Prophylactic ligation of the thoracic duct in the prevention of chylothorax after esophagectomy


Authors: T. Jínek 1;  L. Adamčík 1;  M. Duda 1,2;  P. Buzrla 3;  M. Škrovina 1,4
Authors‘ workplace: Chirurgické oddělení Nemocnice Nový Jičín, a. s., Centrum vysoce specializované onkologické péče pro dospělé Nový Jičín, Vzdělávací a výzkumný institut AGEL, o. p. s. 1;  II. chirurgická klinika Lékařské fakulty Univerzity Palackého a Fakultní nemocnice Olomouc 2;  Laboratoře AGEL a. s. Nový Jičín, Patologie 3;  I. Chirurgická klinika Lékařské fakulty Univerzity Palackého a Fakultní nemocnice Olomouc 4
Published in: Rozhl. Chir., 2018, roč. 97, č. 7, s. 328-334.
Category: Original articles

Overview

Introduction:

Chylothorax after esophageal resection is an uncommon but serious complication with a reported incidence of 1−10%. It occurs after the injury of the thoracic duct or its tributaries. Chylothorax may cause an overall loss of several liters per day and may lead to dehydration, malnutrition and immunosuppression. Therapeutic approach has not been standardized. Prophylactic ligation of the thoracic duct during primary resection has been introduced to decrease the overall incidence of chylothorax. Its oncological benefit is unknown.

Method:

A retrospective single-center study of patients who underwent transthoracic esophagectomy from 2008−2016 for esophageal carcinoma at the Department of Surgery, Hospital Nový Jičín. 58 patients underwent transthoracic esophagectomy (Ivor-Lewis and McKeown). Prophylactic ligation of the thoracic duct was performed in 31 patients (53%). The incidence of chylothorax and the amount of harvested lymph nodes was analysed in the group with thoracic duct ligation (A PTDL 31 patients) and in the non-ligation group (B 27 patients).

Results:

Overall incidence of chylothorax after transthoracic esophagectomy was 3.4%. Chylothorax occurred in two men (type 3B) in the prophylactic group (6.5%) and it was not observed in the non-ligation group. Statistically significant difference was not confirmed (p=0,494). Chylous leak was successfully treated thoracoscopically and by thoracotomy with repeat ligation of the thoracic duct. Non-significantly more lymph nodes were harvested in the prophylactic group (18 A PTDL vs. 15 B, p=1).

Conclusion:

Prophylactic ligation of the thoracic duct in our study did not reduce the incidence of chylothorax. Redo thoracotomy and redo thoracoscopy for chylothorax is feasible. In patients with high-output and long lasting leaks the indication for redo surgery should be early.

Key words:

