Embolization or disruption of thoracic duct and cisterna chyli leaks post oesophageal cancer surgery should be first lin
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ORIGINAL ARTICLE
Embolization or disruption of thoracic duct and cisterna chyli leaks post oesophageal cancer surgery should be first line management for ECCG-defined type III chyle fistulae Noel E. Donlon 1 & Tim S. Nugent 1 & Robert Power 1 & Waqas Butt 1 & Ahmad Kamaludin 1 & Steven Dolan 2 & Michael Guiney 2 & Niall Mc Eniff 2 & Narayanasamy Ravi 1 & John V. Reynolds 1 Received: 7 September 2020 / Accepted: 7 October 2020 # Royal Academy of Medicine in Ireland 2020
Abstract Chyle leakage from the thoracic duct or cisterna chyli is a relatively rare complication of oesophageal cancer surgery. The majority of cases settle with conservative measures, but high volume leaks may be refractory and result in significant morbidity and require intervention with reoperation or embolization. In the experience of this high-volume centre over the last decade, 3 (0.5%) patients required reoperation and ligation of the thoracic duct; for the so-called type III leaks, interventional radiological approaches were not considered. This article is built around two recent cases, where interventional radiology to embolize and disrupt complex fistulae was successfully performed. The lessons from this experience will change practice at this centre to initial lymphangiography with a view to embolization or disruption of thoracic duct and cisterna chyli leaks as first line therapy for type III chyle leaks, with surgery reserved for where this fails. Keywords Chyle leak . Medium-chain fatty acids . Oesophageal Cancer . Thoracic duct embolization . Thoracic duct ligation
Introduction Chyle leak resulting in chylothorax or a fistula is a rare but potentially life-threatening complication following oesophageal cancer resection [1–4]. Most leaks arise from the thoracic duct (TD), which originates from the cisterna chyli (CC) and courses along the right side of the vertebral column posterior to the oesophagus before crossing the midline at the level of the 5th thoracic vertebrae to continue its course to insertion at the junction between the left subclavian and left internal jugular veins [3]. The CC lies immediately right of the aorta behind the right crus of the diaphragm and is an elongated, sac-like structure formed by the junction of
* Noel E. Donlon [email protected] 1
Department of Surgery, National Oesophageal and Gastric Cancer Center, St. James’s Hospital and Trinity College Dublin, Dublin, Ireland
2
Department of Interventional Radiology, St. James’s Hospital and Beacon Hospital, Dublin, Ireland
a variable number of the lumbar, intestinal, liver and descending intercostal lymphatic trunks. The TD measures approximately 40 cm in length, with a rate of flow between 1.5 and 4.0 L per day. Anatomic variations may occur, including multiple channels or a dominant left TD [5]. The TD is particularly at risk during thoracic oesophageal cancer resection, both en bloc, where the proximal TD is ligated or clipped, or where the TD is not identified. It is also at potential risk of avulsion in a blunt transhiatal resection (THE). The clinica
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