Article Abstract

Oesophagectomy with en bloc resection of the thoracic duct: risk factors for post-operative chyle leak and current management

Authors: Brian Ip, Ka Ting Ng, Simon Packer, Simon Paterson-Brown, Graeme Couper

Abstract

Background: Routine ligation of the thoracic duct during oesophagectomy has been reported to reduce the rate of chyle leak (CL) following oesophagectomy. This study aims to identify risk factors for developing a CL with this approach and review current management.
Methods: All patients who underwent transthoracic oesophagectomy over a 3-year period were identified from a prospectively collected database and their medical records reviewed.
Results: A total of 147 oesophagectomies were performed in the period January 2012–December 2014. Eighteen patients with anastomotic leak were excluded. Eleven (8.5%) of the remaining 129 patients developed a CL. Statistically significant predictive factors for CL were squamous cell carcinoma (6/16, 37.5% vs. 5/113, 4.4% in other tumour types, P=0.0005) and high total chest drain volumes on day 2 post operatively measured prior to commencing enteric feeding. Using a threshold of 600 mL on day 2, the sensitivity and specificity for predicting CL are 92% and 82% respectively. Low BMI (mean 24.1 with CL vs. 27.5 without CL) was also associated with a CL, but was not statistically significant. Neither the extent of lymphadenectomy nor the extent of lymph node involvement (N stage) were associated with CL. Six patients with a low volume CL (<600 mL/day) were successfully managed conservatively. The main thoracic duct was never the source of leakage in the 5 patients requiring re-thoracotomy. All 11 patients were successfully discharged home.
Conclusions: This study demonstrates squamous cell carcinoma remains a significant risk factor for the development of post-oesophagectomy chylothorax despite the routine ligation of the thoracic duct. In the knowledge that with this approach the main thoracic duct is never the source of CL, patients with a chest drainage of <600 mL/24 h can be successfully treated conservatively. Patients with a chest drain volume of >600 mL/24 h despite conservative management should undergo re-thoracotomy at an early stage.