Advertisement

Chyle Leak After Esophageal Surgery

  • Elena M. Ziarnik
  • Jonathan C. Nesbitt
Chapter

Abstract

A chyle leak is a challenging complication following esophageal procedures and occurs as a result of injury to the thoracic duct and its collateral lymphatic channels. The problem commonly presents as a postoperative pleural effusion that is rich in triglycerides. Large quantities, > 2 L/d, of chyle can drain from the site of lymph duct injury and can result in significant fluid and nutritional losses. Initial management involves drainage of the effusion, bowel rest, and total parenteral nutrition (TPN). Less common adjuncts to treatment are available, but if conservative measures fail, operative intervention may become necessary. Surgery typically involves access to the right chest cavity with direct ligation of the thoracic duct.

Keywords

Chyle Chylothorax Chylous effusion Thoracic duct Esophagus Esophagectomy 

Abbreviations

MIE

Minimally invasive esophagectomy

NPO

Nil per os

TPN

Total parenteral nutrition

VATS

Video-assisted thoracoscopic surgery

References

  1. 1.
    Gaspare A. De Lactibussive Lacteis Venis, Quarto Vasorum Mesdarai Corum Genere Novo Invento. G B Bidelli; 1627.Google Scholar
  2. 2.
    Crafoord CA. Contribution to thoracic duct surgery. Acta Chir Scand. 1963–1964;85:99.Google Scholar
  3. 3.
    Bargebuhr A. Chylose and chyliforme Ergusseim Pleura und Pericardialraum. Dtsch Arch Klin Med. 1894–1895;54:410.Google Scholar
  4. 4.
    Quinke H. Überfetthaltige Transudate—Hydropschylosus und Hydropsadiposus. Dtsch Arch Klin Med. 1875;16:121–139.Google Scholar
  5. 5.
    Zesas DG. Die nicht operative entstandenen Verletzungen des Ductus thoracicus, Deutsche Ztschr. f. Chir. 1912;115:49–62.Google Scholar
  6. 6.
    Lee FC. The establishment of collateral circulation following ligation of the thoracic duct. Bull Johns Hopkins Hosp. 1922;33:21–31.Google Scholar
  7. 7.
    Lampson RS. Traumatic chylothorax; a review of the literature and report of a case treated by mediastinal ligation of the thoracic duct. J Thorac Surg. 1948;17(6):778–91.PubMedGoogle Scholar
  8. 8.
    Shackelford RT, Fisher AM. Shackelford and Fisher. Sth Med J (Bgham, Ala). 1938;31.Google Scholar
  9. 9.
    Goorwitch J. Traumatic chylothorax and thoracic duct ligation; case report and review of literature. J Thorac Surg. 1955;29(5):467–79.PubMedGoogle Scholar
  10. 10.
    Sabin FR. The origin and development of the lymphatic system. Johns Hopkins Hosp Rep. 1916;17.Google Scholar
  11. 11.
    Randolph JG, Gross RE. Congenital chylothorax. AMA Arch Surg. 1957;74(3):405–19.CrossRefPubMedGoogle Scholar
  12. 12.
    Klepser RG, Berry JF. The diagnosis and surgical management of chylothorax with the aid of lipophilic dyes. Dis Chest. 1954;25(4):409–26.CrossRefPubMedGoogle Scholar
  13. 13.
    Lowman RM, Hoogerhydr J, Waters LL, Grant C. Traumatic chylothorax; the roentgen aspects of this problem. Am J Roentgenol Radium Ther. 1951;65(4):529–46.PubMedGoogle Scholar
  14. 14.
    Blalock A, Cunningham RS, Robinson CS. Experimental production of chylothorax by occlusion of the superior vena cava. Ann Surg. 1936;104:359–364.Google Scholar
  15. 15.
    Kausel HW, Reeve TS, Stein AA, Alley RD, Stranahan A. Anatomic and pathologic studies of the thoracic duct. J Thorac Surg. 1957;34(5):631–41.PubMedGoogle Scholar
  16. 16.
    Van Pernis PA. Variations of the thoracic duct. Surgery. 1949;26(5):806–9.Google Scholar
