Advertisement

Annals of Surgical Oncology

, Volume 25, Issue 9, pp 2739–2746 | Cite as

Risk Factors for Postoperative Chylothorax After Radical Subtotal Esophagectomy

  • Yu Ohkura
  • Masaki Ueno
  • Junichi Shindoh
  • Toshiro Iizuka
  • Hairin Ka
  • Harushi Udagawa
Gastrointestinal Oncology

Abstract

Background

Chylothorax is one of the complications of esophagectomy for esophageal cancer. The treatment of this condition has been well discussed, but the risk factors for postoperative chylothorax remain unclear.

Methods

A retrospective review of 294 patients who underwent esophagectomy for esophageal cancer was conducted. These were patients with squamous cell carcinoma or adenocarcinoma of the esophagus including Siewert type I tumor of the esophagogastric junction who underwent subtotal esophagectomy with two-field or three-field lymphadenectomy. Of these, 24 patients who were diagnosed with chylothorax as a postoperative complication were allocated to the chylothorax group and the other 270 patients were allocated to the nonchylothorax group.

Results

Univariate analysis showed a significant difference in three factors: resection of thoracic duct, post-chemoradiotherapy, and high intraoperative fluid balance. Multivariate analysis revealed that post-chemoradiotherapy [hazard ratio (HR) = 3.430; 95% confidence interval (CI) 1.364–8.625] and high intraoperative fluid balance (HR = 1.569; 95% CI 1.2.7–2.039) were independent factors predicting chylothorax. In addition, resection of the thoracic duct may be a predictor of chylothorax after esophagectomy (HR = 3.389; 95% CI 0.941–12.201, p = 0.062). Receiver operating characteristic curve analysis of intraoperative fluid revealed that the sensitivity was 62.5%, specificity was 74.1%, and the cutoff value was 6.55 mL/kg/h.

Conclusions

This study revealed that post-chemoradiotherapy and high intraoperative fluid balance are predictors of chylothorax after esophagectomy. The elucidation of clinicopathological factors that can predict the incidence of chylothorax will help to establish more effective perioperative management for esophageal cancer patients.

Notes

Author Contributions

Yu Ohkura, Masaki Ueno, and Junichi Shindoh designed the study, wrote the manuscript, revised it critically for important intellectual content, and gave final approval for the content; Yu Ohkura, Masaki Ueno, Masaki Ueno, Toshiro Iizuka, Hairin Ka and Harushi Udagawa created study materials or recruited patients.

Conflict of interest

The authors declare that they have no conflict of interest.

