RISK FACTORS FOR CHYLE LEAK AFTER ESOPHAGECTOMY
AbstractBackground: Chylothorax is an uncommon (3–8% risk) but potentially fatal complication of esophagectomy with poorly understood risk factors. It has a high morbidity due to loss of fluids, electrolytes, and other nutrients, loss of lymphocytes and immune dysfunction. Methods: Retrospective chart review of adult patients who underwent esophagectomy between 2009 and 2016 was performed. Cases with chyle leak were identified according to a set criteria. Clinical features, operative findings and postoperative variables were recorded and predictors of chyle leak were analyzed. Results: During the study period, a total of 193 adult patients underwent esophagectomy of which 186 received neo adjuvant chemotherapy. The mean age was 53 years with 118 males and 74 females. Type of procedure performed was 3-stage esophagectomy in 98, Transhiatal esophagectomy in 79 and Ivor-Lewis esophagectomy in 15 patients. Chyle leak was identified in 9 (4.6%) patients. There was no significant association of chyle leak with age, gender, co-morbid, level of tumor, Neo-adjuvant therapy and Type of esophagectomy. Chest drain output on postoperative day 5 was significantly predictive of chyle leak (p-value<0.05). Drain output more than 1000 on day 4 was highly suggestive of chyle leak (p-value<0.05). Day on which chest drain was removed was also found to be significantly related to chyle leak (p-value <0.05). Conclusion: No significant preoperative risk factors were identified for chyle leak. High chest drain output on postoperative day 5 and drain output more than 1000 on day 4 are significant predictors of chyle leak.Keywords: Thoracic duct; chylothorax; chylous ascites; chest drain
Dougenis D, Walker WS, Cameron EW, Walbaum. Management of chylothorax complicating extensive esophageal resection. Surg Gynecol Obstet 1992;174(6):501–6.
Bolger C, Walsh TN, Tanner WA, Keeling P, Hennessy TP. Chylothorax after oesophagectomy. Br J Surg 1991;78(5):587–8.
Collard JM, Otte JB, Reynaert M, Michel L, Carlier MA, Kestens PJ. Esophageal resection and by-pass: a 6-year experience with a low postoperative mortality. World J Surg 1991;15(5):635–41.
Orringer MB, Marshall B, Iannettoni MD. Transhiatal esophagectomy for treatment of benign and malignant esophageal disease. World J Surg 2001;25(2):196–203.
Merrigan BA, Winter DC, O'sullivan GC. Chylothorax. Br J Surg 1997;84(1):15–20.
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.
Machleder HI, Paulus H. Clinical and immunological alterations observed in patients undergoing long-term thoracic duct drainage. Surgery 1978;84(1):157–65.
Cerfolio RJ, Allen MS, Deschamps C, Trastek VF, Pairolero PC. Postoperative chylothorax. J Thorac Cardiovasc Surg 1996;112(5):1361–6.
Lemaire LC, Van Lanschot JB, Stoutenbeek CP, van Deventer SJ, Dankert J, Oosting H, et al. Thoracic duct in patients with multiple organ failure: no major route of bacterial translocation. Ann Surg 1999;229(1):128–36.
Nath DS, Savla J, Khemani RG, Nussbaum DP, Greene CL, Wells WJ. Thoracic duct ligation for persistent chylothorax after pediatric cardiothoracic surgery. Ann Thorac Surg 2009;88(1):246–52.
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.
NCCN. Clinical Practice Guidelines in Oncology. Esophageal and Esophagogastric Junction Cancers. [Internet]. National Comprehensive Cancer Network [cited 2017 Jan 4]. Available from: http://www.nccn.org/professionals/physician_gls/pdf/esophageal.pdf
van Hagen P, Hulshof MC, Van Lanschot JJ, Steyerberg EW, van Berge Henegouwen MI, Wijinhoven BP, et al. Preoperative chemoradiotherapy for esophageal or junctional cancer. N Engl J Med 2012;366(22):2074–84.
Roffman CE, Buchanan J, Allison GT. Charlson comorbidities index. J Physiother 2016;62(3):171.
Mishra PK, Saluja SS, Ramaswamy D, Bains SS, Haque PD. Thoracic duct injury following esophagectomy in carcinoma of the esophagus: ligation by the abdominal approach. World J Surg 2013;37(1):141–6.
Miao L, Zhang Y, Hu H, Ma L, Shun Y, Xiang J, et al. Incidence and management of chylothorax after esophagectomy. Thoracic Cancer 2015;6(3):354–8.
Hou X, Fu JH, Wang X, Zhang LJ, Liu QW, Luo KJ, et al. Prophylactic thoracic duct ligation has unfavorable impact on overall survival in patients with resectable oesophageal cancer. Eur J Surg Oncol 2014;40(12):1756–62.
Crucitti P, Mangiameli G, Petitti T, Condolucia A, Rocco R, Gallo IF, et al. Does prophylactic ligation of the thoracic duct reduce chylothorax rates in patients undergoing oesophagectomy? A systematic review and meta-analysis. Eur J Cardiothorac Surg 2016;50(6):1019–24.
Nair SK, Petko M, Hayward MP. Aetiology and management of chylothorax in adults. Eur J Cardiothorac Surg 2007;32(2):362–9.
Marts BC, Naunheim KS, Fiore AC, Pennington DC. Conservative versus surgical management of chylothorax. Am J Surg 1992;164(5):532–5.
Orringer MB, Bluett M, Deeb GM. Aggressive treatment of chylothorax complicating transhiatal esophagectomy without thoracotomy. Surgery 1988;104(4):720–6.
Tam PC, Fok M, Wong J. Reexploration for complications after esophagectomy for cancer. J Thorac Cardiovasc Surg 1989;98(6):1122–7.
Bonavina L, Incarbone R, Peracchia A. Thoracoscopic treatment of iatrogenic chylothorax after esophageal surgery. Proceedings of the Second International Congress of Thoracic Surgery. In 1998.
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.
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