Pre-operative oil ingestion reduces the probability of thoracic duct trunk ligation during esophagectomy.

Chylothorax is an important complication after esophagectomy. Ligation of the injured thoracic duct is the main method to prevent chylothorax after esophagectomy, but may be associated with adverse effects. Whether ligation of the injured tributary alone, keeping the main trunk intact, may suffice to prevent post-operative chylothorax is not well known. Since March 2017, 40 mL of olive oil was administered to patients posted for esophagectomy. We compared patients admitted between March 2017 and December 2019 with patients admitted between July 2014 and February 2017, who had not received pre-operative oil. The outcome measures were the need for thoracic duct main trunk or tributary ligation, development of chylothorax and missed ligation. There were 371 patients in the oil ingestion group and 308 patients in the standard control group. Chylothorax in the oil ingestion group was significantly lower than that in the standard control group (1.3% vs. 4.5%, P = 0.012). Chyle leak from thoracic duct tributaries was diagnosed in a significantly higher percentage (5.7% vs. 0.0%, P < 0.001) and missed ligation of the injured thoracic duct was significantly lower (0.3% vs. 3.9%, P = 0.002) in the oil ingestion group compared with the standard control group. The incidence of post-operative chylothorax was not statistically different (6.3% vs. 10.0%, P = 1.000) between the tributary and the trunk ligation group. Pre-operative oil ingestion can help visualize the thoracic duct trunk and its tributaries during esophagectomy. Thus, non-selected thoracic duct trunk ligation and missed ligation during esophagectomy can be reduced. Precise ligation of the injured tributary while the main trunk is intact can also prevent post-operative chylothorax.

Prophylactic thoracic duct obliteration and resection during esophagectomy: What is the impact on perioperative risks and long-term survival? A systematic review and meta-analysis.

There is no agreement whether prophylactic thoracic duct ligation (TDL), with or without resection, during esophagectomy for patients with cancer is beneficial. The effects of these procedures on postoperative complications and overall survival remain unclear. This systematic review included 16 articles. TDL did not influence short- and long-term outcomes. However, thoracic duct resection increased postoperative chylothorax and overall complications, with no improvement in survival.

Intra-Nodal Indocyanine Green Injection to Delineate Thoracic Duct During Minimally Invasive Esophagectomy.

INTRODUCTION: Post-operative chylothorax is a dreaded complication after esophagectomy; hence real-time identification of the thoracic duct (TD) may aid in avoiding its injury or promptly tackling injury when it occurs. We utilized intra-nodal injection of Indocyanine green (ICG) dye to delineate TD anatomy while performing esophagectomy for esophageal carcinoma. METHOD: Two ml of 1 mg/ml solution of ICG was injected into the inguinal lymph nodes under ultrasound guidance. TD was checked with the laparoscopic Karl Storz IMAGE1 STM or Robotic da Vinci Xi system. The thoracic esophagus, periesophageal tissue, and lymph nodes were dissected. The TD was visualized throughout the dissection using OverlayTM technology & Firefly mode™ and checked at the end to rule out any dye leak. TD was clipped if any dye leakage or TD injury (TDI) was noted using Near Infra-Red Spectroscopy. RESULTS: Twenty one patients with M:F 13:8 underwent minimally invasive esophagectomy (MIE) [thoracoscopic assisted (n = 15) and robotic-assisted (n = 6)]. TD was visualized in all the cases after a median (IQR) time of 35 (30, 35) min. The median (IQR) duration of the thoracic phase was 150 (120,165) min. TDI occurred in 1 case, identified intra-operatively, and TD was successfully clipped. There were no post-operative chylothorax or adverse reactions from the ICG injection. CONCLUSION: Intra-nodal ICG injection before MIE helps to identify the TD in real-time and is a valuable intra-operative aid to prevent or successfully manage a TD injury. It may help to prevent the dreaded complication of post-operative chylothorax after esophagectomy.

Lymph or Chyle Leak After Neck Dissection in Patients With Thyroid Carcinoma: Results of a Study on 1724 Patients.

