Post-esophagectomy Chylothorax Research Articles

Octreotide's role in the management of post-esophagectomy chylothorax.

The use of octreotide in managing intrathoracic chyle leak following esophagectomy has gained popularity in the adult population. While the benefits of octreotide have been confirmed in the pediatric population, there remains limited evidence to support its use in the adults post-esophagectomy. Thus, we performed a single-institution cohort study to characterize its efficacy. The study was performed using a prospective, single-center database, from which clinicopathologic characteristics were extracted of patients who had post-esophagectomy chyle leaks. Kaplan-Meier and multivariable Cox regression analyses were performed to investigate the effect of octreotide use on chest tube duration (CTD), hospital length of stay (LOS), and overall survival (OS). In our cohort, 74 patients met inclusion criteria, among whom 27 (36.5%) received octreotide. Kaplan-Meier revealed no significant effect of octreotide on CTD (P = 0.890), LOS (P = 0.740), or OS (P = 0.570). Multivariable Cox regression analyses further corroborated that octreotide had no effect on CTD (HR = 0.62, 95% confidence interval [CI]: 0.32-1.20, P = 0.155), LOS (HR = 0.64, CI: 0.34-1.21, P = 0.168), or OS (1.08, CI: 0.53-2.19, P = 0.833). Octreotide use in adult patients with chyle leak following esophagectomy lacks evidence of association with meaningful clinical outcomes. Level 1 evidence is needed prior to further consideration in this population.

Postesophagectomy chylothorax: a review of the risk factors, diagnosis, and management.

Chylothorax is a crucial postoperative complication of esophagectomy. Characterized by the leakage of chyle and lymphatic fluid through the thoracic duct, chylothorax could result in pleural effusion, respiratory distress, shortness of breath, cardiac arrhythmia, electrolyte imbalance, and malnutrition. Postesophagectomy chylothorax is associated with high morbidity and mortality, and its diagnosis and management require prompt and accurate identification of risk factors and treatment strategies. A variety of strategies are available to treat postesophagectomy chylothorax, ranging from conservative management to pharmacological, lymphangiographic, and surgical treatments. This study reviews the physio-anatomical basis, disease presentation, diagnostic methods, risk factors, and management options for postesophageal chylothorax, filling the literature gap, and highlighting the importance of early recognition and timely intervention in improving patient outcomes.

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

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. 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. 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. 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.

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

BackgroundPost-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 presentationA 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.ConclusionThis 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.

High-Output Chylothorax: Novel Imaging Techniques Provide Specific Treatment

Post-esophagectomy chylothorax is a therapeutic dilemma. Understanding anatomy and leakage site is essential, although imaging techniques for thoracic lymphatics are challenging and not always available. We describe a patient with chylothorax post-esophagectomy from a left-sided thoracic duct traversing to the right chest. We applied intranodal Lipiodol® lymphangiography, computed tomographic lymphangiography, and performed fluorescence-guided thoracic duct ligation at the level of the aortic arch. These techniques are not only useful in a postoperative setting but may be used as preventive strategies to reduce morbidity and mortality from chylothorax after any thoracic surgical procedure where the thoracic duct is at risk.

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.

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.

Perioperative complications of esophagectomy - prevention, diagnosis and management

Esophageal resection with reconstruction is complex surgical procedure with high rate of postoperative morbidity, with decreasing mortality rate during last decades, particularly in high-volume hospitals. Numerous preoperative, intraoperative and postoperative factors have contribute to incidence and type of complications. Intraoperative haemorrhage and tracheobronchial lesions could be avoid by good surgical judgement and operative technique. Pulmonary complications are often, with multifactorial etiology, and they are the main cause of postoperative mortality after esophagectomy. Dehiscence of esophageal anastomosis could be fatal, and only high index of suspicion and early diagnosis lead to successful treatment. In majority of such cases conservative measures are successful, however, conduit necrosis is indication for surgical reoperation. Vocal cord palsy due to intraoperative injury of recurrent laryngeal nerves is not rare and increases pulmonary complications rate. New onset of arrhythmia could be associate with other surgical complications. Postesophagectomy chylothorax is life-threatening complication due to rapid development of immunosuppression and septic complications, and early ligation of thoracic duct is often mandatory. Intrathoracic herniation of intrabdominal viscera is rare, and ischemic spinal cord lesions are very rare after esophagectomy. Majority of perioperative complications could be prevented or solved, decreasing mortality rate of esophagectomy.