  17. 17.
    Skandalakis JE, Skandalakis LJ, Skandalakis PN. Anatomy of the lymphatics. Surg Oncol Clin N Am. 2007;16(1):1–16.CrossRefPubMedGoogle Scholar
  18. 18.
    Crandall L Jr, Barker SB, Graham DG. A study of the lymph from a patient with thoracic duct fistula. Gastroenterology. 1943;1040–1046.Google Scholar
  19. 19.
    Lam KH, Lim ST, Wong J, Ong GB. Chylothorax following resection of the oesophagus. Br J Surg. 1979;66(2):105–9.CrossRefPubMedGoogle Scholar
  20. 20.
    Orringer MB, Bluett M, Deeb GM. Aggressive treatment of chylothorax complicating transhiatal esophagectomy without thoracotomy. Surgery. 1988;104(4):720–6.PubMedGoogle Scholar
  21. 21.
    Ferguson MK, Little AG, Skinner DB. Current concepts in the management of postoperative chylothorax. Ann Thorac Surg. 1985;40(6):542–5.CrossRefPubMedGoogle Scholar
  22. 22.
    Merrigan BA, Winter DC, O‘Sullivan GC. Chylothorax. Br J Surg. 1997;84(1):15–20.CrossRefPubMedGoogle Scholar
  23. 23.
    Rindani R, Martin CJ, Cox MR. Transhiatal versus Ivor-Lewis oesophagectomy: is there a difference? Aust N Z J Surg. 1999;69(3):187–94.CrossRefPubMedGoogle Scholar
  24. 24.
    Dugue L, Sauvanet A, Farges O, Goharin A, Le Mee J, Belghiti J. Output of chyle as an indicator of treatment for chylothorax complicating oesophagectomy. Br J Surg. 1998;85(8):1147–9.CrossRefPubMedGoogle Scholar
  25. 25.
    Orringer MB, Marshall B, Iannettoni MD. Transhiatal esophagectomy: clinical experience and refinements. Ann Surg. 1999;230(3):392–400. Discussion-3.CrossRefPubMedCentralPubMedGoogle Scholar
  26. 26.
    Merigliano S, Molena D, Ruol A, Zaninotto G, Cagol M, Scappin S, et al. Chylothorax complicating esophagectomy for cancer: a plea for early thoracic duct ligation. J Thorac Cardiovasc Surg. 2000;119(3):453–7.CrossRefPubMedGoogle Scholar
  27. 27.
    Shen Y, Feng M, Khan MA, Wang H, Tan L, Wang Q. A simple method minimizes chylothorax after minimally invasive esophagectomy. J Am Coll Surg. 2014;218(1):108–12.CrossRefPubMedGoogle Scholar
  28. 28.
    Lagarde SM, Omloo JM, de Jong K, Busch OR, Obertop H, van Lanschot JJ. Incidence and management of chyle leakage after esophagectomy. Ann Thorac Surg. 2005;80(2):449–54.CrossRefPubMedGoogle Scholar
  29. 29.
    Sachs PB, Zelch MG, Rice TW, Geisinger MA, Risius B, Lammert GK. Diagnosis and localization of laceration of the thoracic duct: usefulness of lymphangiography and CT. AJR Am J Roentgenol. 1991;157(4):703–5.CrossRefPubMedGoogle Scholar
  30. 30.
    Deso S, Kabutey NK, Vilvendhan R, Kim D, Guermazi A. Lymphangiography in the diagnosis, localization, and treatment of a lymphaticopelvic fistula causing chyluria: a case report. Vasc Endovascular Surg. 2010;44(8):710–3.CrossRefPubMedGoogle Scholar
  31. 31.
    Guo W, Zhao YP, Jiang YG, Niu HJ, Liu XH, Ma Z, et al. Prevention of postoperative chylothorax with thoracic duct ligation during video-assisted thoracoscopic esophagectomy for cancer. Surg Endosc. 2012;26(5):1332–6.CrossRefPubMedGoogle Scholar
  32. 32.
    Marts BC, Naunheim KS, Fiore AC, Pennington DG. Conservative versus surgical management of chylothorax. Am J Surg. 1992;164(5):532–4. Discussion 4–5.CrossRefPubMedGoogle Scholar
  33. 33.
    Cho HJ, Kim DK, Lee GD, Sim HJ, Choi SH, Kim HR, et al. Chylothorax complicating pulmonary resection for lung cancer: effective management and pleurodesis. Ann Thorac Surg. 2014;97(2):408–13.CrossRefPubMedGoogle Scholar