BACKGROUND: To discuss the prevention and treatment of lymph or chyle leak following neck dissection in patients with thyroid carcinoma. METHODS: A total of 1724 patients with thyroid carcinoma received neck dissection in the Sun Yat-sen University Cancer Center between November 2009 and October 2014. The incidence and management of leak were analyzed. RESULTS: A total of 92 (5.34%) patients developed leak, 28 (1.62%) developed lymph leak, 59 (3.42%) developed chyle leak, and 5 (.29%) developed chylothorax. Medical management to stop postoperative lymph or chyle leak included pressure dressing, reoperation, fasting, or low-fat diet therapy. CONCLUSIONS: Lymph or chyle leak may occur in thyroid carcinoma patients who underwent neck dissection. Clinicians should alert to leak when there were IV + VI region lymph node metastasis and should become aware of chylothorax after pressure dressing. A careful identification and ligation of lymphatic duct may be an effective way to avoid lymph or chyle leak.

Anatomical study of the thoracic duct and its clinical implications in thoracic and pediatric surgery, a 70 cases cadaveric study.

INTRODUCTION: Given the high variability and fragility of the thoracic duct, good knowledge of its anatomy is essential for its repair or to prevent iatrogenic postoperative chylothorax. The objective of this study was to define a site where the thoracic duct is consistently found for its ligation. The second objective was to define an anatomically safe surgical pathway to prevent iatrogenic chylothorax in surgery for aortic arch anomalies with vascular ring, through better knowledge of the anatomical relationships of the thoracic duct. METHODS: Seventy adult formalin-fixed cadavers were dissected. The anatomical relationships of the thoracic duct were reported at the postero-inferior mediastinum, at levels T3 and T4. RESULTS: The thoracic duct was consistently situated between the left anterolateral border of the azygos vein and the right border of the aorta between levels T9 and T10, whether it was simple, double, or plexiform. It was located medially, anteromedially, or posteriorly to the left subclavian artery in 51%, 21%, and 28% of the cases, respectively, at the level of T3. At T4, it was posteromedial in 27% of the cases or had no direct relationship with the aortic arch. CONCLUSION: These results favor mass ligation of the thoracic duct at levels T9-T10 between the right border of the aorta and the azygos vein, eventually including the latter. To prevent iatrogenic postoperative chylothorax in aortic arch anomalies with vascular ring surgery, we recommend remaining strictly lateral to the left subclavian artery at the level of T3 to reach the aortic arch anomalies with vascular ring at T4.

Clinical impacts of magnetic resonance thoracic ductography on preventing postoperative chylothorax after thoracoscopic esophagectomy for esophageal cancer.

PURPOSE: The study aimed to determine whether magnetic resonance thoracic ductography (MRTD) is useful for preventing injury to the thoracic duct (TD) during thoracoscopic esophagectomy and for reducing the incidence of postoperative chylothorax. MATERIALS AND METHOD: A total of 389 patients underwent thoracoscopic esophagectomy between September 2009 and February 2019 in Tokai University Hospital. Of them, we evaluated 228 patients who underwent preoperative MRTD (MRTD group) using Adachi's classification and our novel classification (Tokai classification). Then, the clinicopathological factors of the MRTD group (n = 228) were compared with those of the non-MRTD group (n = 161), and comparative analyses were conducted after propensity score matching (PSM). RESULTS: The TD could be visualized by MRTD in 228 patients. The MRTD findings were divided into 9 classifications including normal findings and abnormal TD findings (Adachi classification vs Tokai classification; 5.3% vs 16.2%). After PSM, both groups consisted of 128 patients. The rate of postoperative chylothorax after thoracoscopic esophagectomy was significantly lower in the MRTD group (0.8%) than in the non-MRTD group (6.3%) (p = 0.036). In the multivariate analysis for risk factors for chylothorax, the independent prognostic factors were preoperative therapy and the presence of MRTD. CONCLUSIONS: This study revealed that MRTD was useful for preventing of chylothorax after thoracoscopic esophagectomy for esophageal cancer.

Management options for post-esophagectomy chylothorax.