Etilefrine投与が有用であった食道癌術後乳糜胸の1例

症例は72歳，女性．胸部中部食道癌に対して胸腔鏡下食道亜全摘術を施行した．第2病日より経腸栄養を開始したところ，翌日の胸腔ドレーンの排液量が急激に増加した．第4病日に白濁した胸水を認めたため乳糜胸と診断した．完全静脈栄養としたが胸水量が減少せず，第7病日よりoctreotide acetateを投与した．全身状態が安定していたことと，CTで上大静脈に血栓が見つかり保存的治療を一貫して行った．第28病日よりetilefrineの投与を開始すると徐々に排液量が減少した．Etilefrineを中止しても排液量が増加しないことを確認し，第54病日に胸腔ドレーンを抜去した．食道癌術後の乳糜胸は比較的まれな合併症であるが，その治療に難渋することが少なくない．Etilefrine投与による乳糜胸の治療報告例は少ないが，副作用が少なく効果の高い有用な治療法であると考えられた．

A 2-wk conservative treatment regimen preceding thoracic duct ligation is effective and safe for treating post-esophagectomy chylothorax

BackgroundChylothorax is a pathologic condition defined by an accumulation of lymphatic fluid, the chyle, in the thorax. Postoperative chylothorax is a potentially lethal complication, with a reported mortality rate of 15.4%–25%. Patients and methodsEsophageal cancer patients hospitalized for elective radical esophagectomy by thoracotomy (n = 10,574) were consecutively enrolled between January 1996 and December 2011. Patients (n = 306) who experienced post-esophagectomy chylothorax were assigned to a 48-h (group A, n = 186) or to a 2-wk (group B, n = 120) conservative treatment regimen. For patients with a daily chylothorax output >1000 mL, thoracic duct ligation (TDL) was performed by thoracotomy. Measured outcomes included frequency of TDL, overall and treatment-specific morbidity and mortality rates, and the rate of chylothorax recurrence. ResultsA total of 171 patients (171 of 306 [55.9%]) underwent TDL. A larger proportion of patients in group A required TDL compared with group B (72.6% versus 30.0%, P < 0.001). Group A had a significantly higher rate of overall morbidity compared with group B (31.7% versus 19.2%, P = 0.02). Moreover, the overall mortality rate was significantly higher in group A (14.0% versus 4.2%, P = 0.006). Chylothorax recurred in nine patients (9 of 306 [2.9%]), and there was no difference between the two groups (3.2% versus 2.5%, P = 1.000). ConclusionsThe 2-wk regimen reduced the requirement for TDL and the overall morbidity and mortality rates compared with the 48-h regimen. Importantly, this regimen does not increase the risk of chylothorax recurrence.

