Prevention of postoperative chylothorax with thoracic duct ligation during video-assisted thoracoscopic esophagectomy for cancer

Background  

Minimally invasive esophagectomy (MIE) is a feasible technique that has been shown to be safe for the treatment of esophageal cancer. Chylothorax remains a challenging and potentially life-threatening postoperative complication of MIE. In this retrospective series, we evaluated the results of preventive intraoperative thoracic duct ligation in patients who underwent video-assisted thoracoscopic esophagectomy for cancer.     

膈上胸导管结扎术在食管癌切除术中的应用

目的探讨胸导管结扎术对食管癌术后乳糜胸的预防和治疗作用。方法回顾性分析我院2003年1月至2009年6月的两组共836例食管癌切除术后的乳糜胸发生情况和治疗效果。其中结扎组431例,术中常规在膈上水平整块结扎胸导管,非结扎组405例,术中未常规结扎胸导管,术后并发乳糜胸者,再次采用手术治疗。结果结扎组无术后乳糜胸发生。非结扎组术后发生乳糜胸15例（3．7％）,治愈13例（86．7％）,死亡2例（13．3％）,1例死于呼吸功能衰竭,1例死于多器官功能衰竭。结论食管癌切除术中常规结扎胸导管可有效预防术后乳糜胸的发生。膈上胸导管结扎法稳妥有效。食管癌术后并发乳糜胸应积极手术治疗。     

结扎胸导管预防不同部位胸段食管癌切除术后乳糜胸的疗效分析

目的分析术中结扎胸导管对不同部位胸段食管癌患者手术后预防发生乳糜胸的作用。方法对2003年3月至2007年6月手术切除的胸段食管癌243例患者的临床资料进行回顾性分析。根据不同病变部位将患者分为上段、中上段、中段、中下段和下段5组，了解不同部位胸段食管癌患者术中结扎和不结扎胸导管与术后乳糜胸发生有无相关性。结果术后共计8例患者出现乳糜胸，总发生率3．3％。上段病变结扎组乳糜胸发生3例，未结扎组5例；中上段病变结扎组和未结扎组均未发生乳糜胸；中段病变未结扎组1／28（3．6％）；中下段病变结扎组乳糜胸发生率1／39（2．6％），未结扎组1／35（2．9％）；下段病变结扎组乳糜胸发生率1／37（2．7％），未结扎组2／44（4．5％）。Logistic回归分析显示。不同部位胸段食管癌切除术中是否结扎胸导管结扎对术后乳糜胸的发生均无影响（P〉0．05）。结论预防性结扎胸导管不能降低不同部位胸段食管癌术后继发乳糜胸的发生率。     

Results of prophylactic thoracic duct ligation in advanced esophageal carcinoma

Objective  Esophageal carcinoma is one of the most common lethal malignancies in northwest Iran. The purpose of this study is to determine the efficiency of prophylactic thoracic duct ligation and compare the incidence, risk factors and outcomes of chylothorax in patients undergoing esophageal cancer surgery. Methods and Material  From 1995 through 2005 a total 420 patients undergoing esophageal resection with or without mediastinal lymph node dissection. In first five years (Group I: 210 patients) that after any esophagectomies we have not used prophylactic thoracic duct ligation (1995–2000). In last five years for prevention of chylothorax after any esophagectomies (Group II: 210 patients), thirty patients with advanced stage of esophageal carcinoma underwent to prophylactic thoracic duct ligation (2000–2005). Data analysis included Chi-square or Fisher exact test and Independent Samples t test. A p-value of <0.05 was considered significant. All analyzes were performed using the SPSS.15/_win software. Results  There were 100 men and 110 women with a mean age of 53.18±12.35 years in Group I, 108 men and 102 women with a mean age of 56.1±9.83 years in Group II. The initial procedures were transhiatal esophagectomies and transthoracic esophagectomies. Six patients of group I, developed to chylothorax with average daily postoperative drainage greater than 1000 ml/day for 6 days, and underwent to reoperation at a mean of 7.12±1.85 days after diagnosis (4–8 days). Chest tube drainage was stopped during 48 hours after reoperation. In Group II chylothorax did not occur. Conclusions  Chylothorax increases mortality and duration of hospitalization after esophageal cancer surgery. Most cases of chylothorax after esophageal resection are cured with early surgical intervention. It could be concluded that prophylactic thoracic duct ligation reduce the occurrence of chylothorax in advanced cases of esophageal carcinoma.     