Chylothorax, although an uncommon complication of esophagectomy, is associated with high morbidity and mortality if not treated promptly. Consequently, knowledge of the thoracic duct (TD) anatomy is essential to prevent its inadvertent injury during surgery. If the TD is injured, early diagnosis and immediate intervention are of paramount importance; however, there is still no universal consensus about the management of post-operative chylothorax. With increasing advances in the spheres of interventional radiology and minimally invasive surgery, there are now several options for managing TD injury. We review this topic in detail to provide a comprehensive and practical overview to help surgeons manage this challenging complication. In particular, we discuss an appropriate step-up approach to prevent the morbidity associated with open surgery as well as the metabolic, nutritional, and immunological disorders that accompany a prolonged illness.

Prophylactic ligation of the thoracic duct branch prevents chylothorax after pulmonary resection for right lung cancer.

PURPOSE: Chylothorax is a rare and challenging complication of thoracic surgery. Whereas most current studies focus on postoperative treatment and preventative measures for esophageal cancer surgery, the current study investigates the impact of prophylactic ligation of the thoracic duct branch on postoperative chylothorax after pulmonary resection for right lung cancer. METHODS: The subjects of this retrospective study were 1165 patients who underwent right pulmonary resection and mediastinal lymph-node dissection in our department between January 2015 and August 2019. Those who underwent prophylactic ligation of the thoracic duct branch after 4R lymph-node dissection were assigned to group A (n = 475), and those who did not were assigned to group B (n = 690). The incidence of postoperative chylothorax, the success rate of conservative treatment, the postoperative hospital stay, and the chest drainage volume were recorded and compared statistically between the two groups. RESULTS: The incidence of postoperative chylothorax was significantly lower in group A than in group B (0.84% vs. 2.90%, p = 0.015). Patients who had a chylothorax in group A had a significantly shorter postoperative hospital stay, less mean drainage volume per day, and less total drainage than those in group B (7.25 ± 0.50 days vs. 11.00 ± 2.81 days, p = 0.003; 0.64 ± 0.04 L vs. 0.80 ± 0.09 L, p = 0.003; 4.64 ± 0.40 L vs. 8.82 ± 2.84 L; p = 0.002). The success rate of conservative treatment was higher in group A than in group B, but the difference was not significant (100% vs. 75.0%, p = 0.544). CONCLUSION: Performing prophylactic ligation of the thoracic duct branch during right pulmonary resection and mediastinal lymph-node dissection is an effective and safe method of preventing postoperative chylothorax.

Short- and long-term outcomes of prophylactic thoracic duct ligation during thoracoscopic-laparoscopic McKeown esophagectomy for cancer: a propensity score matching analysis.

BACKGROUND: Chylothorax remains a challenging and potentially life-threatening postoperative complication after minimally invasive esophagectomy (MIE). The effect of intraoperative prophylactic thoracic duct ligation on preventing postoperative chylothorax still remains controversial. Moreover, the potential impact of thoracic duct ligation on long-term outcome after MIE has not been well established. METHODS: From September 2009 to July 2018, a total of 600 consecutive patients suffering from thoracic esophageal cancer who underwent thoracoscopic-laparoscopic McKeown esophagectomy in the Department of Thoracic surgery at Daping hospital were eligible. Among them, 559 patients received esophagectomy with preventive thoracic duct ligation and 41 patients did not. Propensity score matching (PSM) was performed to improve comparability between the two groups. Log-rank test was used to assess the survival differences between groups. RESULTS: Postoperative chylothorax occurred in five patients in the preservation group (PG) and in seven patients in the ligation group (LG) (12.2% vs. 1.3%, P = 0.001). The median age of the patients in the preservation group (PG) was 57.78 (range, 37-76) years, while the median age in the ligation group (LG) was 62.75 (range, 39-87) years. The PG had more patients with tumor located in middle thoracic esophagus and stage T3 than LG, 82.9% vs. 55.6%, 70.7% vs. 45.6%, respectively. After PSM (40 matched patients in PG and 134 in LG), there was no significant between-group difference with respect to age, tumor location, and T stage. The median survival times for patients in the PG and LG were 69.5 months (95% interval confidence, CI 54.6-84.3) and 65.2 months (95% CI 56.3-74.1), respectively (P = 0.977). The 5-year survival rates were comparable between PG and LG (54.9% vs. 54.4%, P = 0.977). CONCLUSION: On the basis of the present results, routine thoracic duct ligation during minimally invasive McKeown esophagectomy for cancer is an effective and safe method for prevention of postoperative chylothorax, and does not exert unfavourable effect on long-term survival.