chylothorax − esophageal resection − prophylactic thoracic duct ligation


Sources
  1. Miao L, Zhang Y, Hu H, et al. Incidence and management of chylothorax after esophagectomy. Thorac Cancer 2015;6:354−8.
  2. Shah RD, Luketich JD, Schuchert MJ, et al. Postesophagectomy chylothorax: incidence, risk factors, and outcomes. Ann Thorac Surg 2012;93:897−903.
  3. Brinkmann S, Schroeder W, Junggeburth K, et al. Incidence and management of chylothorax after Ivor Lewis esophagectomy for cancer of the esophagus. J Thorac Cardiovasc Surg 2016;151:1398−1404.
  4. Rindani R, Martin CJ, Cox MR. Transhiatal versus Ivor-Lewis oesophagectomy: is there a difference? Aust N Z J Surg 1999;69:187−19
  5. Bolger C, Walsh TN, Tanner WA, et al. Chylothorax after oesophagectomy. Br J Surg 1991;78:587−8.
  6. Hayden JD, Sue-Ling HM, Sarela AI, et al. Minimally invasive management of chylous fistula after esophagectomy. Dis Esophagus 2007;20:251−5.
  7. Kumar S, Kumar A, Pawar DK. Thoracoscopic management of thoracic duct injury: Is there a place for conservatism? J Postgrad Med 2004;50:57−59.
  8. Cerfolio RJ. Chylothorax after esophagogastrectomy. Thorac Surg Clin 2006;16:49−52.
  9. Merrigan BA, Winter DC, O´Sullivan GC. Chylothorax. Br J Surg 1997;84:15−20.
  10. Kranzfelder M, Gertler R, Hapfelmeier A, et al. Chylothorax after esophagectomy for cancer: impact of the surgical approach and neoadjuvant treatment: systematic review and institutional analysis. Surg Endosc 2013;27:3530−8.
  11. Guo W, Zhao YP, Jiang YG, et al. Prevention of postoperative chylothorax with thoracic duct ligation during video-assisted thoracoscopic esophagectomy for cancer. Surg Endosc 2012;26:1332−6.
  12. Wurnig PN, Hollaus PH, Ohtsuka T, et al. Thoracoscopic direct clipping of the thoracic duct for chylopericardium and chylothorax. Ann Thorac Surg 2000;70:1662−5.
  13. Dougenis D, Walker WS, Cameron EW, et al. Management of chylothorax complicating extensive esophageal resection. Surg Gynecol Obstet 1992;174:501−6.
  14. Hou X, Fu JH, Wang X, et al. Prophylactic thoracic duct ligation has unfavorable impact on overall survival in patients with resectable oesophageal cancer. Eur J Surg Oncol 2014;40:1756−62.
  15. Low DE, Alderson D, Cecconello I, et al. International consensus on standardization of data collection for complications associated with esophagectomy: Esophagectomy Complications Consensus Group (ECCG). Ann Surg 2015;262:286−94.
  16. Rice TW, Ishwaran H, Kelsen DP, et al. Worldwide Esophageal Cancer Collaboration Investigators. Recommendations for neoadjuvant pathologic staging (ypTNM) of cancer of the esophagus and esophagogastric junction for the 8th ed. AJCC/UICC staging manuals. Dis Esophagus 2016;29:906−12.
  17. Rice TW, Ishwaran H, Hofstetter WL, et al. Worldwide Esophageal Cancer Collaboration Investigators. Recommendations for pathologic staging (pTNM) of cancer of the esophagus and esophagogastric junction for the 8th ed. AJCC/UICC staging manuals. Dis Esophagus 2016;29:897−905.
  18. Kondrup J, Rasmussen HH, Hamberg O, et al. Ad Hoc ESPEN Working Group. Nutritional risk screening (NRS 2002): a new method based on an analysis of controlled clinical trials. Clin Nutr 2003;22:321−6.
  19. Stolz A, Pafko P, Bicek V, et al. Chylothorax. In: Komplikace v plicní chirurgii. Praha, Grada Publishing 2010:124−37.
  20. Kim D, Cho J, Kim K, et al. Chyle leakage patterns and management after oncologic esophagectomy: A retrospective cohort study. Thorac Cancer 2014;5:391−7.
  21. Lai FC, Chen L, Tu YR, et al. Prevention of chylothorax complicating extensive esophageal resection by mass ligation of thoracic duct: a random control study. Ann Thorac Surg 2011;91:1770−4.
  22. Fu JH, Hu Y, Huang WZ, et al. Evaluating prophylactic ligation of thoracic duct during radical resection of esophageal carcinoma. Ai Zheng 2006;25:728−30.
  23. Crucitti P, Mangiameli G, Petitti T, et al. Does prophylactic ligation of the thoracic duct reduce chylothorax rates in patients undergoing oesophagectomy? A systematic review and meta-analysis. Eur J Cardiothorac Surg 2016;50:1019−24.
  24. NCCN Clinical Practice Guidelines in Oncology, Esophageal and Esophagogastric junction Cancers, Version I.2017. Available from: www:<https://www.nccn.org/professionals/physician_gls/pdf/esophageal.pdf>.
  25. Peyre CG, Hagen JA, DeMeester SR, et al. The number of lymph nodes removed predicts survival in esophageal cancer: an international study on the impact of extent of surgical resection. Ann Surg 2008;248:549−56.
  26. 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;44:1134−6.
  27. Schumacher G, Weidemann H, Langrehr JM, et al. Transabdominal ligation of the thoracic duct as treatment of choice for postoperative chylothorax after esophagectomy. Dis Esophagus 2007;20:19−23.
  28. Cagol M, Ruol A, Castoro C, et al. Prophylactic thoracic duct mass ligation prevents chylothorax after transthoracic esophagectomy for cancer. World J Surg 2009;33:1684−6.
  29. Johnstone D. Anatomy of the thoracic duct and chylothorax. In: Shields TW, Locicero III J, Reed CE, et al. General thoracic surgery. 7th ed. Lippincott Williams&Wilkins 2009:827−33.
  30. Browse NL, Allen DR, Wilson NM. Management of chylothorax. Br J Surg 1997;84:1711−6.
  31. Ohkura Y, Ueno M, Iizuka T, et al. New combined medical treatment with etilefrine and octreotide for chylothorax after esophagectomy: A case report and review of the literature. Medicine (Baltimore) 2015;94:e2214.
  32. Collard JM, Laterre PF, Boemer F, et al. Conservative treatment of postsurgical lymphatic leaks with somatostatin-14. Chest 2000;117:902−5.
  33. Dugue L, Sauvanet A, Farges O, et al. Output of chyle as an indicator of treatment for chylothorax complicating oesophagectomy. Br J Surg 1998;85:1147−9.
  34. Hayden JD, Sue-Ling HM, Sarela AI, et al. Minimally invasive management of chylous fistula after esophagectomy. Dis Esophagus 2007;20:251−20:
  35. Crosthwaite GL, Joypaul BV, Cuschieri A. Thoracoscopic management of thoracic duct injury. J R Coll Surg Edinb 1995;40:303−4.
Labels
Surgery Orthopaedics Trauma surgery
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