Chylothorax after esophagectomy: thoracoscopic sealing of the thoracic duct

Chylothorax after esophagectomy for cancer is an uncommon, but potentially life-threatening postoperative complication with a reported incidence rate of 1-4%. A high index of suspicion for duct injury must be maintained in all patients after operation. Here we show the case of a 61-year-old man who presented a massive right chylothorax, days after a laparoscopic transhiatal radical esophagectomy for adenocarcinoma of the lower esophagus with preoperative neoadjuvant chemotherapy.

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Chylothorax after esophagectomy: thoracoscopic sealing of the thoracic duct

Authors

B Dallemagne, S Perretta, J Marescaux

Abstract

Chylothorax after esophagectomy for cancer is an uncommon, but potentially life-threatening postoperative complication with a reported incidence rate of 1-4%. A high index of suspicion for duct injury must be maintained in all patients after operation. Here we show the case of a 61-year-old man who presented a massive right chylothorax, days after a laparoscopic transhiatal radical esophagectomy for adenocarcinoma of the lower esophagus with preoperative neoadjuvant chemotherapy.

Keywords

Chylothorax after esophagectomy, thoracoscopic sealing, thoracic duct

Media type

Surgical video

Duration

05'50''

Publication

2010-04

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E-publication

WeBSurg.com, Apr 2010;10(04).
URL: http://www.websurg.com/doi-vd01en2915.htm

Chylothorax after esophagectomy: thoracoscopic sealing of the thoracic duct

1. Introduction 00'19''

Here we show the case of a 61-year-old man who underwent laparoscopic transhiatal radical esophagectomy for adenocarcinoma of the lower esophagus after preoperative neoadjuvant chemotherapy. Chylothorax after esophagectomy for cancer is an uncommon, but potentially life-threatening postoperative complication, with a reported incidence rate of 1 to 4%. A high index of suspicion for duct injury must be maintained in all patients after operation.

2. Esophagectomy 00'56''

After gastrolysis has been completed, here you see the second step of the operation consisting in esophageal mobilization and lymphadenectomy. The lesser omentum is incised in order to achieve a wide access to the diaphragmatic hiatus. The diaphragm can be incised in order to increase the access in the mediastinum. The incision of the diaphragm can be performed on the anterior aspect or we can also divide the right crus that will facilitate the passage of the gastric transplant. Opening of the mediastinum is made in the usual fashion. The dissection is carried next to the pleura in order to achieve a wide excision of all the tissues surrounding the esophagus. During the mediastinal mobilization performed with the Ligasure® device, the thoracic duct was identified and no obvious leak was detected. On postoperative day 6, the right thoracic drain was removed and subsequent chest x-rays were normal prior to discharge on postoperative day 10. The patient was readmitted 10 days later for acute pulmonary and cardiovascular distress. Emergency CT-scan demonstrated a massive right chylothorax. A chest tube was inserted and drained 8L of of chylous fluid. Once the patient was stable a surgical repair was scheduled. The thoracic duct is a paper-thin tubular structure of 2 to 3mm in diameter. To optimize the visualization of the leak the patient was fed a high-fat meal to enhance chyle production 20 minutes prior to induction of anesthesia.

3. Patient position for thoracoscopy 03'08''

At reoperation the patient was placed in a left lateral position. Three trocars were inserted in the right pleural cavity.

4. Exploration and leak identification 03'17''

The right lung was lifted up and the thoracoscopic exploration identified rapidly the leak from a lateral injury of the thoracic duct.

5. Clips and suture placement 03'28''

Clips and a suture were used on the proximal segment with an immediate stop of the chylous flow. Fewer than 5% of patients develop chylothorax after esophagectomy, and such development is usually a result of injury to the thoracic duct. The thoracic duct has a close anatomical relationship with the esophagus throughout its course. In cancer patients, the esophagus is more adherent to surrounding soft tissues, and thoracic duct injury can occur during its mobilization. Laceration of thoracic duct virtually presents in the early postoperative period as an excessive drainage. The diagnosis of chylothorax may be easily missed in the early postoperative period, because the fluid is straw-colored and not milky. Fibrin glue was applied to reinforce the seal and a chest tube was left in place.

6. Results 05'30''

Postoperatively, the patient recovered rapidly, resumed oral intake on postoperative day 2, with minimal drain output and normal chest X-rays. He was discharged on postoperative day 6.

7. Conclusions 05'44''

Delayed chylothorax after transhiatal radical esophagectomy can be managed efficiently by a thoracoscopic approach capable of reproducing the sealing techniques used in thoracotomy.