Prophylactic octreotide does not reduce the incidence of postoperative chylothorax following lobectomy: Results from a retrospective study.

Chylothorax after lobectomy is common, lacking reliable preventive measures. Octreotide is widely used for treatment of chyle leakage, but its role in preventing chylothorax has not been estimated. The aim of this study was to evaluate whether prophylactic octreotide could reduce the incidence of postoperative chylothorax.Patients who underwent lobectomy for lung cancer from January 2016 to September 2018 were retrospectively reviewed. The cases in prophylactic group received octreotide 1 day before the surgery until removal of chest tubes, while those in the control group did not use it unless the diagnosis of chylothorax.A total of 379 patients were enrolled, with 190 patients in control and 189 cases in prophylactic group. Octreotide was well tolerated in patients who received this agent. No 30-day mortality was indicated. Seven cases in control (3.7%, 7/190) and 3 cases in prophylactic group (1.6%, 3/189) with chylothorax were observed (P = .337). The patients in prophylactic group showed shorter duration of chest drainage ([3.6 ±â€Š1.6] days vs [4.1 ±â€Š2.0] days, P = .006) and reduced drainage volume ([441.8 ±â€Š271.1] mL vs [638.7 ±â€Š463.3] mL, P < .001). In addition, they showed similar stations and numbers of dissected lymph nodes, surgery-related complications, and postoperative hospital stay. Besides, 11 (5.8%, 11/190) patients in control and 6 (3.2%, 6/189) cases in the prophylactic group were readmitted for pleural effusion needing reinsertion of chest tubes (P = .321). Moreover, multivariable logistic analysis showed that induction therapy (odds ratio [OR] =12.03; 95% confidence interval [CI] 3.15-46.03, P < .001) was a risk factor, while high-volume experience of the surgeon (OR = 0.23; 95% CI 0.06-0.97, P = .045) was a preventive factor of surgery-related chylothorax. Additionally, prophylactic octreotide (OR = 0.18; 95% CI 0.11-0.28, P < .001) and perioperative low-fat diet (OR = 0.46; 95% CI 0.29-0.73, P = .001) were negatively associated with the drainage volume of pleural effusion. Furthermore, high-volume experience of the surgeon (OR = 6.03; 95% CI 1.30-27.85, P = .021) and induction therapy (OR = 8.87; 95% CI 2.97-26.48, P < .001) were risk factors of unplanned readmission.Prophylactic octreotide does not reduce the incidence of postoperative chylothorax or unplanned readmission following anatomic lobectomy. The routine application of octreotide should not be recommended. High-quality trials are required to validate these findings.

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.

Low-Fat Tube Feeding After Esophagectomy Is Associated With a Lower Incidence of Chylothorax.

BACKGROUND: Chylothorax is a treacherous complication after esophagectomy associated with significant morbidity. Early enteral nutrition after esophagectomy is important for recovery but increases the pressure in the lymphatic system owing to the absorption of triglycerides. To lower the incidence of chylothorax after esophagectomy, the use of low fat-containing tube feeding was evaluated as a standard of care after esophagectomy. METHODS: All consecutive patients who underwent an esophagectomy with gastric tube reconstruction and placement of jejunostomy at the University Medical Center Utrecht between January 1, 2012, and December 31, 2017, were included. Tube feeding was started as standard of care on postoperative day 1 with a normal fat-containing formula in the period between 2012 and 2014 and with a low fat-containing formula between 2014 and 2017. RESULTS: Between 2012 and 2017, 198 patients were included. The tube feeding formula contained normal fat in 86 (43.4%) and low fat in 112 (53.6%). Chylothorax, associated with triglyceride levels exceeding 1.24 mmol/L in 27 patients (61.4%) with a clinical diagnosis of chylothorax, was significantly less observed in the low fat-formula group (15 [13.4%] vs 29 [33%], p = 0.001). No difference was seen in drain output, triglyceride levels in the pleura fluid, treatment strategy, and hospital mortality. At multivariable analysis, the normal-fat formula was associated with a 5.1 odds (95% confidence interval, 2.1 to 12.1) for postoperative chylothorax. Other factors independently associated with chylothorax were transthoracic resection, anastomotic leakage, number of resected lymph nodes, and lower body mass index. CONCLUSIONS: Administration of low fat-containing tube feed after esophagectomy was associated with a lower incidence of chylothorax.

