Management options for post-esophagectomy chylothorax
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REVIEW ARTICLE
Management options for post‑esophagectomy chylothorax Vaibhav Kumar Varshney1 · Sunita Suman1 · Pawan Kumar Garg2 · Subhash Chandra Soni1 · Pushpinder Singh Khera2 Received: 22 May 2020 / Accepted: 3 August 2020 © Springer Nature Singapore Pte Ltd. 2020
Abstract Chylothorax, although an uncommon complication of esophagectomy, is associated with high morbidity and mortality if not treated promptly. Consequently, knowledge of the thoracic duct (TD) anatomy is essential to prevent its inadvertent injury during surgery. If the TD is injured, early diagnosis and immediate intervention are of paramount importance; however, there is still no universal consensus about the management of post-operative chylothorax. With increasing advances in the spheres of interventional radiology and minimally invasive surgery, there are now several options for managing TD injury. We review this topic in detail to provide a comprehensive and practical overview to help surgeons manage this challenging complication. In particular, we discuss an appropriate step-up approach to prevent the morbidity associated with open surgery as well as the metabolic, nutritional, and immunological disorders that accompany a prolonged illness. Keywords Chylothorax · Post-esophagectomy · Lymphangiography · Thoracoscopic ligation · Embolization
Introduction
Anatomy
The thoracic duct (TD) is often damaged during mobilization of esophageal cancers, via right thoracotomy or via the trans-hiatal route [1]. In the event of TD injury, chylothorax usually presents in the first week after surgery. Initial management is generally conservative, but high volume leaks require surgical management. Re-exploration either via thoracotomy or via laparotomy will add to the morbidity of esophagectomy. A minimally invasive approach via lymphangiography, with or without embolization, for postesophagectomy chylothorax has been reported with good success rates [2, 3]. We discuss the anatomy of the TD, then review the clinical presentation of its injury and the various treatment options for post-esophagectomy chylothorax, focusing on minimally invasive approaches.
The thoracic duct (TD) drains lymph from the entire body, except from the right hemithorax, upper limb, and right side of the head and neck. Consequently, it is a long structure, measuring 38–45 cm with a diameter of 2–5 mm, extending from the apex of the cisterna chyli to the neck [4]. The small lymphatic vessels converge to form the right and left lumbar trunks and the intestinal lymph trunks, which in turn unite to form the cisterna chyli, usually at the level of the L2 vertebrae and to the right of the aorta. It is found in only about 53% of lymphangiography studies [5]. The TD originates at the apex of the cisterna chyli and traverses through the aortic hiatus and ascends in the posterior mediastinum between the thoracic aorta in the left and the azygous vein in the right. Here, the vertebral column and right intercostal arteries lie posterior to the TD, and the diaphragm and esophagus lie anter
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