Management of chylothorax after minimally invasive esophagectomy: Description of case series

Stylianos Tzedakis, Silvana Perretta, Marius Nedelcu, Didier Mutter, Emanuele Boatta, Bernard Dallemagne. Nouvel Hopital Civil

INTRODUCTION: Chylothorax after esophagectomy remains an uncommon but challenging clinical problem with an incidence of 0.4%- 4% and a mortality rate reaching 30-50% if untreated. Chylothorax may lead to acute cardiorespiratory distress via mechanical compression or long-term immunodepression and malnutrition due to chronic depletion of chyle. Among others, identified causes for thoracic duct injury include anatomical variants of the thoracic duct and low BMI (<30kg/m2). Treatment of chylous leaks remains controversial even today and is based on conservative, radiological and surgical techniques.

Here we show the management of post-esophagectomy chylothorax in three patients while providing an overview of the different minimal invasive options available and indications for surgical intervention.

METHODS: Between Mars 2010 and Mars 2015, 3 patients with post-operative chylous leaks following minimally invasive esophagectomy (MIE) were identified. The first patient (48yo woman) developed an early chylothorax at postoperative day (POD) 2 after MIE for a recurrent caustic esophageal stricture. Due to high flow rate after conservative treatment a ligature of the thoracic duct was performed under thoracoscopy at POD7. The second patient (60yo man) was admitted to the emergency room for respiratory distress at POD26 after MIE for an ypT3N1MO adenocarcinoma of the distal esophagus. Similarly, after diagnosing chylothorax, aggressive conservative treatment failed, leading to reoperation and ligation under thoracoscopy. The third patient (60yo woman) presented a chylothorax at POD7 after MIE procedure for a lower esophageal ypT1N0M0 squamous cell carcinoma. Initial conservative treatment and thoracoscopic ligation of the thoracic duct at POD14 failed. For this reason a radiological upstream embolization of the thoracic duct was attempted.

RESULTS: All but one patient were successfully managed with surgical ligation of thoracic duct after after  failure of  conservative management and persistence of high chyle flow rate (>10ml/kg/day). In one patient radiologic embolization with glue was successful and demonstrated an anatomical variation of the thoracic duct course and of its tributaries which could explain both the injury during MIE and the unsuccessful surgical attempt to ligate it.

CONCLUSIONS: Postoperative chylothorax is associated with significant postoperative morbidity and mortality. There is no generally accepted consensus on the indication and timing of surgical intervention. When non-operative management techniques fail, prompt ligation of the thoracic duct at the diaphragmatic hiatus should be attempted. Although its exact role remains to be determined, radiographic embolization offers an attractive minimally invasive alternative to surgery.

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