Preoperative Administration of Olive Oil Reduces Chylothorax After Minimally Invasive Esophagectomy.

BACKGROUND: Chylothorax after esophagectomy is uncommon but potentially fatal. We performed a retrospective study to assess the effect of olive oil administered orally before surgery on reducing chylothorax in patients who underwent minimal invasive esophagectomy. METHODS: Between May 2013 and December 2016, patients with esophageal squamous cell cancer who underwent minimal invasive esophagectomy were screened. Patients in the investigational group were preoperatively administered olive oil orally 8 hours before surgery, and patients in the control arm received no olive oil. We used a propensity score matching model to derive 1:1 cohorts. Statistical analysis was performed by using the t test or χ2 or Fisher's exact test. RESULTS: The propensity score matching model finally selected 384 of 425 patients, with 192 patients in each group. The patient characteristics were balanced. Oral olive oil was well tolerated. The thoracic duct identification rate was higher in the investigational group (100% versus 45.31%, χ2 = 141.78, p < 0.01). The investigational group was associated with a reduced incidence of ligation (7.81% versus 18.22%, χ2 = 8.03, p = 0.003). The incidence of chylothorax was significantly reduced in the investigational group compared with that of the control group (0% versus 3.12%, χ2 = 4.23, p = 0.03). CONCLUSIONS: Preoperative administration of olive oil is a simple and safe method to minimize chylothorax complicating minimal invasive esophagectomy.

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

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 Jicín. 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.

[Energy Device and Soft Coagulation System in Thoracic Surgery].

While the recent emergence of energy-based surgical techniques and soft coagulation has made surgical procedures less invasive, the safety and proper use of such advances have yet to be investigated. Herein we review the experimental and clinical use of ultrasonically-activated coagulating shears, a vessel sealing system, incorporating ultrasonic and vessel sealing technology, and a soft coagulation system in thoracic surgery. All energy devices have been reported to be safe for use on pulmonary vessels, and use in combination with a ligature appears to be adequate. The thoracic duct has been reported to be sealed with sufficient pressure using energy devices, which are expected to prevent chylothorax formation. Bipolar scissors can be safely and efficiently applied for dissection of pulmonary vessels without damage to the vessel wall. Monopolar soft coagulation can be applied to shrink bullous changes and stop air leakage or bleeding within the lung.

[Prevention and Surgical Therapy of Chylothorax]. / Prävention und operative Therapie des Chylothorax.

BACKGROUND: Chylothorax is a rare complication after thoracic trauma or surgery, especially oesophagectomy, which, if left untreated, can be potentially life-threatening. METHODS: This article provides an overview of the existing literature on the prevention and surgical therapy of chylothorax. RESULTS: The risk of chyle leakage after oesophagectomy increases with the difficulty of mediastinal dissection and is reported to be around 3% for oesophagectomy. With this risk, there is the possibility of a prophylactic intraoperative ligature of the thoracic duct, either as a selective or mass ligation. Meta-analyses confirm the effectiveness of this measure, with a reduction in the risk to less than 1%. In the case of postoperative chylothorax, a conservative therapeutic trial may be undertaken with drainage of up to 1000 ml per day for up to one week. If there is any indication of persistent leakage, rapid surgical reintervention appears appropriate. This can be either transthoracic or transhiatal as a selective or mass ligation and has a probability of success of over 90%. CONCLUSION: The prophylactic primary or therapeutic secondary ligature of the thoracic duct is an effective surgical preventive measure and therapy of postoperative chyle leakage.