食道癌術後の乳糜胸に対してオクトレオチド投与を含めた保存的加療を行った１例

食道癌術後の乳糜胸に対してオクトレオチド投与を含めた保存的加療を行った１例

胸腔鏡が有用であった食道癌術後乳び胸の１例

胸腔鏡が有用であった食道癌術後乳び胸の１例

Postesophagectomy Chylothorax: Incidence, Risk Factors, and Outcomes

Chylothorax is a rare but potentially lethal complication of esophagectomy. This study evaluated the rate of postesophagectomy chylothorax, identified associated risk factors, and compared postoperative outcomes in patients with and without chylothorax. We reviewed 892 consecutive patients who underwent esophagectomy (1997 to 2008). Preoperative, operative, and postoperative details, including adverse outcomes and mortality, were analyzed. Postesophagectomy chylothorax occurred in 34 patients (3.8%). Chylothorax was significantly associated with 30-day major complications (85% vs 46%; p<0.001), including an increased likelihood of sepsis (p=0.001), pneumonia (p=0.009), reintubation (p=0.002) or reoperation (p<0.001), and death (17.7% vs 3.9%, p<0.001). Median length of stay was 17 vs 8 days (p=0.005). Median time to chylothorax diagnosis was 5 days. Thoracic duct ligation was performed in 21 (62%) at a median 13 days after esophagectomy. Two patients required repeat duct ligation for persistent chylothorax. Squamous cell cancer histology (9 of 34; 26%) was an independent predictor of postoperative chylothorax (odds ratio, 4.18; 95% confidence interval, 1.39 to 12.6). Odds of chylothorax were 36 times greater with average daily chest tube output exceeding 400 mL in the first 6 postoperative days (odds ratio, 35.9; 95% confidence interval, 8.2 to 157.8). Postoperative chylothorax is associated with significant postoperative morbidity and mortality. Patients with squamous cell cancer may be at increased risk. In addition, average daily chest tube output exceeding 400 mL in the early postoperative period should prompt fluid analysis for chylothorax to facilitate early diagnosis and consideration of thoracic duct ligation.

Successful Management Of Chylothorax Following Transhiatal Esophagectomy

Chylothorax is an uncommon complication following esophagectomy and should be suspected when there is an unexplained high-volume chest-tube output in the postoperative period. Prolonged conservative treatment for these patients who are already debilitated has been associated with high morbidity and mortality. Early operative intervention and ligation of the thoracic duct has been advocated to salvage these patients. We report the successful management of a patient with post-esophagectomy chylothorax.

Post-esophagectomy chylothorax successfully treated with the combination of thoracic duct clipping and octreotide administration

We herein describe the case of a 61-year-old man with stage II esophageal cancer who experienced chylothorax after esophagectomy. He was successfully treated with thoracic duct clipping and octreotide administration. Previously the patient had had a head and neck cancer treated with multimodality treatment: neoadjuvant chemoradiation therapy, operation, and adjuvant CRT. Then, esophagectomy with lymph node dissection without resection of the thoracic duct was performed via a right thoraco-abdominal approach. On postoperative day 1, enteral nutrition was started. On day 5, the chest tube drainage increased to 2000 ml per day. On day 7, the drainage fluid increased to 3000 ml per day, and its color turned cloudy white. We then performed lymphoscintigraphy and diagnosed the patient as having chylothorax. Immediately we administered intermittent subcutaneous octreotide 100 μg × 3 per day; however, it could not stop the leakage. On day 13, we performed an operation: a fat-rich supplement was administered through the jejunostomy tube before the operation, the thoracic duct injury was readily identified, and we clipped the thoracic duct in the superior mediastinum, followed by 300 μg per day octreotide treatment. On day 16, however, 400 ml per day of chyle leaked from the drain again, and we increased the dose of octreotide to 600 μg per day. On day 18, the drainage stopped, and the patient was discharged on day 38. Octreotide administration combined with surgical treatment should be considered as a treatment option for chylothorax, which is a rare complication of esophagectomy.

Successful management of post-esophagectomy chylothorax/chyloperitoneum by etilefrine.

Post-operative chylothorax and chyloperitoneum resulting from a thoracic duct injury are possible complications of esophagectomy for carcinoma. Management of such conditions includes conservative methods (pleural drainage, chyle flow reduction and supportive nutrition) and surgery. Etilefrine, a sympathomimetic drug used in the management of postural hypotension, also causes smooth muscle contraction of the thoracic duct. We successfully treated three patients with post-esophagectomy chylothorax and chyloperitoneum using intravenous etilefrine. Etilefrine infusion allowed chyle flow resolution in a few days without any side-effects. As result of this experience, we believe that etilefrine deserves to be considered as an alternative therapy in the management of post-esophagectomy chylothorax/chyloperitoneum.