Chylothorax after thoracoscopic esophagectomy.

Among 30 patients who underwent thoracoscopic esophagectomy with lymphadenectomy for thoracic esophageal cancer, from July 1995 to May 1997, chylothorax developed in 2 patients (7%). In Case 1, the ligation of the thoracic duct under conventional right thoracotomy was performed on the 9th day after esophagectomy. After ligation, the pleural effusion was decreased, and the patient was discharged from hospital on the 25th day after the second operation. In Case 2, massive pleural effusion developed on the 10th day after esophagectomy (at 3 days after thoracic drainage tube was removed). The thoracic duct was ligated at the level just cranial to the diaphragm thoracoscopically on the 14th day after esophagectomy. The patient was discharged from hospital on the 30th day after the second operation. Injury to the thoracic duct due to a magnification effect of the view of scopic surgery remains a pitfall in thoracoscopic esophagectomy. But thoracoscopic ligation of thoracic duct was effective and safe for these two cases of chylothorax after esophagectomy.     

Intraoperative fluorescence lymphography using indocyanine green in a patient with chylothorax after esophagectomy: report of a case

We report a case of chylothorax treated successfully by a new diagnostic tool: indocyanine green (ICG) fluorescence lymphography. The patient, a 65-year-old man with adenocarcinoma of the esophagogastric junction, underwent radical esophagectomy, which was followed by the development of chylothorax. On postoperative day 10, we performed transabdominal ligation of the thoracic duct. During the re-operation, we injected ICG into the mesentery of the small bowel. We then performed mass ligation of the tissue right and dorsal of the aorta, including the thoracic duct, after which a near-infrared camera system revealed a fluorescent stripe on the caudal part of the ligation. The remnant thoracic duct appeared to be dilated as a result of lymphatic stasis. The patient was discharged 35 days after his initial surgery. We report this case to demonstrate the usefulness of intraoperative ICG lymphography as a tool to identify and confirm ligation of the thoracic duct transabdominally.     

Prone thoracoscopic thoracic duct ligation for postsurgical chylothorax

Background  Chylothorax after complex abdominal and thoracic procedures remains a challenging complication with a mortality rate reaching 50% if untreated [1]. Iatrogenic trauma accounts for almost 20% of all chyle leaks, and esophagectomy is the most common iatrogenic cause [2]. Consequences of ongoing chyle leak include dehydration, malnutrition, and immunocompromise. Methods  When nonoperative management techniques fail, prompt ligation of the thoracic duct at the diaphragmatic hiatus should be attempted. The authors present prone thoracoscopic thoracic duct ligation performed for two patients after laparoscopic transthoracic esophagectomy and revision paraesophageal hernia repair. Results  The prone position for thoracoscopic thoracic duct ligation offers several benefits to the surgeon. Gravity retracts the lung anteriorly, exposing the diaphragmatic hiatus. Single-lumen endotracheal intubation combined with low-pressure carbon dioxide insufflation efficiently collapses the lung to create ample working space. For the two reported patients, only three trocars were necessary to complete suture ligation of the thoracic duct via the right chest. Both patients had complete resolution of their chylothorax and recovered uneventfully. Based on this experience, the authors currently advocate early thoracoscopic treatment for cost and morbidity savings. Conclusions  The authors believe prone thoracoscopic thoracic duct ligation offers significant advantages to the patient in preventing the dangerous consequences of chyle leak in a timely, minimally invasive fashion. Importantly, the prone technique with carbon dioxide insufflation makes the technical challenges of thoracic duct ligation more facile for the surgeon. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

A left thoracic approach in a prone position for thoracoscopic thoracic duct ligation in a patient with post-esophagectomy chylothorax: A case report