References

  1. 1.
    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(49):e2214.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Ohkura Y, Ueno M, Iizuka T, Udagawa H. Effectiveness of etilefrine regimen for chylothorax after esophagectomy with thoracic duct resection. Esophagus. 2018;15(1):33–8.CrossRefPubMedGoogle Scholar
  3. 3.
    Tamura T, Kubo N, Yamamoto A, et al. Cervical chylous leakage following esophagectomy that was successfully treated by intranodal lipiodol lymphangiography: a case report. BMC Surg. 2017;17(1):20.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Carcoforo P, Soliani G, Maestroni U, et al. Octreotide in the treatment of lymphorrhea after axillary node dissection: a prospective randomized controlled trial. J Am Coll Surg. 2003;196:365–9.CrossRefPubMedGoogle Scholar
  5. 5.
    Lin Y, Li Z, Li G, et al. Selective en masse ligation of the thoracic duct to prevent chyle leak after esophagectomy. Ann Thorac Surg. 2017;103:1802–7.CrossRefPubMedGoogle Scholar
  6. 6.
    Tachibana M, Kinugasa S, Yoshimura H, et al. Does fibrin glue reduce lymph leakage (pleural effusion) after extended esophagectomy? Prospective randomized clinical trial. World J Surg. 2003;27:776–81.CrossRefPubMedGoogle Scholar
  7. 7.
    Udagawa H, Akiyama H. Surgical treatment of esophageal cancer: Tokyo experience of the three-field technique. Dis Esophagus. 2001;14:110–4.CrossRefPubMedGoogle Scholar
  8. 8.
    Sobin LH, Gospodarowicz MK, Wittekind C (eds) International Union Against Cancer. Oesophagus including oesophagogastric junction. TNM classification of malignant tumours. West Sussex, UK: Wiley-Blackwell; 2009:66–72.Google Scholar
  9. 9.
    Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205–13.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Ajani JA, Winter K, Komaki R, et al. Phase II randomized trial of two nonoperative regimens of induction chemotherapy followed by chemoradiation in patients with localized carcinoma of the esophagus: RTOG 0113. J Clin Oncol. 2008;26:4551–6.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Kiyozumi Y, Yoshida N, Ishimoto T, et al. Prognostic factors of salvage esophagectomy for residual or recurrent esophageal squamous cell carcinoma after definitive chemoradiotherapy. World J Surg. 2018; Feb 8. [Epub ahead of print].Google Scholar
  12. 12.
    Akiyama H, Miyazono H, Tsurumaru M, et al. Use of the stomach as an esophageal substitute. Ann Surg. 1978;188:606–10.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Udagawa H, Ueno M, Kinoshita Y. Rationale for video-assisted radical esophagectomy. Gen Thorac Cardiovasc Surg. 2009;57:127–31.CrossRefPubMedGoogle Scholar
  14. 14.
    Udagawa H, Ueno M, Shinohara H, et al. The importance of grouping of lymph node stations and rationale of three-field lymphoadenectomy for thoracic esophageal cancer. J Surg Oncol. 2012;106(6):742–7.CrossRefPubMedGoogle Scholar
  15. 15.
    Udagawa H, Ueno M, Shinohara H, et al. Should lymph nodes along the thoracic duct be dissected routinely in radical esophagectomy? Esophagus, 2014;11:204–10.CrossRefGoogle Scholar
  16. 16.
    Ohkura Y, Ueno M, Iizuka T, et al. Factors predicting effectiveness of neoadjuvant therapy for esophageal squamous cell carcinoma. Medicine (Baltimore). 2016;95(15):e3365.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Staats BA, Ellefson RD, Budahn LL, et al. The lipoprotein profile of chylous and nonchylous pleural effusions. Mayo Clin Proc. 1980;55(11):700–4.PubMedGoogle Scholar
  18. 18.
    Gupta R, Singh H, Kalia S, et al. Chylothorax after esophagectomy for esophageal cancer: Risk factors and management. Indian J Gastroenterol. 2015;34:240–4.CrossRefPubMedGoogle Scholar
  19. 19.
    Congdon CC. The destructive effect of radiation on lymphatic tissue. Cancer Res. 1966;26:1211–20.PubMedGoogle Scholar
  20. 20.
    Wiig H, Swartz MA. Interstitial fluid and lymph formation and transport: physiological regulation and roles in inflammation and cancer. Physiol Rev. 2012;92:1005–60.CrossRefPubMedGoogle Scholar
  21. 21.
    Nisanevich V, Felsenstein I, Almogy G, et al. Effect of intraoperative fluid management on outcome after intra-abdominal surgery. Anesthesiology. 2005;103:25–32.CrossRefPubMedGoogle Scholar
  22. 22.
    Tsurumaru M. Complications and treatment after esophagectomy with extended lymph node dissection for esophageal carcinoma. Jpn Soc Gastroenterol Surg. 1996;29:109–13.CrossRefGoogle Scholar
  23. 23.
    Crucitti P, Mangiameli G, Petitti T, et al. Does prophylactic ligation of the thoracic duct reduce chylothorax rates in patients undergoing oesophagectomy? A systemic review and meta-analysis. Eur J Cardiothorac Surg. 2016;50:1019–24.CrossRefPubMedGoogle Scholar
  24. 24.
    Davis HK. A statistical study of the thoracic duct in man. Devel Dyn. 1915;17: 211–44.Google Scholar
  25. 25.
    Adachi B. Der ductus thoracicus Japaner. pp 1–8. In: Kihara T (ed) Das Lymphagefasssystem der Japaner. Kenkyusha, Tokyo. 1953.Google Scholar

Copyright information

© Society of Surgical Oncology 2018

Authors and Affiliations

  • Yu Ohkura
    • 1
  • Masaki Ueno
    • 1
  • Junichi Shindoh
    • 1
  • Toshiro Iizuka
    • 2
  • Hairin Ka
    • 3
  • Harushi Udagawa
    • 1
  1. 1.Department of Gastroenterological Surgery, Toranomon HospitalOkinaka Memorial Institute for Medical ResearchTokyoJapan
  2. 2.Department of Gastroenterology, Toranomon HospitalOkinaka Memorial Institute for Medical ResearchTokyoJapan
  3. 3.Department of AnesthesiologyToranomon HospitalTokyoJapan

Personalised recommendations