Clinical outcome of transthoracic esophagectomy with thoracic duct resection

Abstract

The number of dissected lymph nodes (LNs), surgical outcomes, and postoperative recurrence-free survival (RFS) were compared between thoracic duct (TD)-preserved and TD-resected groups. The distribution of metastasis in LNs around TD (TDLN) was reviewed. Transthoracic esophagectomy (TTE) with TD resection for esophageal cancer patients has been one of the standard procedures. Because the adipose tissue surrounding the TD contains LNs, TD resection might be necessary for radical LN dissection. However, few studies have investigated the oncological outcome of TTE with TD resection. Two hundred fifty-six consecutive patients who underwent TTE between 2004 and 2015 were retrospectively reviewed and classified into TD-preserved or TD-resected groups. The number of dissected LNs for each LN station and surgical outcomes were compared. RFS was analyzed in 155 patients who underwent TTE before December 2012. Since 2013, the TDLN number was prospectively examined, independent of the regional LNs (n = 72). Of these, the TDLN number for each location (TDLN-Ut/Mt/Lt) was investigated and the correlation between TDLN metastasis and clinicopathological factors was analyzed. The TD was preserved in 89 patients and resected in 167 patients. Patients with TD resection showed significant advanced stage. There was no significant difference in the incidence of postoperative complications, including pneumonia, anastomotic leakage, and chylothorax. The number of dissected mediastinal LNs was significantly increased in the TD-resected group. The 5-year RFS rate of cStage I patients was 67.3% in the TD-preserved group against 90.3% in the TD-resected group, showing a tendency towards RFS extension that did not quite reach statistical significance (P = 0.055). The mean TDLN-Ut/Mt/Lt numbers were 0.89/0.56/0.44, respectively. Eight of 72 (11%) patients displayed TDLN metastasis. Metastatic TDLNs were observed on the same or cranial level of the primary lesion in 7 of 8 patients. Transthoracic esophagectomy with TD resection could increase the number of dissected mediastinal LNs without increase of postoperative complication. TDLN metastasis was observed in patients with advanced disease. A prospective trial, investigating the survival between TD-preserved and TD-resected groups, should be conducted to clarify if TD should be resected in TTE.

Prognostic impact of thoracic duct lymph node metastasis in esophageal squamous cell carcinoma

“…The current study successfully validated our previous findings that there was the existence of LN metastasis around the TD in ESCC. 16 Subsequently, we further confirmed that TDLN metastasis occurred In contrast to the value of TDLN metastasis as a prognostic indicator, the efficacy of lymphadenectomy of TDLN with TD resection might not be remarkable. Based on the current study, which the first study evaluating the prognosis of patients with TDLN metastasis for each location, the incidence rate of TDLN metastasis was relatively low, and its prognosis was proven to be extremely poor.…”

“…As previously reported, since June 2013, the TDLN has been examined independently of paratracheal and aortic LNs in our institution. 16 All patients who underwent TTE with TD resection for esophageal malignancies at the Keio University Hospital between June 2013 and December 2019 were reviewed. We excluded patients with a cT4 tumor, adenocarcinomas, patients that underwent salvage esophagectomy after definitive chemoradiotherapy, and those with R2 resection.…”

Lymphangiography and focal pleurodesis treatment of chylothorax with an aberrant thoracic duct following oesophagectomy: a case report

“…Regarding whether to resect the thoracic ducts or preserve them in oesophageal resection, there have been few reports on the efficacy of thoracic duct resection [8], and a consensus of resection of thoracic duct has yet to be reached. In our hospital, we usually clip and dissect the thoracic duct at the level above the diaphragm for oesophageal cancer; however, postoperative chylothorax still remains a rare complication.…”

Effectiveness of etilefrine regimen for chylothorax after esophagectomy with thoracic duct resection

“…Besides the present study, there have been hardly any reports showing the effectiveness of etilefrine in cases of chylothorax after esophagectomy with TDR [ 12 ]. In surgery for esophageal cancer, the thoracic duct is resected to ensure thorough removal of the lymph nodes around the thoracic duct, and the oncological effectiveness of TDR has been demonstrated [ 13 , 14 ]. In performing TDR, we double-clip the thoracic duct above the diaphragm in patients with cStage II or more advanced esophageal cancer.…”