IntroductionWe debate whether or not to approach from right thorax for the left chylothorax after esophagectomy.Presentation of caseA 50 s-year-old female underwent right-sided thoracoscopic esophagectomy with three-field lymphadenectomy for esophageal carcinoma (type 0-IIa, 3.4 × 2.2 cm, T1bN0M0, Stage IA), followed by reconstruction with esophagogastric anastomosis through the posterior mediastinum. The thoracic duct was excised and ligated. The left thoracic drainage increased to 2115 mL/day on the fifth postoperative day. Thoracic duct injury was diagnosed, and surgery was performed on sixth postoperative day. With the patient in a prone position, the thoracic duct was ligated successfully under thoracoscopy in the left thorax. The leakage point was found in the crushed duct by 8.8-mm titanium clips. Then, we performed mass ligation of the thoracic duct with 11-mm titanium clips below the leakage point after careful dissection. The surgery took 58 min, with an estimated total blood loss of 0 g.DiscussionAlthough thoracic duct is anatomically located on the right side of the descending aorta, we employed a left-sided thoracoscopic approach due to the chylous leakage in the left thorax. With the patient in the prone position, surgeons can easily convert from a left thoracic approach to a right thoracic approach immediately without postural change if the thoracic duct cannot be found in the left thoracic cavity.ConclusionThis technique is useful and should be considered for patients with left chylothorax.     

Surgery technique: preventive ligation of the thoracic duct during esophagectomy for cancer

Chylothorax is a rare but life-threatening complication of esophagectomy for cancer. Elective ligation of the thoracic duct above the diaphragm does not suppress completely the risk of chylothorax due to possible trauma of the thoracic duct wall at the level of ligation, or incomplete ligation in case of anatomic variation. This study describes a technique of preventive ligation "en block" with surrounding tissues in order to minimize the risk of chylothorax following oesophagectomy, whatever performed transthoracically or through transhiatal approach.     

Linfografía y embolización del conducto torácico como tratamiento del quilotórax tras esofagectomía por cáncer de esófago

IntroductionChylothorax 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 methodOur 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.Results274 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.ConclusionsLymphography 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.     

Thoracoscopic management of chylothorax complicating esophagectomy

BACKGROUND: Chylothorax is a relatively uncommon complication of esophageal surgery that may lead to severe respiratory, nutritional, and immunologic deficiencies. PATIENTS AND METHODS: Between 1992 and 2000, 3 of 316 patients (0.9%) undergoing transthoracic esophagectomy for carcinoma developed postoperative chylothorax. Two of them had previously been treated with neoadjuvant chemoradiation, and one had been submitted to esophagogastric resection through a left thoracotomy. After a 2-week trial of total parenteral nutrition and drainage, two patients underwent thoracic duct ligation via thoracotomy. In the last patient, the operation was completed by thoracoscopy. The azygos vein and the periaortic tissue above the diaphragm were encircled en bloc by a right-angled clamp, and a roticulating endostapler was applied. RESULTS: Reoperation was successful in all patients. The postoperative hospital stay was 4 days. CONCLUSION: Thoracoscopy is a safe and effective procedure for the treatment of chylothorax complicating esophagectomy. Given the minimal trauma to the patient, early thoracoscopic reoperation can be advocated in patients with high-output chyle loss in order to reduce the hospital stay.     

Efficacy and Predictor of Octreotide Treatment for Postoperative Chylothorax After Thoracic Esophagectomy

Background

Postoperative chylothorax sometimes follows thoracic esophagectomy for esophageal cancer. The effectiveness of octreotide treatment for it and factors that predict its response are unclear. This study aimed to evaluate the efficacy of octreotide for treating postoperative chylothorax following thoracic esophagectomy for esophageal cancer and factors that might predict successful treatment and allow chest drain removal.

Methods

We assessed 521 consecutive patients who underwent thoracic esophagectomy for esophageal cancer to investigate the efficacy of octreotide for postoperative chylothorax. Among those with postoperative chylothorax, one group (group A) underwent conservative management, and the other (group B) was treated conservatively with added octreotide administration. We evaluated the clinical outcomes after octreotide administration and assessed the factors associated with successful treatment.

Results

Among the 521 patients, 20 (3.8 %) developed postoperative chylothorax: five in group A and 15 in group B. Two of the five (20 %) group A patients and 13 of the 15 (86.6 %) group B patients were treated successfully (p = 0.03). Factors significantly associated with treatment failure were (1) chest drain output of >1,000 ml/day before treatment (p = 0.04); (2) no reduction in chest drainage by the second day of treatment (p = 0.016); (3) chest drainage of >1,000 ml/day through the second day of treatment (p = 0.006).

Conclusions

For patients with esophageal cancer who undergo thoracic esophagectomy, octreotide can be an effective treatment for postoperative chylothorax.     

