Risk Factors for Postoperative Chylothorax After Radical Subtotal Esophagectomy



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.


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.


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.


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.

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  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.

    Article  PubMed  PubMed Central  CAS  Google 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.

    Article  PubMed  Google 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.

    Article  PubMed  PubMed Central  Google 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.

    Article  PubMed  Google 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.

    Article  PubMed  Google 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.

    Article  PubMed  Google 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.

    Article  PubMed  CAS  Google 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.

  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.

    Article  PubMed  PubMed Central  Google 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.

    Article  PubMed  PubMed Central  CAS  Google 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].

  12. 12.

    Akiyama H, Miyazono H, Tsurumaru M, et al. Use of the stomach as an esophageal substitute. Ann Surg. 1978;188:606–10.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  13. 13.

    Udagawa H, Ueno M, Kinoshita Y. Rationale for video-assisted radical esophagectomy. Gen Thorac Cardiovasc Surg. 2009;57:127–31.

    Article  PubMed  Google 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.

    Article  PubMed  Google 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.

    Article  Google 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.

    Article  PubMed  PubMed Central  CAS  Google 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.

    PubMed  CAS  Google 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.

    Article  PubMed  Google Scholar 

  19. 19.

    Congdon CC. The destructive effect of radiation on lymphatic tissue. Cancer Res. 1966;26:1211–20.

    PubMed  CAS  Google 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.

    Article  PubMed  CAS  Google 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.

    Article  PubMed  Google 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.

    Article  Google 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.

    Article  PubMed  Google 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.

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Author information




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.

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Correspondence to Yu Ohkura MD.

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Ohkura, Y., Ueno, M., Shindoh, J. et al. Risk Factors for Postoperative Chylothorax After Radical Subtotal Esophagectomy. Ann Surg Oncol 25, 2739–2746 (2018). https://doi.org/10.1245/s10434-018-6640-1

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  • Postoperative Chylothorax
  • Subtotal Esophagectomy
  • Intraoperative Fluid Balance
  • Three-field Lymphadenectomy
  • Video-assisted Thoracoscopic Surgery (VATS)