Khan OA. Is early surgical management of chylothorax following oesophagectomy beneficial?: Table 1:. Interact Cardiovasc Thorac Surg 2014; 19:117-9. [DOI: 10.1093/icvts/ivu084] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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16
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Hoeppner J, Hopt UT. Transabdominal mass ligation of the thoracic duct for the prevention of chylothorax following en bloc oesophagectomy. Eur J Cardiothorac Surg 2013; 44:1134-1136. [DOI: 10.1093/ejcts/ezt287] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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17
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Mishra PK, Saluja SS, Ramaswamy D, Bains SS, Haque PD. Thoracic Duct Injury Following Esophagectomy in Carcinoma of the Esophagus: Ligation by the Abdominal Approach. World J Surg 2012; 37:141-6. [DOI: 10.1007/s00268-012-1811-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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18
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Allen CJ, DiPasco PJ, Koshenkov V, Franceschi D. Non-Hodgkin's Lymphoma as a Risk Factor for Persistent Chylothorax After Transhiatal Esophagectomy. World J Oncol 2012; 3:233-235. [PMID: 29147312 PMCID: PMC5649902 DOI: 10.4021/wjon523w] [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] [Accepted: 06/14/2012] [Indexed: 11/14/2022] Open
Abstract
We report a case of an 82 years old female with Non-Hodgkin Lymphoma (NHL) in remission whom underwent a transhiatal esophagectomy (THE) for esophageal adenocarcinoma. The post-operative course was complicated by severe chylothorax requiring an additional thoracotomy for ligation of the thoracic duct. The influence of the patient's history of NHL on the development of such a severe chylothorax is under question.
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Affiliation(s)
- Casey J. Allen
- Dewitt Daughtry Family Department of Surgery, Division of Surgical Oncology, University of Miami Miller School of Medicine, Clinical Research Building ,4th Floor (C232), 1120 NW 14th Street, Miami, FL, 33136, USA
| | - Peter J. DiPasco
- Dewitt Daughtry Family Department of Surgery, Division of Surgical Oncology, University of Miami Miller School of Medicine, Clinical Research Building ,4th Floor (C232), 1120 NW 14th Street, Miami, FL, 33136, USA
| | - Vadim Koshenkov
- Dewitt Daughtry Family Department of Surgery, Division of Surgical Oncology, University of Miami Miller School of Medicine, Clinical Research Building ,4th Floor (C232), 1120 NW 14th Street, Miami, FL, 33136, USA
| | - Dido Franceschi
- Dewitt Daughtry Family Department of Surgery, Division of Surgical Oncology, University of Miami Miller School of Medicine, Clinical Research Building ,4th Floor (C232), 1120 NW 14th Street, Miami, FL, 33136, USA
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19
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Rottoli M, Russo IS, Bernardi D, Bonavina L. Atypical presentation and transabdominal treatment of chylothorax complicating esophagectomy for cancer. J Cardiothorac Surg 2012; 7:9. [PMID: 22273581 PMCID: PMC3277471 DOI: 10.1186/1749-8090-7-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2011] [Accepted: 01/24/2012] [Indexed: 11/10/2022] Open
Abstract
Chylotorax is a relatively uncommon and difficult to treat complication after esophagectomy for cancer. We report a case of a young adult male who underwent neoadjuvant chemoradiationtherapy followed by Ivor-Lewis esophagectomy for a squamous-cell carcinoma of the distal esophagus. During the postoperative course the patient presented recurrent episodes of hemodynamic instability mimicking cardiac tamponade, secondary to compression of the left pulmonary vein and the left atrium by a mediastinal chylocele. Mediastinal drainage and ligation of the cisterna chyli and the thoracic duct was successfully performed through a transhiatal approach.
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Affiliation(s)
- Matteo Rottoli
- University of Milano, Department of Surgery, IRCCS Policlinico San Donato, San Donato Milanese, Italy
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Cestero J, Bukhary H, Carrillo E, Rosenthal H, Pepe A, Sanchez R, Lee SK. Refractory chylothorax following a transhepatic gunshot wound to the abdomen requiring unorthodox surgical treatment. J Surg Case Rep 2010; 2010:3. [PMID: 24946329 PMCID: PMC3649136 DOI: 10.1093/jscr/2010.6.3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
An 18 year-old-male sustained a gunshot wound to the abdomen which required an uneventful hepatorrhaphy. He later returned with a large right effusion and was diagnosed with a chylothorax. The output was persistent despite conservative measures. Thoracotomy with attempted thoracic duct ligation was unsuccessful at decreasing the output. Re-exploration and ligation of the thoracic duct was required thru an abdominal approach.