Effect of Prophylactic Thoracic Duct Ligation in Reducing the Incidence of Postoperative Chylothorax during Esophagectomy: A Systematic Review and Meta-analysis.

OBJECTIVES: There is no consensus on the effectiveness of prophylactic thoracic duct ligation (PLG) in esophagectomy for reducing the incidence of postoperative chylothorax. We performed a systemic review and meta-analysis to study its efficacy. METHODS: A systemic review of the publications was performed on three databases to identify all the relevant literature on comparative outcomes of PLG and nonprophylactic thoracic duct ligation (NPLG). The primary end point was the incidence of postoperative chylothorax. RESULTS: Seven studies with comparative data on PLG (n = 2,178) versus NPLG (n = 3,048) were identify from the current publications. Comparison showed no significant difference between PLG and NPLG on the incidence of postoperative chylothorax (relative risk = 0.431; 95% confidence interval, 0.186 to 1.002; p = 0.050). CONCLUSIONS: Although some studies showed that PLG during the esophagectomy was effective to lower the incidence of postoperative chylothorax, no evidence was observed in the present meta-analysis. Further research is warranted to validate the findings.

[Postoperative Chylotholax;Intraoperative Prevention and Postoperative Management].

Postoperative chylothorax is a relatively rare but potentially fatal complication caused by iatrogenic injury to thoracic duct system, with an incidence ranging from 2 to 4% after major lung surgery or esophagectomy. The pathophysiologic features of chylothorax include dehydration, loss of nutrients and immunological components. Intraopreative prevention is the first step for the management, and treatment options include conservative therapy, percutaneous intervention, and redo-operation. Although the treatment algorithm has not been standardized, chylothorax which is refractory to conservative treatment, or that with high output greater than 1,000 ml/day should be treated aggressively with thoracic duct embolization or redo-operation in a timely fashion. We herein review the anatomy and physiology of thoracic duct system and describe the overview of prevention and each theapeutic options of postoperative chylothorax.

Selective En Masse Ligation of the Thoracic Duct to Prevent Chyle Leak After Esophagectomy.

BACKGROUND: Postoperative chylothorax remains an important cause of reoperation and prolonged hospital stay after esophagectomy for the treatment of esophageal carcinoma. Chylothorax is potentially life threatening and difficult to manage. The benefit of routine thoracic duct ligation is controversial. A promising alternative is to identify chyle leaks at the time of esophagectomy and perform the ligation selectively. We developed a novel technique to identify chyle leak at the time of esophagectomy and compared it with routine ligation of thoracic duct. METHODS: This cohort study involved all of the qualified patients with resectable esophageal carcinoma treated between March 1, 2011, and December 31, 2015, by a single surgical team at West China Hospital. Patients receiving routine en masse ligation of the thoracic duct were assigned to group A, and patients receiving selective en masse ligation of the thoracic duct were assigned to group B. All patients in the selective ligation group received 120 mL olive oil orally before the operation. The end point included frequencies of chyle leak detected at the time of esophagectomy, postoperative chylothorax, and need for chylothorax-related reoperation. RESULTS: The study enrolled 296 patients who fulfilled the study requirement: 55 in group A and 241 in group B. Patients in group A experienced significantly higher incidences of postoperative chylothorax and chylothorax-related reoperation than group B (9.1% vs 0% [p < 0.01] and 3.6% vs 0% [p < 0.01]). Incidence of detection of intraoperative chyle leak (chylothorax plus chylous ascites) was significantly higher in group B than in group A (9.5% vs 0%, p < 0.01). No intraoperative or postoperative complications related to preoperative oral olive oil administration or selective en masse ligation of the thoracic duct were observed. CONCLUSIONS: Our method of selective en masse ligation of the thoracic duct during esophagectomy was feasible and safe and was associated with reduced rates of postoperative chylothorax.