  34. 34.
    Maldonado F, Cartin-Ceba R, Hawkins FJ, Ryu JH. Medical and surgical management of chylothorax and associated outcomes. Am J Med Sci. 2010;339(4):314–8.PubMedGoogle Scholar
  35. 35.
    Shimizu K, Yoshida J, Nishimura M, Takamochi K, Nakahara R, Nagai K. Treatment strategy for chylothorax after pulmonary resection and lymph node dissection for lung cancer. J ThoracCardiovasc Surg. 2002;124(3):499–502.Google Scholar
  36. 36.
    Zabeck H, Muley T, Dienemann H, Hoffmann H. Management of chylothorax in adults: when is surgery indicated? Thorac Cardiovasc Surg. 2011;59(4):243–6.CrossRefPubMedGoogle Scholar
  37. 37.
    Roehr CC, Jung A, Proquitte H, Blankenstein O, Hammer H, Lakhoo K, et al. Somatostatin or octreotide as treatment options for chylothorax in young children: a systematic review. Intensive Care Med. 2006;32(5):650–7.CrossRefPubMedGoogle Scholar
  38. 38.
    Michelet P, Embriaco N, Roch A, Giudicelli R, Auffray JP. [Somatostatin for the treatment of a post-oesophagectomychylothorax]. Ann Fr Anest Reanim. 2004;23(1):56–8.CrossRefGoogle Scholar
  39. 39.
    Tatar T, Kilic D, Ozkan M, Hatipoglu A, Aslamaci S. Management of chylothorax with octreotide after congenital heart surgery. Thorac Cardiovasc Surg. 2011;59(5):298–301.CrossRefPubMedGoogle Scholar
  40. 40.
    Nakabayashi H, Sagara H, Usukura N, Yoshimitsu K, Imamura T, Seta T, et al. Effect of somatostatin on the flow rate and triglyceride levels of thoracic duct lymph in normal and vagotomized dogs. Diabetes. 1981;30(5):440–5.CrossRefPubMedGoogle Scholar
  41. 41.
    Buck ML. Octreotide for the management of chylothorax in infants and children. Pediatric pharmacotherapy of Children’s Medical Center at the University of Virginia. 2004;10:10.Google Scholar
  42. 42.
    Cope C, Kaiser LR. Management of unremitting chylothorax by percutaneous embolization and blockage of retroperitoneal lymphatic vessels in 42 patients. J VascInterv Radiol. 2002;13(11):1139–48.CrossRefGoogle Scholar
  43. 43.
    Cope C, Salem R, Kaiser LR. Management of chylothorax by percutaneous catheterization and embolization of the thoracic duct: prospective trial. J VascInterv Radiol. 1999;10(9):1248–54.CrossRefGoogle Scholar
  44. 44.
    Shah RD, Luketich JD, Schuchert MJ, Christie NA, Pennathur A, Landreneau RJ, et al. Postesophagectomy chylothorax: incidence, risk factors, and outcomes. Ann Thorac Surg. 2012;93(3):897–903. Discussion-4.CrossRefPubMedCentralPubMedGoogle Scholar
  45. 45.
    Alexiou C, Watson M, Beggs D, Salama FD, Morgan WE. Chylothorax following oesophagogastrectomy for malignant disease. Eur J Cardiothorac Surg. 1998;14(5):460–6.CrossRefPubMedGoogle Scholar
  46. 46.
    Gupta D, Ross K, Piacentino V 3rd, Stepnowski D, McClurken JB, Furukawa S, et al. Use of LeVeen pleuroperitoneal shunt for refractory high-volume chylothorax. Ann Thorac Surg. 2004;78(1):e9–12.CrossRefPubMedGoogle Scholar
  47. 47.
    Ross JK. A review of the surgery of the thoracic duct. Thorax. 1961;16:12.CrossRefPubMedCentralPubMedGoogle Scholar
  48. 48.
    Ferguson MK. Thoracic duct. In: Ferguson MK, Editor. Thoracic surgery atlas. Oxford: Elsevier; 2007. p. 229–31.Google Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  1. 1.Department of Thoracic SurgeryVanderbilt University Medical CenterNashvilleUSA
  2. 2.Department of Thoracic SurgeryVanderbilt UniversityNashvilleUSA

Personalised recommendations