Does prophylactic ligation of the thoracic duct reduce chylothorax rates in patients undergoing oesophagectomy? A systematic review and meta-analysis

Abstract

A systematic review of English and non-English articles using OVID MEDLINE (1980-2014) was performed to evaluate the potential value of prophylactic ligation of the thoracic duct in preventing chylous leakage after oesophagectomy for cancer. Search terms included [Oesophagectomy OR esophagectomy] AND [chylothorax] AND [thoracic duct ligation]. Only those papers that directly compared the incidence of chylothorax in patients who underwent prophylactic ligation [ligation group (LG)] with that in those who had conservative treatment were selected [preservation group (PG)]; all the articles presenting original data and supplying sufficient information on the chylothorax rate after oesophagectomy were included. Independent extraction of articles was performed by two authors using predefined data fields, including study quality indicators. The PRISMA guidelines were carefully adhered to. A total of 5254 subjects were included in the 7 clinical studies examined into the current meta-analysis. Of these, 2179 patients underwent prophylactic ligature of the thoracic duct (LG group) and 3075 had preservation of the thoracic duct (PG group). A significant difference in terms of chylothorax rate [odd ratios (ORs) 0.47 in favour of LG, 95% confidence interval (CI) 0.27-0.80] was noted between the LG group and the PG group. According to our meta-analysis and taking into account-specific caveats, prophylactic ligation of the thoracic duct could be considered as an effective preventative measure to reduce the incidence of postoperative chylothorax.

Diagnosis, assessment, and management of surgical complications following esophagectomy

“…Although a rare event, chylothorax affects the postoperative morbidity by promoting the occurrence of pneumonia, with respiratory failure, malnutrition, and death in 20% of cases . Currently, the debate is not completely resolved whether to perform systematic dissection of the thoracic duct, although this practice can prevent the occurrence of severe chylothorax . Many therapeutic options for postoperative chylothorax, including conservative treatment, lymphangiography, and surgical revision, have been described.…”

“…125 Currently, the debate is not completely resolved whether to perform systematic dissection of the thoracic duct, although this practice can prevent the occurrence of severe chylothorax. 126 Many therapeutic options for postoperative chylothorax, including conservative treatment, lymphangiography, and surgical revision, have been described. The optimal management is still under debate both in relation to timing and treatment modalities.…”

Nutrition in peri-operative esophageal cancer management

“…If an anastomotic leakage occurs, the patient should be kept nil by mouth, and full enteral tube feeding in accordance with the individual's estimated energy, protein and fluid requirements, or parenteral nutrition if the enteral route is not available is needed until oral feeding can be reinitiated. Another rare but severe complication from esophagectomy is a chylothorax, which is associated with life-threatening metabolic, immunologic, and respiratory complications [94][95][96][97]. It is caused by leakage or disruption of the thoracic duct during en bloc lymphadenectomy and typically becomes clinically apparent at 2-10 days after surgery [96][97][98].…”

“…Rapid identification of the presence of a chylothorax is crucial in managing a chylous leak, since early detection has been shown to improve patient outcomes and limit complications [97]. Complications can be devastating and include malnutrition, physiological derangements, and immunodepression [94,95,97]. It is universally accepted that nutritional depletion occurs soon after the onset of a chyle leak, necessitating early nutritional support [97].…”

Prävention und operative Therapie des Chylothorax

“…Verschiedene Metaanalysen bestätigen die Effektivität der prophylaktischen Ligatur des Ductus thoracicus. So zeigt eine Metaanalyse aus dem Jahre 2016 an insgesamt über 5000 Patienten nach Ösophagusresektion, dass das Auftreten eines Chylothorax nach prophylaktischer Ligatur mit einer Odds Ratio von 0,47 signifikant niedriger liegt [15,16]. In einer weiteren Metaanalyse aus dem Jahre 2017 scheitert der Nachweis eines Vorteils der prophylaktischen Ligatur sehr knapp am Signifikanzniveau [17].…”