Aggressive treatment of chylothorax complicating transhiatal esophagectomy without thoracotomy

Chylothorax is an unusual complication after transhiatal esophagectomy (THE) and in the past 10 years has occurred in 11 of 320 patients (3%) undergoing this operation for diseases of the intrathoracic esophagus. Four patients had benign esophageal disease: scleroderma reflux esophagitis (1), caustic stricture (1), and achalasia (2), and each had undergone at least one previous esophageal operation. Seven patients had intrathoracic esophageal carcinoma--two upper-third, two middle-third, and three distal-third lesions. Excessive chest tube drainage more than 72 hours after THE was the standard presentation, and the diagnosis of chylothorax was confirmed by the administration of cream through the jejunostomy feeding tube placed routinely at operation. The character of the chest tube drainage changed from serous to opalescent. Aggressive treatment of this complication was the rule, and every patient underwent a thoracotomy between 2 to 14 days (average, 6 days) after the diagnosis was established. Cream was administered through the jejunostomy tube before operation, and in each case the thoracic duct injury was readily identified and controlled with suture ligatures. There were no deaths in this group, and there was one recurrence of the fistula that required reoperation; all patients were discharged from the hospital within 3 to 29 days (average, 10 days) after thoracic duct ligation. It is concluded that early recognition of a chylothorax after transhiatal esophagectomy with prompt transthoracic ligation of the injured duct results in a shorter overall hospitalization and lower morbidity and mortality from this complication. The traditional conservative management of chylothorax with intravenous hyperalimentation and no or low-residue enteral feedings has little place in this nutritionally depleted patient population.     

LOW THORACIC DUCT LIGATION FOR POSTOPERATIVE CHYLOUS EFFUSIONS IN INFANTS AND CHILDREN

Three patients aged from three months to six years underwent thoracic duct ligation at the level of the diaphragm for chylothorax which occurred following cardiac operations. Another three-month-old patient underwent thoracic duct ligation for massive postoperative chylopericardium. Indications for operation were a large recurrent chyle accumulation or prolonged chyle drainage. Operative ductograms to deliniate the cisterna chyli and to exclude the presence of multiple lymph channels were performed in three patients. Excellent postoperative results were obtained in all patients for periods of up to two years. Low thoracic duct ligation is a reliable means of control of postoperative chylothorax and lengthy persistence with conservative treatment is no longer necessary.     

食管癌二次手术19例原因分析

目的：探讨食管癌行二次手术的原因及防治措施。方法回顾性分析2000年1月至2012年12月间北京大学肿瘤医院单一手术组施行的946例食管癌手术患者的临床资料,其中19例因术后严重并发症需行二次手术,总结该19例患者的临床特点及治疗经过。结果19例二次手术的患者中因术后胸腔内出血行开胸止血术4例,因膈疝行膈疝还纳、膈肌修补术4例,因乳糜胸行胸导管结扎术4例,因腹部切口裂开行切口缝合术4例,因创伤性胰腺炎行胸腹腔探查、腹腔置管引流术1例,因肠梗阻行回盲部切除、回肠造瘘术1例,因双侧喉返神经麻痹行气管切开术1例。19例二次手术患者全部治愈,无围手术期死亡和再次并发症发生。结论食管癌术后再次手术常见原因主要为术后出血、膈疝、乳糜胸和腹部切口裂开。     

Low thoracic duct ligation for postoperative chylous effusions in infants and children.

Three patients aged from three months to six years underwent thoracic duct ligation at the level of the diaphragm for chylothorax which occurred following cardiac operations. Another three-month-old patient underwent thoracic duct ligation for massive postoperative chylopericardium. Indications for operation were a large recurrent chyle accumulation or prolonged chyle drainage. Operative ductograms to deliniate the cisterna chyli and to exclude the presence of multiple lymph channels were performed in three patients. Excellent postoperative results were obtained in all patients for periods of up to two years. Low thoracic dust ligation is a reliable means of control of postoperative chylothorax and lengthy persistence with conservative treatment is no longer necessary.     