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Ishikawa T, Michiue T, Zhao D, Quan L, Li DR, Maeda H. Undiagnosed late-onset chylothorax accompanied by fatal acute pulmonary thromboembolism after surgical treatment of lung cancer: An autopsy case and review of the literature. Leg Med (Tokyo) 2010; 12:35-8. [DOI: 10.1016/j.legalmed.2009.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2009] [Revised: 10/16/2009] [Accepted: 10/19/2009] [Indexed: 10/20/2022]
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Maldonado F, Hawkins FJ, Daniels CE, Doerr CH, Decker PA, Ryu JH. Pleural fluid characteristics of chylothorax. Mayo Clin Proc 2009; 84:129-33. [PMID: 19181646 PMCID: PMC2664583 DOI: 10.1016/s0025-6196(11)60820-3] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To determine the biochemical parameters of chylous pleural fluids and better inform current clinical practice in the diagnosis of chylothorax. PATIENTS AND METHODS We retrospectively reviewed 74 patients with chylothorax (defined by the presence of chylomicrons) who underwent evaluation during a 10-year period from January 1, 1997, through December 31, 2006. The biochemical parameters and appearance of the fluid assessed during diagnostic evaluation were analyzed. RESULTS The study consisted of 37 men (50%) and 37 women (50%), with a median age of 61.5 years (range, 20-93 years). Chylothorax was caused by surgical procedures in 51%. The chylous pleural fluid appeared milky in only 44%. Pleural effusion was exudative in 64 patients (86%) and transudative in 10 patients (14%). However, pleural fluid protein and lactate dehydrogenase levels varied widely. Transudative chylothorax was present in all 4 patients with cirrhosis but was also seen with other causes. The mean +/- SD triglyceride level was 728+/-797 mg/dL, and the mean +/- SD cholesterol value was 66+/-30 mg/dL. The pleural fluid triglyceride value was less than 110 mg/dL in 10 patients (14%) with chylothorax, 2 of whom had a triglyceride value lower than 50 mg/dL. CONCLUSION Chylothoraces may present with variable pleural fluid appearance and biochemical characteristics. Nonmilky appearance is common. Chylous effusions can be transudative, most commonly in patients with cirrhosis. Traditional triglyceride cutoff values used in excluding the presence of chylothorax may miss the diagnosis in fasting patients, particularly in the postoperative state.
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Affiliation(s)
| | | | | | | | | | - Jay H. Ryu
- Individual reprints of this article are not available. Address correspondence to Jay H. Ryu, MD, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905 ().
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Maldonado F, Hawkins FJ, Daniels CE, Doerr CH, Decker PA, Ryu JH. Pleural fluid characteristics of chylothorax. Mayo Clin Proc 2009; 84:129-33. [PMID: 19181646 PMCID: PMC2664583 DOI: 10.4065/84.2.129] [Citation(s) in RCA: 129] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
OBJECTIVE To determine the biochemical parameters of chylous pleural fluids and better inform current clinical practice in the diagnosis of chylothorax. PATIENTS AND METHODS We retrospectively reviewed 74 patients with chylothorax (defined by the presence of chylomicrons) who underwent evaluation during a 10-year period from January 1, 1997, through December 31, 2006. The biochemical parameters and appearance of the fluid assessed during diagnostic evaluation were analyzed. RESULTS The study consisted of 37 men (50%) and 37 women (50%), with a median age of 61.5 years (range, 20-93 years). Chylothorax was caused by surgical procedures in 51%. The chylous pleural fluid appeared milky in only 44%. Pleural effusion was exudative in 64 patients (86%) and transudative in 10 patients (14%). However, pleural fluid protein and lactate dehydrogenase levels varied widely. Transudative chylothorax was present in all 4 patients with cirrhosis but was also seen with other causes. The mean +/- SD triglyceride level was 728+/-797 mg/dL, and the mean +/- SD cholesterol value was 66+/-30 mg/dL. The pleural fluid triglyceride value was less than 110 mg/dL in 10 patients (14%) with chylothorax, 2 of whom had a triglyceride value lower than 50 mg/dL. CONCLUSION Chylothoraces may present with variable pleural fluid appearance and biochemical characteristics. Nonmilky appearance is common. Chylous effusions can be transudative, most commonly in patients with cirrhosis. Traditional triglyceride cutoff values used in excluding the presence of chylothorax may miss the diagnosis in fasting patients, particularly in the postoperative state.
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Affiliation(s)
| | | | | | | | | | - Jay H. Ryu
- From the Division of Pulmonary and Critical Care Medicine (F.M., C.E.D., J.H.R.), Department of Internal Medicine (F.J.H.), and Division of Biomedical Information and Biostatistics (P.A.D.), Mayo Clinic, Rochester, MN; and Pulmonary, Critical Care & Sleep Medicine Consultants, Houston, TX (C.H.D.)
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Zerrweck C, Caiazzo R, Arnalsteen L, Dezfoulian G, Porte H, Pattou F. Chylothorax: Unusual Complication After Laparoscopic Gastric Banding. Obes Surg 2009; 19:667-70. [DOI: 10.1007/s11695-008-9798-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2008] [Accepted: 12/17/2008] [Indexed: 11/24/2022]
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Pandey R, Lee DF. Laparoscopic ligation of the thoracic duct for the treatment of traumatic chylothorax. J Laparoendosc Adv Surg Tech A 2008; 18:614-5. [PMID: 18721017 DOI: 10.1089/lap.2007.0243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Laparoscopic ligation of the thoracic duct was successfully used in the treatment of traumatic chylothorax where video-assisted thoracoscopy and conservative methods had failed. This minimally invasive approach contributed to the early discharge of our patient.
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Affiliation(s)
- Ramesh Pandey
- Department of Upper GI Surgery, St. Vincent's Hospital, Sydney, Australia.
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Valentí V, Martínez-Cecilia D, Gil A, Martínez-Isla A. [Thoracoscopic treatment of postsurgical chylothorax after the oral administering of a fat-rich diet]. Cir Esp 2008; 84:51-2. [PMID: 18590679 DOI: 10.1016/s0009-739x(08)70607-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Víctor Valentí
- Departamento de Cirugía General, Clínica Universitaria de Navarra, Pamplona, Navarra, Spain.
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