Management of MIS esophagectomy complications: A multidisciplinary ‘step-up approach’

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

INTRODUCTION: Minimally invasive (MI) esophagectomy presents proven benefits over the open approach. Nevertheless postoperative leaks and chylothorax still remain an important cause of morbidity and mortality. The optimal treatment for esophago-gastric anastomotic leaks is controversial with minimally invasive techniques, especially self-expandable metallic stents (SEMS) gaining popularity. Chylothorax after esophagectomy also remains a challenging clinical problem with a mortality rate reaching 30-50% if left untreated. 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 and is based on conservative, radiological and surgical techniques.

The aim of this video is to demonstrate a combined minimally invasive 'step-up approach' with thoracoscopic, endoscopic and radiologic management of a postoperative anastomotic leak and chylothorax following a prone MIE for cancer.

METHODS/RESULTS: A MI McKeown procedure in prone position was performed for a lower esophagus ypT1N0 squamous cell carcinoma in a 60yo woman with a past medical history significant for COPD and a BMI of 14kg/m2. At postoperative day (POD) 7 she developed chylothorax. After failure of the initial conservative management (total parenteral nutrition and NPO) at POD14, due to the large chylus output, a thoracoscopic ligation of the thoracic duct was performed. During thoracoscopy an ischemic anastomotic leak was incidentally found and sutured. A perioperative endoscopy, carried out to evaluate the viability of the gastric tube, identified a 3 cm perianastomotic ischemic area of the gastric conduit. A fully covered SEMS was used to protect the anastomosis. The stent was secured to the esophageal mucosa to prevent migration with an over the scope clip. Postoperatively, while the esophageal leak was successfully controlled the chylus leak persisted. A radiological embolization of the thoracic duct was attempted successfully and demonstrated an anatomical variation of the thoracic duct and of its tributaries, which could explain both the injury during MIE and the unsuccessful attempt to surgically ligate it. The SEMS was changed at 6 weeks and finally removed 5 weeks later after endoscopic confirmation complete healing of the leak and a healthy gastric conduit.

CONCLUSIONS: Postoperative anastomotic leaks and chylothorax are associated with significant postoperative morbidity and mortality. There is no generally accepted consensus directing management. Here we show the merits of a minimally invasive 'step-up approach' combining laparoscopic and radiologic techniques successfully used to manage complex cases such as this.