Chyle Leak Following Radical En Bloc Esophagectomy with Two-Field Nodal Dissection: Predisposing Factors, Management, and Outcomes

Abstract

Background Chyle leak is an uncommon complication following esophagectomy, accounting for significant morbidity and mortality; however, the optimal treatment for the chylothorax is still controversial. Objective The aim of this study was to evaluate the incidence, management, and outcomes of chyle leaks within a specialist esophagogastric cancer center. Methods Consecutive patients undergoing esophagectomy for esophageal cancers (adenocarcinoma or squamous cell carcinoma) between 1997 and 2017 at the Northern Oesophagogastric Unit were included from a contemporaneously maintained database. Primary outcome was overall survival, while secondary outcomes were overall complications, anastomotic leaks, and pulmonary complications. Results During the study period, 992 patients underwent esophagectomy for esophageal cancers, and 5% (n = 50) of them developed chyle leaks. There was no significant difference in survival in patients who developed a chyle leak compared with those who did not (median: 40 vs. 45 months; p = 0.60). Patients developing chyle leaks had a significantly longer length of stay in critical care (median: 4 vs. 2 days; p = 0.002), but no difference in total length of hospital stay. Conclusion Chyle leak remains a complication following esophagectomy, with limited understanding on its pathophysiology in postoperative recovery. However, these data indicate chyle leak does not have a long-term impact on patients and does not affect long-term survival.

Management of chyle leaks following esophageal resection: a systematic review

“…Four studies did not outline their definition of a chyle leak. 19 , 31 , 34 , 36 One study used the Esophageal Complications Consensus Group (ECCG) definition of chyle leaks, 39 in 4 studies this was a clinical diagnosis based on quantity and quality of chest drainage, 21–23 , 42 and the remaining 16 confirmed this clinical diagnosis biochemically with triglycerides and/or chylomicrons in chest drain fluid. A summary of study characteristics is presented in Table 1 .…”

“…Most regimens consisted of TPN and/or enteral dietary modification with continued chest drainage. 10 , 20 , 22 , 23 , 25–30 , 32 , 35 , 38 , 39 , 41 , 42 Enteral MCT nutrition were used in three studies; in 1 instead of TPN, 26 in another before TPN, 42 and the other did not report the sequence of nutritional modification. 38 One series reported the use of elemental low-fat tube feeding if chyle output was <500 mL/24 hours, and TPN if this output exceeded this threshold.…”

“…These varied between a chest drain output exceeding a defined volume, ranging from 100 mL to 1.1 L per day and/or a chyle leak persistent after 2 to 14 days of conservative management. 19 , 25 , 26 , 28 , 36 , 39 , 42 , 44 Miao et al 30 and Shah et al 38 retrospectively identified a common flow rate threshold for patients undergoing reoperation, which stood at 13.5 mL/kg per day and 11.6 mL/kg per day, respectively. Clinical success in the conservatively managed group ranged from 11% to 75.4%.…”

“…Clinical success in the conservatively managed group ranged from 11% to 75.4%. In all but four studies, 30 , 42 patients who failed conservative management were also included in the reoperation subgroup in which clinical success rates ranged from 31% to 100% with a technical success rate, defined by successful identification and ligation of the leaking duct, of 100% in six out of the seven studies that reported it. Mortality after TDL ranged from 0% to 33%.…”

ASO Author Reflections: Chyle Leak: No Long-Term Impact on Survival

“…The present study indicates that surgical outcomes of patients developing chyle leak were similar to those who had an uneventful surgery, except for the length of critical care stay which was longer for those developing a chyle leak. 5 More importantly, a chyle leak was not associated with any detrimental long-term effect. In particular, there was no significant difference in overall survival regardless of tumour histology between patients who developed a leak and those who did not.…”