Chylothorax complicating esophagectomy for cancer: a plea for early thoracic duct ligation

OBJECTIVE: Postoperative chylothorax remains an uncommon but potentially life-threatening complication of esophagectomy for cancer, and the ideal management is still controversial. The aim of the study was to compare the outcomes of patients treated nonoperatively with those of patients promptly undergoing reoperation. METHODS: From 1980 to 1998, 1787 esophagectomies for esophageal or cardia cancer were performed, and 19 (1.1%) patients had postoperative chylothorax. We analyzed type of operation, surgical approach, delay of diagnosis of chylothorax, daily chest tube output, type of management, major complications, death, hospital stay, and final outcome. RESULTS: Of the 19 patients with chylothorax, 11 were initially managed nonoperatively (group A): 4 (36%) patients had spontaneous resolution of chylothorax, and the other 7 required reoperation for the persistence of a high-volume output. There were three infectious complications and one postoperative death in this group. No reliable predictive criteria of successful versus unsuccessful nonoperative management could be found. The 8 most recent patients underwent early reoperation (group B). All patients recovered, and no major complications possibly related to chylothorax or hospital deaths were observed. They were discharged after a median of 22 days (range, 12-85 days) compared with a median of 36 days (range, 21-64 days) for patients of group A. CONCLUSIONS: Early thoracic duct ligation is the treatment of choice for chylothorax occurring after esophagectomy. Reoperation should be performed immediately after the diagnosis is made to avoid the complications related to nutritional and immunologic depletion caused by prolonged nonoperative treatment.     

Chylothorax after cardiothoracic surgery

8 patients with postoperative chylothorax were reported: 7 after resection of esophageal carcinoma, 1 after radical correction of tetralogy of Fallot. 1 case was treated conservatively and 7 by ligation of thoracic duct after rethoracotomy. All the cases recovered. The factors causing postoperative chylothorax, the principles of treatment, and the role of prophylactic ligation of thoracic duct were discussed. The authors point out that, the mechanisms of postoperative chylothorax after open heart surgery by sternotomy may be: (1) injury of perithymotic and anterior mediastinal lymph ducts; (2) injury of thoracic duct through posterior wall of pericardium; and (3) effect of hypertension of systemic veins on flow of thoracic duct.     

Video-assisted right supradiaphragmatic thoracic duct ligation for non-traumatic recurrent chylothorax.

BACKGROUND: Chylothorax is an uncommon disorder with respiratory, nutritional and immunological manifestations. Surgical management is indicated in case of recurrence or failure after conservative treatment. We report our experience with video-assisted right-sided supradiaphragmatic thoracic duct ligation for non-traumatic, non-postoperative persistent or recurrent chylothorax. PATIENTS AND METHODS: The medical records of six patients operated at our institution between 1999 and 2004 were retrospectively reviewed. A right-sided chylothorax was found in four patients, a left-sided in one, and a bilateral in one. Three patients developed chylothorax after chemotherapy and chest irradiation for malignant diseases (lymphoma in two patients and breast cancer in one), one in the context of lymphangioleiomyomatosis, one due to a non-diagnosed lymphoma, and one after heart transplantation. RESULTS: The mean operative time was 102 min, with an average length of hospital stay of 14 days. Persistent cessation of chylous effusion within 7 days after surgery was observed in 5/6 patients without recurrence during a mean follow-up time of 41 months. One patient with undiagnosed mediastinal lymphoma required re-operation and thoracic duct ligation on day 8 by right-sided thoracotomy due to persistent chylothorax. No 30-day mortality was recorded. Two patients presented postoperative complications including respiratory insufficiency requiring mechanical ventilation in one, and chylous ascites development requiring peritoneo-venous LeVeen shunting in one patient. CONCLUSIONS: Recurrent or persistent non-traumatic chylothorax may be successfully treated by video-assisted right supradiaphragmatic thoracic duct ligation.     

Thoracoscopic clipping of the thooracic duct for chylothorax following esophagectomy: report of a case

Thoracoscopic clipping of the thoracic duct was successfully performed for the treatment of postoperative chylothorax. Chylothorax occurred in a 67-year-old man following an esophagectomy for esophageal cancer. Following unsuccessful conservative therapy for 3 weeks, we performed thoracoscopic surgery to examine the thoracic duct and found a leaking point of chylous fluid. The thoracic duct was successfully clipped resulting in complete elimination of the effusion immediately after surgery. Generally, chylothorax complicated by an esophagectomy has been managed by medical treatment first, followed by surgical intervention in case of uncontrollable pleural effusion. We think you should try this method at first in case chylothorax was able to be treated with not thoracotomy but thoracoscopic surgery: minimal invasiveness.